Introduction

Substance abuse is being increasingly appreciated for contributing to overall mortality and morbidity in the United States. Yet, at the same time, substance use continues to be criminalized, especially for African Americans. Disparities in morbidity and mortality across ethnic groups continue to persist. Mortality rates for African Americans are about 1.6 times higher than those for whites, with much higher disparities for certain causes, such as HIV/AIDS and diabetes. A major factor in the disparities is the consequence of use of drugs of abuse. However, the problem is not simply excess of use by minorities. Disparities exist in the level of substance use and abuse but the greatest impact is from consequences resulting from the lack of access to treatment.

Substance abuse is perceived as being more common among African Americans, yet that is often not the case. Among ethnic minorities, drug abuse has been shown in repeated studies to disproportionately contribute to individual, family, and societal burden. Moreover it also complicates mental disorders and contributes to the spread of chronic disorders such as HIV/AIDS and hepatitis C infection, which also disproportionately affect African Americans. African Americans have less treatment access and disproportionately face punitive interventions such as the correctional system. More needs to be done to recognize and address the misconceptions and disparities in care seen with African Americans.

Epidemiology

We and others reported that after adjustments, both African Americans and Caribbean blacks had a lower lifetime likelihood than non-Hispanic whites of having any Axis I substance abuse disorder, including alcohol abuse, alcohol dependence, drug abuse, drug dependence, and nicotine dependence. Dr. Dan Blazer reported that “There’s a perception among many individuals that African Americans as a group—regardless of socioeconomic status—tend to abuse or use drugs at higher rate and this [does not support] that.” He reported that young African Americans were less likely than whites to use drugs and less likely to develop substance use disorders. Another study, a 12-year longitudinal study, showed that the rates of hard drug abuse were highest among non-Hispanic whites, followed by Hispanics and then African Americans. Whites were more than 30 times likely to have cocaine-use disorder, 50 times more likely to develop opiate-use disorder, and 18 times more likely to have PCP-use disorder than blacks. Dr. Teplin, the principal investigator, noted that “Those findings are striking considering the widely accepted stereotype of African-Americans as the most prevalent abusers of hard drugs. Our findings add to the growing debate on how the war on drugs has affected African-Americans.” She is referring to the ongoing problem that was precipitated by the War on Drugs. African American youth are arrested for drug crimes at a rate 10 times higher than that of whites. Moreover nearly one in three black men will be imprisoned, and nearly half of black women currently have a family member or extended family member who is in prison. In addition, this overrepresentation of African Americans in the correctional system has long been noted and is not helped by the misconception that African Americans are more likely to be addicts. War on Drugs policing has failed to reduce domestic street-level drug activity. The cost of drugs remains low and drugs remain widely available.

The issue of cocaine use remains problematic in the African American community but has been exacerbated by correctional system involvement. Crack cocaine is more commonly used than powdered cocaine by African Americans and may be related to income, since the former is much cheaper. Black males between the ages of 26 and 34 reported using crack cocaine more than any other racial and gender combination and most offenders arrested for crack cocaine are black. Because African Americans make up the majority of most crack cases, they are more likely to receive the mandatory minimum prison sentencing more than any other ethnicity. Drug trafficking, the availability of crack, and the Federal Anti-Drug Abuse Act led to mandatory minimum prison sentencing of dealers, which has been a controversial issue. Originally the sentencing for crack versus cocaine was 100:1, meaning the amount of crack versus the amount of powder cocaine needed to establish a mandatory minimum prison sentence. Driving the disparate sentencing was the increased homicide rate in the African American community during the 1990s. Homicides increased among African Americans when crack cocaine was popular but decreased with the decline of crack cocaine and crack cocaine consumption in recent years. It is important to note that the violence associated with crack cocaine is probably not linked to the psychopharmacological effects of the substance, as much as it is to the crack cocaine distribution in neighborhoods that are stricken with poverty and economic disadvantages, along with distribution competition. Most importantly, differential sentencing did not lead to improvement in quality of life in African American communities.

Since 2000 there has been a shift in focus on eliminating the additional sentencing for crack cocaine and a shift to the use of treatment. This shift was prompted by findings that tended to show that the mandatory minimum prison sentencing was racially motivated and specifically targeted blacks. Moreover, mandatory sentencing did not reduce the amount of drug trafficking into the United States. Instead it turned state-level offenses into federal crimes, created strain on families by imprisoning violators for long periods, and impacted minorities, resulting in vastly different sentences for equally blameworthy offenders. ” As noted earlier, non-Hispanic whites are now more likely to abuse hard drugs, such as cocaine or opiates, than their black counterparts, and by a substantial amount.

Racial differences have been seen in opiate use, but the increasing use in nonminorities and overall death rate have overshadowed these disparities. Major cities are experiencing hundreds of overdose deaths every year. What changed about US heroin consumption to make it more dangerous? Analyses of market trends have repeatedly demonstrated a relationship between the price of an item and demand for it, and a similar relationship exists between heroin price, consumption, and associated dangers. Moreover, a major goal of drug supply control efforts is to increase the street price of a drug by shifting the supply curve; this in turn reduces the quantity demanded by consumers as the market reaches a new equilibrium.

In addition there has been a shift in who is abusing opioid. Whites and Native Americans have experienced the largest increase in death rates, particularly when it comes to opioid-related fatalities. Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin). The Centers for Disease Control and Prevention (CDC) analyzed recent multiple cause-of-death mortality data to examine current trends and characteristics of drug overdose deaths, including the types of opioids associated with drug overdose deaths. During 2014, a total of 47,055 drug overdose deaths occurred in the United States, representing a 1-year increase of 6.5%, from 13.8 per 100,000 persons in 2013 to 14.7 per 100,000 persons in 2014. The rate of drug overdose deaths increased significantly for both sexes, persons 25–44 years of age and ≥55 years of age, non-Hispanic whites and non-Hispanic blacks, and in the Northeastern, Midwestern, and Southern regions of the United States. Rates of opioid overdose deaths also increased significantly, from 7.9 per 100,000 in 2013 to 9.0 per 100,000 in 2014, a 14% increase. Individuals who began using heroin in the 1960s were predominantly young men (82.8%; mean age, 16.5 years) whose first opioid of abuse was heroin (80%). However, more recent users were older (mean age, 22.9 years) men and women living in less urban areas (75.2%) who were introduced to opioids through prescription drugs (75.0%). Whites and nonwhites were equally represented in individuals initiating use prior to the 1980s, but nearly 90% who began use in the last decade were white. Although the high produced by heroin was described as a significant factor in its selection, it was often used because it was more readily accessible and much less expensive than prescription opioids.

Fentanyl is a synthetic and short-acting opioid analgesic, is 50–100 times more potent than morphine, and is approved for managing acute or chronic pain. Increases in fentanyl deaths were driving the increases in synthetic opioid deaths in six states. Among high-burden states, all demographic groups experienced substantial increases in synthetic opioid death rates. Increases of >200% occurred among males (227%); persons aged 15–24 years (347%), 25–34 years (248%), and 35–44 (230%) years; Hispanics (290%), and persons living in large fringe metro areas (230%). The highest rates of synthetic opioid deaths in 2014 were among males (5.1 per 100,000); non-Hispanics whites (4.6 per 100,000); and persons aged 25–34 years (8.3 per 100,000), 35–44 years (7.4 per 100,000), and 45–54 years (5.7 per 100,000). Note that in contrast to public perceptions, the highest rates were NOT in African Americans. Drug overdose is now the leading cause of unintentional death nationwide, driven by increased prescription opioid overdoses. Although African Americans are not the heaviest abusers nationally, drug abuse remains a problem in many communities. In San Francisco, for example, from 2010 to 2012, 331 African Americans died of accidental overdose caused by opioids (310 involving prescription opioids and 31 involving heroin). The deaths were concentrated in a small, high-poverty, central area of San Francisco and disproportionately affected African American individuals. Nevertheless the news media and intervention programs have focused on non-Hispanic whites.

Racial differences in alcohol abuse have also been reported, but again African Americans are not the heaviest abusers. Compared to European Americans, African Americans report later initiation of drinking, lower rates of use, and lower levels of use across almost all age groups. However, African Americans are more likely to have negative health-related and socioeconomic consequences, as is true for other drugs of abuse. African Americans are more likely than European Americans to encounter legal problems from drinking, even at the same levels of consumption. African American culture is characterized by norms against heavy alcohol use or intoxication, which probably protects against heavy use but also provides within-group social disapproval.

Marijuana use and consequences are complicated by cultural issues in the African American community, as are other drugs of abuse. As noted earlier, multiple studies have shown that African Americans are less likely to use cannabis. More recent studies, however, have shown an uptick in cannabis use. Part of the issue may be a result of the increasing diversity of African Americans. We reported earlier that differences exist in mental disorders and substance abuse with African Americans and Afro-Caribbeans. Another study of noninstitutionalized Caribbeans living in the United States, Jamaica, and Guyana revealed that substance use and other physical health conditions and major depressive disorder and mania vary by national context, with higher rates among Caribbeans living in the United States, but lower rates of cannabis use. Context and generation status influenced health outcomes and drug use. The results of this study support the need for additional research to explain how national context, migratory experiences, and generation status contribute to understanding substance use and mental disorders and physical health outcomes among Caribbean first generation and descendants within the United States, compared to those remaining in the Caribbean region.

Consistent with other drugs of abuse, African Americans have higher marijuana arrest rates than those for whites. Arrest data in New York indicated that during the 1990s the primary focus of policing became smoking marijuana in public view. By 2000, smoking marijuana in public view had become the most common misdemeanor arrest, accounting for 15% of all NYC adult arrests and rivalling controlled substance arrests as the primary focus of drug abuse control. Moreover, most arrestees were African American or Hispanic, and they were more likely to be detained prior to arraignment, convicted, and sentenced to jail than their white counterparts.

Although the benefits and safety of marijuana have been promoted in recent years, this has increased health as well as legal risks for African Americans. Heavy or chronic cannabis use is associated with a wide range of health-related conditions, such as motor vehicle injuries, cognitive impairment, chronic bronchitis symptoms, and cardiovascular diseases, which may exacerbate the disparities in health-related problems seen in African Americans. To date, 33 states and the District of Columbia currently have passed laws broadly legalizing marijuana in some form. As the wave of state-specific policies on cannabis legalization continues to spread across the nation, they could have unintended consequences (e.g., an increase in supply or use-related problems) with lasting implications for the health and social systems of racial and ethnic minorities.

There has been an emergence of synthetic cannabinoid use. Synthetic cannabinoid receptor agonists (SCRAs), also known as “K2” or “Spice,” have drawn considerable attention due to their potential for abuse and harmful consequences. The most frequently mentioned effects were “getting high” (44.0%), “hallucinations” (10.8%), and “anxiety” (10.2%). Synthetic cannabinoids (SCs) are a large, heterogeneous group of chemicals that are structurally similar to δ-9-tetrahydrocannabinol. Many are high-efficacy full agonists of the CB1 and/or CB2 cannabinoid receptors, resulting in a potent group of chemicals with a variety of negative health effects, including death. They are available to adolescents at convenience stores and smoke shops and on the Internet. However, little is known about the risk factors that contribute to eventual use of in adolescents, and no research has examined the psychiatric, personality, and substance-use risk factors that prospectively predict use. Thus far African Americans have been less likely to use SCs. However, these chemicals are especially tempting for African American youth because they often test negative on screens for job applicants; positive drug screens are often a challenge for inner city African Americans seeking employment.

Preventive and Risk Factors

A risk factor is gateway drugs. The good news is the lower risk of cigarette smoking, drug use, and alcohol abuse in African American adolescents. However, we also noted an uptake in marijuana use in adolescents and the increasing legalization. Although marijuana use is common during adolescence, it can have adverse long-term consequences, with serious criminal involvement being one of them, especially in African Americans. The effects of heavy adolescent marijuana use (20 or more times) on adult criminal involvement, including perpetration of drug, property, and violent crime, as well as being arrested and incarcerated, was examined in the Woodlawn study, a longitudinal study of African Americans through the lifespan. Heavy adolescent marijuana use led to drug and property crime and criminal justice system interactions, but not violent crime. The significant associations of early heavy marijuana use with school dropout, and the progression to cocaine and/or heroin use only partially account for these findings. Nevertheless, these results suggest that the prevention of heavy marijuana use among adolescents could reduce the perpetration of drug and property crime in adulthood, as well as the burden on the criminal justice system, but would have little effect on violent crime.

In another study adolescent regular smokers also showed significantly higher odds of using marijuana, cocaine, and heroin, having alcohol abuse problems and any drug dependence, and abuse problems in adulthood. Educational attainment mediated most of the drug progression pathway, including cigarette smoking, marijuana, cocaine and heroin use, and drug dependence or abuse problems in adulthood, but not alcohol abusers. Thus the benefits of not being early smokers in African Americans may be offset by high school dropout rates and other educational challenges.

Contextual factors are increasingly prominent in studies of illegal drug use in the United States. Studies suggest, for example, that neighborhood economic disadvantage predicts illegal drug use, and that local social disorder and unemployment rates predict the prevalence of injection drug use in metropolitan areas. Preventive efforts for African Americans therefore must focus on these important socio-environmental factors that are prevalent in many African American communities. These factors extend to the health consequences of drug use. African Americans were more likely to be HIV-negative and drug free if they lived in less economically disadvantaged counties, or in communities with less criminal-justice activity (i.e., lower drug-related arrest rates, lower policing/corrections expenditures).

These types of observations can be extended to alcohol use. Use of alcohol treatment may be affected by factors such as trends in public knowledge about treatment, social pressures to reduce drinking, and changes in the public financing of treatment. As noted previously, within-group social disapproval also plays an important role in the lower risk of drinking in African American youth.

An adverse family environment in late adolescence was found to be related to greater marijuana use in emerging adulthood. This in turn was positively associated with partner marijuana use in young adulthood, which in turn, was ultimately related to maladaptive behaviors in adulthood. An adverse family environment in late adolescence was also related to greater marijuana use in emerging adulthood, which in turn, was associated with an adverse relationship with one’s partner in young adulthood. Such a negative partner relationship was related to maladaptive behaviors in adulthood. The findings suggest that family-focused interventions should be considered.

Community violence, witnessing of violent crime, and victimization has been an ongoing problem in low-income African American communities. One longitudinal study examined the interrelationship among victimization, posttraumatic stress disorder (PTSD), and substance use in African Americans; victimization at ages 19, 24, and 29 was directly associated with substance use at age 36 and was also related to PTSD at age 36. PTSD, in turn, was related to substance use at age 36. This study indicated the importance of intervention for those who have been victimized, with a focus on PTSD treatment. In addition, in another study, youth with greater exposure to violent victimization were 3.89 times as likely to initiate marijuana first than to initiate tobacco first. African American youth and youth with greater exposure to victimization had an increased risk of initiating marijuana before tobacco. Substance use prevention efforts should consider taking into account that marijuana use may put certain youth at risk of initiating tobacco use. Future research needs to monitor sequencing as well as risk factors for and consequences of the various patterns, particularly because marijuana use and the mixing of tobacco and marijuana use are gaining acceptability in general populations and the African American community, which historically have been at lower risk.

It has been reported that African American youth are significantly more religious than white and Hispanic youth, which could explain the lower rates of drug use. However, more recent studies have found that religion does, in fact, protect African American and Hispanic youth from substance abuse, but the strength of this relationship is greater for white than for non-white youth. The reasons for racial and ethnic differences in the strength of the relationship between religiosity and substance abuse are not clear. One possibility is that religiosity may be more of a cultural or group phenomenon among non-white youth, whereas among white youth it may be more of an individual factor affecting individual behavior such as substance use. Understanding the mechanisms by which religion might influence substance use and the reasons that these mechanisms may vary by race and ethnicity may provide clues to implementing effective prevention programs.

Impact on the Individual

As noted previously, drug abuse adversely affects health outcome irrespective of race. African Americans, however, seem to be more adversely affected and have worse social and health care outcomes. A study examined a nationally representative sample of whites, African Americans, and Latinos and predicted expenditures for each racial/ethnic group. African Americans required more expenditures because of the greater health consequences.

The problem of increased risk of incarceration in African Americans for drug use was noted earlier in this chapter. Recent incarceration independently predicted worse health outcomes and greater use of emergency services among HIV-infected adults currently in HIV care. Options to improve the HIV continuum of care, including preenrollment for health care coverage and discharge planning, may lead to better health outcomes for HIV-infected inmates postrelease.

Consistent with other studies, significant racial-ethnic disparities were seen in opioid prescriptions, with non-Hispanic African Americans being less likely to receive opioid prescription at discharge during emergency department visits for back pain and abdominal pain, but not for toothache, fractures, and kidney stones, compared to non-Hispanic whites after adjusting for other covariates. Differential prescription of opioids by race-ethnicity could lead to widening of existing disparities in health, and may have implications for a disproportionate burden of opioid abuse among whites.

Experiences of discrimination in health care settings may contribute to disparities in mental health outcomes for African Americans and Latinos. Perceived discrimination in mental health/substance abuse visits was found to contribute to participants’ ratings of treatment helpfulness and led to stopping treatment. The most commonly reported reasons for health care discrimination were race/ethnicity for blacks (52%) and Latinos (31%), and insurance status for whites (40%). Experiences of discrimination in mental health/substance abuse visits were associated with early treatment termination for African Americans. Experiences of discrimination are associated with negative mental health/substance abuse treatment experiences and stopping treatment, and could be a factor in mental health outcomes.

A review and critique of empirical research on perceived discrimination and health suggested that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway, and this research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.