Good afternoon, everyone, we'll just give folks a few minutes to come into the room. All right, I see people trickling in. All right, good afternoon, everyone, and welcome to today's webinar titled Social Determinants of Health and Opioid Use Disorder in BIPOC Communities, hosted by the Providers Clinical Support System in partnership with the National Council for Mental Wellbeing. Thank you so much for joining us. My name is Coil Shropshire, Project Coordinator of Practice Improvement at the National Council for Mental Wellbeing, and I will be moderating today's session. Before we begin, I'd like to cover a few housekeeping notes. Today's webinar is being recorded and all participants will be kept in listen mode only. The recording and slides will be made available on the PCSS website within two weeks. And there will be an opportunity to ask questions at the end of the webinar, so we encourage you to submit your questions throughout the webinar in the Q&A box located at the bottom of your screen. I am pleased to introduce today's presenters, which are Dr. Rachel Talley and Dr. Jessica Isom. Dr. Talley is an Assistant Professor of Clinical Psychiatry in the Department of Psychiatry at the University of Pennsylvania. She is Director of UPenn Department of Psychiatry's Fellowship in Community Psychiatry and is also an Associate Program Director for the UPenn Department of Psychiatry's Adult Psychiatry Residency Program. She has several years of frontline clinical experience in community-based settings. Dr. Talley received her BA from Harvard University and her MD from Stanford University School of Medicine. She completed both her residency training in adult psychiatry and public psychiatry fellowship at Columbia University slash New York State Psychiatric Institute. She has several peer-reviewed publications examining the integration of physical health services into behavioral health settings. She is a mentor of the Board of the American Association for Community Psychiatry, counselor on the Executive Committee of the Philadelphia Chapter of the Pennsylvania Psychiatric Society, a branch of the American Psychiatric Association, and is also a member of the National Council for Mental Well-Being's Medical Director Institute. Next, Dr. Jessica Isom is a board-certified community psychiatrist and clinical instructor in the Yale Department of Psychiatry. She primarily works in Boston as an attending psychiatrist at Codman Square Health Center and with Boston Medical Center Psychiatry Emergency Services. She received her MD from the University of North Carolina at Chapel Hill, where she also received her MPH with a focus on public health leadership. She currently serves as a member of the American Psychiatric Association Assembly, representing early career psychiatrists, where her contributions center on illuminating the need for health equity in organized psychiatry. She also has been elected to the counselor position for the Massachusetts Psychiatric Society, where her focus on social justice and health equity provides an opportunity to improve the care provided to marginalized populations in the state. She continues to work with the Yale Department of Psychiatry Residency Program as a faculty track consultant leader for the social justice and health equity curriculum. Next are disclosures. Dr. Talley would like to disclose that she is the medical advisor of Vanna Health. Dr. Isom has nothing to disclose. And finally, the overarching goal of PCSS is to train health care professionals in evidence based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well for the prevention and treatment of substance use disorders. Now I'm going to pass it over to Dr. Talley, who will start by outlining our educational objectives. So, Dr. Talley. Well, thank you so much, Coyle, for setting the stage and for that generous introduction. Welcome to everybody on the call, and I'm delighted to be here with my colleague, Dr. Isom, to speak a little bit about this interface of the social determinants of health, opioid use disorder, and marginalized and minoritized communities. To start out, in terms of our educational objectives, at the conclusion of this activity, we are hoping that you as participants will be able to examine how social determinants of health may impact initiation of and ongoing substance use, discuss factors that facilitate and hinder engagement and long term treatment and recovery for BIPOC individuals, and identify strategies for organizations to assess and address opioid use among BIPOC individuals through addressing social determinants of health. And so I'm going to kick us off by sort of setting the stage in terms of this connection between social determinants of health, the connection with opioid use, as well as disparities in terms of use and treatment. And then I'll turn it over to my colleague, Dr. Isom, to speak a little bit about factors in terms of hindering and engagement of BIPOC individuals. Next slide, please. So first, and I know that folks are still sort of introducing themselves in the chat, but I'm going to ask for a little bit of chat participation. And I will say that I hope that this is a nice easy question that you folks out there in the field are likely well versed in these issues, particularly as they've, I think, fortunately, gotten more prominence in recent years, as far as how we understand health care outcomes and particularly disparity in health care outcomes. But I'll ask that folks just enter into the chat. When I say social determinants of mental health, what does that mean to you? What are the social determinants of mental health? I'll welcome any responses to that as folks are chatting their introductions. And I see, awesome, level of education, environment, socioeconomic status, income, housing, as expected, folks on the call are all over this. And what we're talking about is, is just as folks are chatting and all these sort of upstream factors, racism, I see food insecurity, income support, that can potentially trickle down and impact both our general health, but also our mental health outcomes and drive disparity along those issues. Next slide, please. So this diagram, which is from an excellent book that I highly recommend if you have not run across it before, The Social Determinants of Mental Health, edited by Drs. Michael Compton and Ruth Shim, provides a diagram that I really like as sort of encapsulating this sort of trickle down effect. This is sort of a conceptual framework for the social determinants and how we can basically think of the social determinants of mental health as issues that stem from basically our public policies, which are in part driven by our social and societal norms, and that those public policies and societal norms sort of trickle down and influence the distribution of opportunity amongst our communities. In turn, distribution of opportunities and particularly disparity in terms of distribution of opportunities can lead to differences in terms of opportunities for safe and stable housing, secure sources of food, stable employment, safety and resources in the built environment, discrimination, and issues in these realms and problems in these realms can absolutely drive poor health outcomes and poor mental health outcomes. In other words, for folks who are struggling with issues in the realm of social determinants of mental health, struggling with secure housing, secure sources of income, secure sources of food, et cetera, folks with challenges in these areas are absolutely more likely to experience mental health challenges. Next slide, please. Now, importantly, something I want to highlight in terms of framing, and please go ahead and click through the animation on this slide, is this most upstream portion in terms of the public policies and social norms. And what I want to particularly frame is that disparities in the social determinants of mental health do not necessarily occur by accident, right? It's not simply out of nowhere that certain communities, and particularly marginalized and minoritized communities, BIPOC communities, often experience disparate poor outcomes and are disproportionately impacted by the social determinants of mental health. And these things don't just occur by happenstance. Often they are driven by biases and social norms that in turn drive discriminatory policies leading to unequal distribution of opportunity. Next slide. You can go ahead. Thanks. And so in terms of just giving a highlight, highlighting an example of that, so I am zooming into you from Philadelphia, Pennsylvania, where I teach and provide clinical services in community mental health. Philadelphia, like a lot of urban settings in our country, has many issues around, and I'm just snapshotting this as one social determined example. We have great challenges in Philadelphia around housing access, whether it is homelessness, whether it's housing instability, whether it is challenges in terms of housing burden and ability of folks in the community to afford stable, secure, and well-maintained housing. This is a tremendous challenge across the board in the city of Philadelphia. But as data like this shows, while this is something that a significant number of individuals, regardless of background, struggle with in the city, we do see disparities, particularly amongst those of the racial and ethnic minority identity. This slide, again, just a snapshot of looking at housing burden in terms of folks owning homes in the Philadelphia community and where we see higher rates, particularly among Black and Latinx populations as compared to their counterparts of the majority background. Philadelphia, like many cities, has tremendous issues around residential segregation, differences in terms of the neighborhoods in which folks have access and are able to live and work and thrive. And certainly our minoritized communities, our BIPOC communities in Philadelphia, are disproportionately likely to find themselves in lower income housing, in housing that is not as well-maintained, that is of poor quality, and also simply have less access to housing. Next slide, please. And so this example, I pull out this example from the social determinants just to highlight one example where we can see disparity in terms of social determinants being something that does not always occur simply by accident, but in fact occurs at least in part because of specific social policies that have driven disparity and that have targeted particular individuals and communities. And so this map I have here, and I imagine many on the call have seen maps like this, this is a map sort of highlighting the issue of redlining, basically the issue of unequal access to credit for either home repairs or home ownership based on identity. This map is actually from the Philadelphia area from the 1930s. And just to explain for those on the call who aren't familiar, redlining, particularly of issue in the United States around the 1930s in terms of home, more access to home mortgages and the ability to be issued credit to own a home, basically federal programs depended on the perspective of local brokers and local appraisers in terms of which communities and environments were the best ones in which they should extend credit. Often these local brokers and appraisers had essentially biased at times outright racist views in terms of this is a good neighborhood and this is a bad neighborhood. So that advice was sent up to the federal government and impacted who could get an access to a loan and who could not. And so policies like this dictated by those social norms and biases trickle down and echo even in our society today in terms of folks with a minority background having disproportionately lacking access when it relates to the social determinants of mental health and disproportionately struggling with the social determinants of mental health. Next slide, please. So now diving a little bit more into the connection between social determinants of mental health and substance use. So we only have about an hour here. This is a big, broad topic in terms of these connections. And so I'd say I wish I had the time to go through each social determinants of mental health. But I'm just going to highlight two examples just to sort of give a flavor in terms of data that I think I would almost frame it as data that in a sense proves the obvious, that if you are lacking a safe, stable and clean place to live, regular access to income, to food, to those basic things that give you a sense of comfort and safety and stability in your life, it's certainly not surprising that you might be disproportionately a bit more prone to mental health struggles in general, including substance abuse issues, as far as grappling with some of the hopelessness and the stress and the challenge in terms of one's psychological well-being that can come from lacking access to one's basic needs. But just to put it to share some data, to sort of put an exclamation point on that point, I'm first going to share a little bit of data about housing as a social determinant and its connection with substance abuse. So this is some data from some recent studies from the Boston Health Care for the Homeless Program, as well as some data from San Francisco focused on individuals experiencing homelessness. Basically looking at disparities in terms of the impact of the opioid crisis. Now, of course, we know on the call that the opioid crisis is a tremendous public health concern across the board, impacting individuals both housed and unhoused. But I'm hoping the data that I'm showing here highlights the way in which the situation, the experience of homelessness and housing instability is associated with a much higher rate of difficulty in terms of opioid use, as well as overdose. I'm just highlighting some of the data here. Drug overdose mortality rates were found to be 12 times as higher among individuals experiencing homelessness in Massachusetts, as compared to the general population in Massachusetts. 91 percent of overdose deaths in this population involve opioids. Looking at this data in San Francisco, we see the death rate among individuals experiencing homelessness just rapidly rising in general during this period of the pandemic. We might think, well, the pandemic, COVID, of course, that makes sense. But we see that a key driver here in terms of what was what was rising in terms of the cause of mortality, overdose and overdose cases specifically involving opioids amongst this population. So I hope this gives a little bit of a highlight of this association between a key social determinant of mental health, namely housing stability and risk of substance use and substance use overdose, particularly with opioids. Next slide. Just to highlight another social determinant example. So jumping to the social determinant of mental health of employment status, access to stable employment. So this is a couple of different studies drawing on national data, some from the U.S. National Survey on Drug Use, basically highlighting that employment status repeatedly in studies has been shown to be strongly associated with problematic substance use. In other words, either underemployment or unemployment has been shown to be associated with higher rates of use of substances. Just to draw an example, we see one example from the National Survey on Drug Use and Health of state unemployment rate, positively associated with misuse, specifically of analgesics, oxycodone and heroin. So our topic for today, 2017 analysis of CDC data, basically looking at state level emergency department use, found that a 1% increase in county unemployment was associated with a 3.6 increase in the opioid death rate and a 7% increase in opioid overdose ED visits. So, of course, for those on the call who are scientists, we know that correlation doesn't always imply causation, but that when we see repeated, repeated evidence of associations between one factor and another, we need to, of course, start to think, well, there must be some sort of causal or linked relationship here where employment status and specifically unemployment could be in ways, something that is sort of driving issues in terms of problematic substance use and overdose. Next slide. So here I've highlighted, and if you can click through to throw in my animation circles as well, just to show from one of these studies from Compton and colleagues in 2014, looking at this data from the National Survey on Drug Use and Health. Basically, this is looking at comparisons of unemployed versus employed individuals and rates of both substance use and substance dependence. I've circled here the category of illicit, the general illicit drug use. This study basically looked at alcohol use, tobacco use, and then illicit drug use. And so we can imagine that opioid use is within that category. And so if you compare the column by column examples of employed versus unemployed, you can see that there are, in certain segments of this data, a twofold higher chance of illicit drug use amongst the unemployed as compared to the, as compared to the employed, and similar twofold and beyond in terms of illicit drug abuse, abuse or dependence in the unemployed as compared to the employed. So again, just trying to highlight that association of where we can see data essentially proving what I think would be intuitively obvious to many of us, that the psychological strain, the hopelessness, the struggle that can come with being unemployed, that can come with not having that clear sense of where your next paycheck is or what your access to income is going to be, unsurprisingly, is associated with higher rates of both use of substances as well as dependence on substances. Next slide, please. So the last piece I want to highlight before turning it over to Dr. Isom is thinking a little bit about disparity, since, of course, our conversation for today is specifically focused on BIPOC communities. And so, again, we know that overdose and the use of opioids is a tremendous public health issue across the board, regardless of identity. But here I want to highlight some data basically showing that in terms of the rates that we are seeing of increased use of substance abuse, we are seeing faster increases amongst our amongst our BIPOC communities. So this data from the CDC shows that there is an increase of that overdose deaths increased by 30 percent between 2019 and 2020, but that we see higher rates of increase among Blacks as well as the American Indian and American Native populations as compared with their white counterparts. So a challenge for everybody. We are seeing these rates increase across the board. But this data, I hope, highlights how important it is to really think about what our targeted interventions are for our BIPOC communities, because we are seeing rates going up faster in those communities as compared with others. Next slide, please. Now, thinking about that issue, seeing higher rates amongst these marginalized, minoritized communities, the next thing we would certainly think about is, well, we have effective evidence-based treatments, how are we doing in terms of engaging BIPOC communities in treatment? And so the last piece I wanna share is a little snapshot of data, data sort of highlighting the point that we certainly have evidence to suggest that it is more challenging for folks of the BIPOC identity to initiate and engage in terms of treatment of opioid use disorder, that we're seeing disparities in terms of who is engaging with this important evidence-based treatment. And so here I have some data from 2019 from a study from JAMA looking at buprenorphine visits. Basically, this study looked at a national dataset and looked at basically ambulatory visits nationally in which a buprenorphine script was sent. Now, the study had some good news as far as just general population uptake of buprenorphine between 2012 and 2015 in this dataset, visits in which a buprenorphine script was dispensed increased from 0.04% to 0.36%. And this is like ambulatory visits across the board, that's why those numbers in general are so small. What I wanna highlight is that's a ninefold increase over those couple of years in terms of visits in which buprenorphine was dispensed, suggesting that we are seeing increasing use of buprenorphine. However, in terms of who it is that is utilizing those, who's receiving those scripts, if we look at the chart on the left in terms of the racial ethnic disparities, we see this increase in the number of visits in which a buprenorphine script was dispensed in the white population. Whereas if we look at the orange line, we see in the black population, pretty much just a flat line. So we see all that increase potentially is primarily in folks of the majority background, if you will. The other side also shows that these increases, we primarily see in the population of those who are either privately insured or self-pay, and speaking a little bit to that income disparity. Next slide. And so lastly, so that study basically looked at sort of volume of visits with buprenorphine, just to give another piece of data in terms of thinking about not only initiation, but engagement in treatment. This study basically looked at trends in terms of the duration of a buprenorphine episode of care, basically sort of sequential visits in which buprenorphine scripts were utilized. And again, we see disparities. And so we see both in terms of the median episode duration, the median sort of number of days in which a person was engaged in buprenorphine treatment, as well as the percentage of episodes that lasted more than 180 days. We see there's a line where there's sort of the aggregate, and that we certainly see that folks of the Caucasian identity had both higher, a higher median duration of episode, as well as a higher percentage of episodes that lasted over 180 days. And so I hope these two little snapshots of data kind of give that flavor that we overall seeing that there are higher, we're seeing higher rates of increase in terms of opioid use amongst our BIPOC communities. And then in a troubling way, we are seeing sort of lower rates in terms of initiation of evidence-based treatment, as well as duration of sort of engagement in evidence-based treatment. And so with that, I'm going to turn it over to my colleague, Dr. Isom, to continue from here. Yes, thank you, Dr. Talley. I'm going to start off by highlighting a specific determinant of health in a transition to bringing us down to the level of a service user with the foundation that Dr. Talley has offered to us. What I'll do after this slide is walk us through a case and then highlight some of the elements of the case that are connected to facilitators of, and barriers to engaging in treatment and being retained. So this is a graphic on the left that I created related to a grant that I have at my health center that's focused on anti-racism and opioid use disorder and innovations around how we construct our services. And in that literature review, I came across a paper that talks about the ways that we as service providers through how we're trained, the way that we offer services, how inclusive we are or not of those who've lived experience and community expertise can shape a service user's experience. And the literature essentially was detailing as well the racialized experiences that folks who make use of opioids can have and specifically those who develop opioid use disorders. So one of the pieces that came from that paper is that exposures to racism and likely other forms of discrimination can increase the age of onset of use, meaning earlier onset of use and also increase use directly. Racism at multiple levels, including how racism structures the way that we're trained, the way that we structure our services can also prevent us from offering culturally relevant assessments and treatment interventions, which of course connects to the rest of this graphic, which is around how those, the lack of culturally relevant assessments and interventions can reduce engagement and also negatively impact retention for those who do actually enter into services. On the right, I included a graphic of a population health approach because I think it's helpful to think about how racism and discrimination as a social determinant impacts service users across a number of different population groups. So you have the healthy population that we might offer interventions to. You have a population with risk factors. You also have a population with symptoms and a population with a known disorder. And with the folks present here, we might all be working at different parts of this continuum. And it's important to take into consideration how we approach our interventions for each of these population groups might be impacted by social determinants, but also how we conceptualize, you know, what's appropriate versus what's not might shape what we offer as interventions and might hinder folks who are actually interested in engaging in our interventions from actually benefiting from them. So with that said, I'm going to move to our case. And this is a case that's distilled from a number of different sources. So it originally appeared in a paper that focused on achieving equity and addictions. It's also informed by relationships with others in the community who are offering services, including those with lived experience to really add some texture to how social determinants impact a particular person. And also to add texture to how, as a service provider, at the provider and organizational level, we might be missing things that could have facilitated increased engagement and, of course, retention and treatment. So Bedside is a 48-year-old woman from the Dominican Republic with open-use disorder who often sleeps in Dorchester off of Washington Street. That's a neighborhood in Boston. She's presented to the area's federally qualified health center, Urgent Care, with concern for an intravenous drug use associated infection. And she reports onset of a rash with streaks two days prior and a subjective fever. And for those who are not medical, that's not good. She says, doc, it's been so hard for me with this rash. I'm worried. And the provider offers, well, I have some questions for you. I'm glad you came in to see us. The physician offers antibiotics to treat the skin rash and then astutely acquires about recent IV drug use and then says to Bedside, when I see rashes like this and marks like those, I wonder if you've been using drugs, Bedside. And Bedside offers, yes, I have. And she says, it's been so hard for me. So Bedside confirms that she's been injecting heroin on a regular basis. The admission is for her a first time sharing her drug use. She's felt significant shame and embarrassment around her use as she knows her family would disapprove and her only daughter would be disappointed. Bedside shares, I've told no one. I can't tell anyone. My life is a mess. I'm so alone and I'm scared. So she's given a referral pamphlet for the substance use disorder team and offered an intake with the Suboxone Clinic. Bedside request a pamphlet in Spanish, which is not available in the clinic. 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And it's really important that we're having this webinar that we're having this webinar because we can highlight the evidence base that we do have access to that we do have access to that shows, well, what does facilitate treatment what does facilitate treatment as far as initiation and engagement as far as initiation and engagement and then what are the possible pivots and then what are the possible pivots that we could put into place that we could put into place at the provider and organizational level at the provider and organizational level to ensure that when folks are ready to engage to ensure that when folks are ready to engage or even pre-contemplatively or even pre-contemplatively thinking about engaging thinking about engaging that we're prepared to serve them that we're prepared to serve them as ready hosts. as ready hosts. So, what I'd like to do now So, what I'd like to do now is go through a bit of is go through a bit of the literature on the next slide. the literature on the next slide. The first I'd like to talk about The first I'd like to talk about is analysis of data. is analysis of data. They interviewed folks from multiple corners. from multiple corners. Those who were practicing Those who were practicing as clinicians, those who are administrators and really connected to thinking about, for example, health plans and how health plans shape access to services. shape access to services. So, I'll start there with this reference. So, in their review So, in their review they found that there were different they found that there were different correlations between correlations between individual provider level individual provider level and environmental and health plan factors. and environmental and health plan factors. At the individual level female being female being female was associated with having more was associated with having more challenges challenges in initiating treatment in initiating treatment and sustaining it. One example or one elaboration described how or one elaboration described how females are disproportionately more likely to be caregivers of children. to be caregivers of children. So, how child care, for example, might interfere with their engaging in services. engaging in services. There was also discussion of how co-occurring conditions of how co-occurring conditions not being managed in addition to the substance use disorder could present some barriers, stigma being identified as a barrier, and also the lack of access to health care to health care and other forms of services and other forms of services as well. as well. At the provider level, At the provider level, which is very salient, which is very salient, I'm sure to many of us here, I'm sure to many of us here, we're dealing with workforce shortages. workforce shortages. Where we work and our practice type and our practice type can determine whether or not folks will have access to us. folks will have access to us. Do we accept cash only? Do we accept cash only? Are we only accepting privately insured or are we open to those who have Medicaid? Are we open to those who have Medicaid? for example, to proper screening and intervention. And then often in relationship to SDOH, social determinants, there's not always enough resources available for us to loop others in, such as community health workers, to support addressing those challenges. As far as environmental and health plan factors, something that we don't often talk about, but really you see this as you're trying to refer folks to other types of treatment, there's a shortage of residential treatment beds. It's how much those other services, such as IOPs and PHPs, partial programs are covered, can vary. The duration of your treatment can vary based on your type of insurance. Some Medicaid programs do not cover residential treatment at all. The insurance reimbursement rates can disincentivize referrals to certain services or accepting certain types of patients based on coverage. And we're also dealing with low reimbursement rates. So for folks who want to offer peer support and recovery specialists, there's a question of whether or not that will be a reimbursed service. And of course, if it's not reimbursed, then you have to figure out financially how, as an organization, you can offer that by eating the cost. Next slide. So the second reference I want to introduce is focused on a systematic review of really a wealth of literature detailing what are some of the barriers and what are some of the facilitators. And I'm going to pull out some that are relevant to Bedsida's presentation. So at the individual level, we saw with Bedsida that there was a belief about treatment that influenced how she engaged that could have been directly addressed, such as believing that the treatment is not necessary or having particular beliefs about the type of intervention being offered, such as medication. There were also family factors that were mentioned, such as how family members might respond to her condition and also to her accessing treatment. Stigma was involved as well. And she also expressed some symptoms that might be reminiscent of a psychiatric comorbidity that could have been addressed as well, for example, by connecting her with an integrated behavioral health clinician to explore that further or the provider themselves exploring it with her. There were also problems with what was supposed to be the team and how they interacted with Bedsida in ways that were not kind or generous or compassionate, I'm sure, for a number of different reasons, such as the workforce shortage and collective burnout that many of us are experiencing. Also, there were some fears that were expressed by Bedsida as well that shaped how much she was able to feel comfortable or safe in that context. Next slide. Continuing with some more of the structural characteristics of Bedsida's case that are connected to the systematic review, there are exclusionary attitudes that are experienced by service users who are trying to engage in services. And that, of course, can affect how much they engage. How much of a harm reduction focus is available is important to think about, too. Bedsida was not at some point interested in the treatment being offered and may have been open to or receptive to harm reduction conversations across the spectrum of folks that she had interacted with. And finally, though she did identify some SDOH concerns, her social determinants were not directly addressed in the interaction. Next slide. Fortunately, though, we do have some evidence-based supporting us and pivoting towards the kinds of things that can help us more successfully engage BIPOC who are trying to initiate treatment and remain in treatment. And some of the things that you see here are identifying for the service user what are their motivations for treatment, connecting their family if they're open to that, to their treatment experience, which I found to be very helpful. Really thinking about how the team collectively is approaching the service user, what's their experience when they walk through the door, when they're placed in the waiting room, when they're coming back with a nurse. All of us considering ourselves a part of creating that therapeutic space for a service user can be very helpful. And then there's some structural considerations as well, such as how we're trained, the logistics of our programming, and also how we're connected to other types of organizations that might support the work that we do, such as connected to peer support. For example, how are we relating to the security presence we have in our building and things of that nature. Next slide. So I'm going to go through now some examples of how an organization might approach its offering of services through a lens of equity-mindedness. And equity-mindedness is a concept that comes from a university in California who discussed this in relationship to how an educator might approach their classroom. And I've taken that equity-mindedness concept out of the classroom and applied it to healthcare. So these are some examples of how you might become equity-minded. Equity-minded essentially means that you're shifting from thinking about offering everyone the same thing and really thinking about offering folks what they need in a way that's informed by the historical arc of their experiences and also their present-day context, taking all of that into consideration. So as far as what you might do around improving access, there can be attention paid to the times of day that services are offered so that folks that work multiple jobs or late shifts can have the time necessary to come and access the service. You can think about targeted marketing and advertising to racially minoritized communities. If we don't see ourselves in a service being offered, that can disincentivize us from presenting. And we're thinking about that very explicitly at my own health center, because we have seen that there's a disproportionately higher number of folks accessing our buprenorphine products who are white, despite living in an area where we serve majority patients who are black and African-American. So there's something there about our marketing that has to be addressed. As far as referring folks out to programs, we might be looking for scholarship programs so that class or access to wealth is not the only thing determining how good or quality treatment can be. And we also can be very transparent about how we recognize how racism, how other social determinants of health do impact our service users' lives and the need for us to address that in the work that we do. Next slide. As far as the intake, I've heard a lot about this from folks who've been in these treatment settings. It is clutch. It is the place that we really make a case for a person around how they will be treated from that point forward. So it's important, for example, to ensure that our screenings are comprehensive and include attention being paid to social determinants and also specifically make use of tools that are available. The structural vulnerability tool is a great one. It also asks in that tool about potential for discrimination. So it broadens the conversation to be inclusive of other types of social determinants. There also should be screenings specifically around how discrimination and mistreatment can be connected to use of substances and also to their experiences within treatment settings. And we should be collecting data that's disaggregated that helps us, as Dr. Talley showed us, to see that there are differential experiences in different settings and also differential experiences out there in the community. Next slide. As far as engagement, again, it's important to ask service users about how they are experiencing our services. We've done that at my health center through the grant. And to expand that to asking about how they are being treated in the actual program itself. It's also important to think about how we connect with those who use our services and to ensure that we're thinking about shared decision making, that we're incorporating our knowledge of concepts such as implicit bias into the actual application of debiasing skills, that we're thinking about concepts like racial anxiety or racial stereotype threat to ensure that we're connecting with service users no matter what background they come from or walk of life. It's also important to touch the expertise found within lived experience and also communities to make sure that we're creating programs that are relevant to those who are deserving of them. Next slide. Just a plug here for cultural sensitivity and responsiveness. This is a SAMHSA tip on cultural competency, a really beautiful resource. I believe it's around 350 pages that has a lot of information about how this could be done generally. Next slide. Some specific recommendations would be, again, addressing concerns for discrimination that does occur in treatment settings by offering a process for service users to report those experiences. I have these conversations a lot with service users around how they might navigate discriminatory experiences in treatment settings on top of navigating the recovery. It's also important to offer people information about where they can go, that they can be handed and make use of and maybe share with others in community with them. Then we need to attend programming outside of even listening to folks like myself and Dr. Talley, intersectional programming that is informed, again, by lived experience so that we can increase our knowledge base and skillset even outside of what's being offered in these formal spaces. Next slide. In addition to that, we definitely need to increase the racial literacy of staff and leadership to address racism specifically as a social determinant. We need to train staff and leadership to recognize and respond to how racism shows up in our treatment settings, and we need to make sure that as administrators and leadership, we're exposing ourselves to the kinds of diversity of experiences that can help us to shape the ways that we approach the decision-making that we have around what we discuss during case reviews, what we discuss during multidisciplinary team meetings. Next slide. It's also important that we know the data. Dr. Talley mentioned this data. Not everyone's aware. It's important that we think about our assumptions, about why the data is the way that it is, that we think about the stereotypes that we've absorbed over time, and that we're having open conversations with each other and our organizations around how all this connects to what we do. It's important to treat the service user as an expert in the relationship. Of course, that brings value to how we come up with our services and how we deliver with that one person a relationship that can promote their retention. It's also important that we out loud say, this is not an add-on, this is not extra, this is a professional competency. Cultural sensitivity and responsiveness has to be something that's baked into what we do. Next slide. Policy interventions are essential as well. As you saw, there are things outside of an organization that influence what we're able to do as both service providers, administrators, researchers, et cetera. Really paying attention to what's happening in the policy space is important. One is crisis services are being revisited, specifically in how they're experienced by racially and ethnically minoritized persons who are experiencing distress. There's some creativity around making those services more trauma-informed, including by the removal of a law enforcement presence at all. Paying attention to that is important locally. It's also important that we are tapped into local ways that community members are being invited to and listened to in ways that inform how we think about what disparities are happening in our communities, how we erect or dismantle some of the barriers to care, how we might suggest policy changes not informed just by the literature, but also the community voice, and how we might hold ourselves as stakeholders and others accountable. It's also important, and this is specifically speaking to public sentiments, that we continue to highlight how social determinants affect relationships with substances and, of course, influence who and how severely communities develop substance use or persons develop substance use disorders. That can help address public misunderstandings and misconceptions about substance use disorders and really facilitate maybe more supportive policies that would help us to do our jobs more effectively. Finally, telehealth is amazing. Any threat to telehealth or telemedicine is a threat to equity, so definitely being involved and speaking up on behalf of keeping those services in place would be important. And then finally, accessing or even requiring in a local way or a state way that there are needs assessments done around how services are offered, that the needs assessments are specifically looking at differential experiences, and then really being inclusive of community members to make sure that we're choosing the kinds of problems and solutions that are most directly connected to their concerns. So with that said, we have some references for you all, and as has been communicated in the chat, we will be sharing the slides. So what we're going to do now is transition to the Q&A. Thank you so much, Dr. Isom. I'm just going to add some spotlights, and we're going to move on to our Q&A section. Thank you so much, Dr. Talley and Dr. Isom, for such a comprehensive and informative presentation. I'm seeing a lot of love in the reactions. With that, we're ready to move on to take questions from the audience. So we have gotten some questions that have come in, so I'm going to kick things off, and this is aimed at either of you, whoever wants to take a stab at it, but is racism a social determinant of health? If so, should we be asking clients about how racism may or may not be impacting their lives? I will hop in and say yes and yes, to keep it brief, but absolutely, and again, I'll point folks on the call to that book, The Social Determinants of Mental Health, edited by Drs. Compton and Shim, has a whole section on the impact of discrimination on poor mental health outcome, and I would say absolutely, that this is, we can, if we sweep this under the rug and don't ask patients about this experience, we don't offer that invitation of this experience is important, and I understand that it impacts, potentially, your psychological well-being. So I think those are absolutely important questions to answer. All in agreement, Dr. Isom? Yes, 100%, and I think this is where the skill development piece comes in, because there is a conspiracy of silence around talking about racism and other forms of discrimination, so there's definitely some skill development that is accessible that can help open the floor for that conversation to be had, and I know service users want to have the conversation, however, there has to be a proper container for it, so I would encourage folks to seek out some guidance on how to do that well. Awesome, thank you. All right, next, we had a question about how can we reduce stigma among providers and apply an anti-racist approach in our practice? Yeah, I think it's interesting, the stigma question, especially with the recent removal of the X waiver requirement, it's less possible to say that's not something I do, because we can all do it, technically, with less of a barrier to actually engaging. I think even for, I'll say for my health center, there's a question around what does it mean that we have a substance use disorder team, and how might we shift the way that we even characterize where folks can go for access to screening and treatment? I think that language shift could be helpful. I also think having honest conversations amongst ourselves about how we as providers experience working with folks who do have substance use disorders would be really helpful. So I'll say from the grant that I'm doing at my health center, we are having conversations that allow us to be transparent, vulnerable, honest, and reflective about how our training, about how our upbringing, our socialization shapes how we view folks that make use of drugs generally, and specifically those that have substance use disorders. And I think bringing this language to life through narratives, through case examples, can help to humanize the drug user or the person with a substance use disorder in ways that might address that stigma as well. The other question's a big question. I'll pass the mic to Dr. I'm sorry, Quil, could you repeat the second part of the question for me? Yeah, of course. So how can we apply an anti-racist approach in our practice? Right, right. And this is where the rubber meets the road in terms of explicitly addressing inequity. I think the first question is, are you looking for it in a data-driven way, proactively? That I think it's important for us to almost assume that there are disparities and inequities baked into the fabric of every aspect of an organization that we work in. And so one option that I will put in a little plug for is the Self-Assessment for Modification of Anti-Racism tool, which is a tool that I helped to develop with the American Association for Community Psychiatry. I will say, my bias as a co-creator aside, that there are many excellent tools like this out there that can really give you a structured way of thinking about inequity from a quality improvement lens, and really taking a step back and thinking about issue by issue, whether it's treatment engagement, whether it is no-show rates, whether it is retention and treatment, whether it is the access to particular types of treatment. Are you looking at your data and seeing, do I see disparities? Are you asking questions about what could be driving that disparity in the first place? Are you thinking about what are the processes we have in place to start to try to address and ultimately eliminate those disparities? And so I'd say, to me, the most important thing is to be systematic, to be data-driven, and to be committed in a sustained way to seek out inequity as it may be popping up in the ways in which an organization operates, and then apply a quality improvement framework to really think about how are we trying to make measurable, concrete change with accountability as far as returning back after a couple months, whatever it might be, of trying to make a change to see, are we seeing a difference? Are we making a difference? Do we need to change our approach? So I think thinking about, I think often inequity is not given that data-driven, rigorous lens that it should be given as far as thinking about these issues. Right. Awesome. Thank you. So this question, Dr. Isom, I think really aligns with the case study that you had for us today. So what recommendations do you have for education for low literacy populations who don't speak English to make medications for opioid use disorder more accessible? Yeah, I think this is an example of where a consultation could be really helpful. And by consultation, I mean aligning with folks who have that expertise, which might come from the public health space around how do we tailor our materials to support any person in making a decision about a healthcare-related need. We say shared decision-making, however, we often don't, and I said we, we often don't tailor our approach to that shared decision-making, taking into consideration those who have English as a second language and or who have low health literacy. So in the communication-related, the communication-related decision-making space, there are graphics that can be created by folks with expertise that help those making decisions to understand what their options are, what the risks are of a certain choice, how they might think through their values to inform the ultimate decision that they make. Those kinds of tools I haven't seen since my public health year. So I saw them in an educational space. They're accessible in other spaces. So for example, people making decisions around some chronic medical conditions, but it would be really lovely to have a consultant-informed creation of those same tools for having these conversations as well. So it's a great question and also an unmet need at this time. Thank you. All right. Moving on to another question. I think this one's great because as we know, the workforce, especially the healthcare workforce definitely expands beyond just providers. So what can lower-level clinical staff do in environments where we cannot control the policy and program design and upper management is ignorant of or even hostile towards anything beyond vague DEIV statements? This is a tough one. I will first say kudos to folks on the front lines who are fighting that battle because it's like that sort of advocacy is hard where you're in a position where potentially it's your folks in the supervisory level, folks who have that control over the work and your livelihood who are not listening, who are not paying attention. Something I might suggest is there's a possible mechanism to get feedback in an organized fashion directly from your clients and the populations that you serve about these issues. I think that can be incredibly powerful because while an organization, sometimes an organization that is somewhat hostile to these issues may not be readily responsive to its own employees, one set of folks that they are typically accountable to is the clients and patients that they are serving. And so considering any form of mechanism for some form of anonymous survey, town halls, focus groups, anything where you can find ways to sort of gather feedback from patients themselves about a feeling of hostility, of stigma, of bias, of discrimination, as far as their experience in the clinical setting, that's one approach that I might suggest as far as tackling that and kind of giving the evidence from the folks whose satisfaction you are charged with addressing. Yeah, it's really tough. I think it would be helpful to consider even a different term, I think, than lower differential access to power and influence maybe in the organization to highlight that there's a lot of different types of power too. So I'll say there's things that my community health worker team member can effectively do that I cannot as a psychiatrist, even though categorically one would conclude I have more power and influence. The other thing I'll say is sometimes administrators need to hear what's in it for me and performative DEIB is not sufficient. So there might be a highlighting of the cost and the cost might be even financial. What is the financial cost of not transforming our services in such a way that we're able to attract more people to our business? That's not a moral argument. However, sometimes it takes a bit of creativity around what kind of strategy you use in communication. But definitely figuring out what's in within your locus of control is something I do all the time because I need to know what I can do and I might be able to influence people around me in ways that don't require support from the powers that be. So good luck to you. All right, thank you so much to the both of you. That is all the time we have for questions today. So again, I'd like to thank Dr. Talley and Dr. Isom for presenting today. We are so appreciative of your willingness to share your knowledge and expertise with everyone. We have a few more slides to close out. But as a reminder, the recording and slides will be posted on the PCSS website within two weeks from today. I'd like to make you aware of two resources offered through PCSS that may be of interest to you. First, the PCSS Mentor Program is designed to offer mentoring assistance to those in need of more one on one interactions with one of our colleagues to address clinical questions. You have the option of requesting a mentor from the mentor directory or PCSS can pair you with one. For more information, please visit the PCSS website noted on this slide. Second, PCSS offers the discussion forum comprised of PCSS mentors and other experts in the field to help provide prompt responses to clinical cases and questions. There is a mentor on call each month who is available to address any submitted questions through the discussion forum. You can create a new login account by clicking their image, clicking the image on the slide to access the registration page. This slide lists the consortium of elite partner organizations that are part of the PCSS project. Finally, the PCSS website, contact info and social media handles are listed here if you would like to find out more about the resources and trainings offered. Thank you all again for joining our webinar today and we hope you have a great rest of your day and week.

Social Determinants of Health

Opioid Use Disorder

BIPOC Communities

Providers Clinical Support System

National Council for Mental Wellbeing

Housing

Employment Status

Disparities in Treatment

Cultural Sensitivity

Anti-racist Approach