The Review of Black Political Economy

, Volume 37, Issue 1, pp 7–23

Can Cultural Competency Speak to the Race Disparities in Methadone Dosage Levels?

Authors

    • The Robert Wood Johnson Foundation (RWJF) Center for Health Policy at Meharry College (MMC)
  • Nadine J. Barrett
    • Institute for Health, Social, and Community ResearchShaw University
    • Department of SociologyUniversity of Central Florida
  • DaJuanicia N. Holmes
    • Institute for Health, Social, and Community ResearchShaw University
Article

DOI: 10.1007/s12114-009-9052-4

Cite this article as:
Howard, D.L., Barrett, N.J. & Holmes, D.N. Rev Black Polit Econ (2010) 37: 7. doi:10.1007/s12114-009-9052-4
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Abstract

Although national methadone treatment trends have improved substantially from 1988 to 2001, current research has found that African Americans still receive lower dosages of methadone treatment than their white and Hispanic counterparts, which has significant public health concerns. We sought to empirically examine whether the degree of cultural competency within an outpatient substance abuse treatment (OSAT) organization has influence on the methadone dosage levels received by African Americans in 1995 and in 2005. The 1995 and 2005 National Drug Abuse Treatment System Survey (NDATSS) provided a nationally-representative, stratified sample of 618 and 566 OSAT organizations, respectively, of which 121 and 140 affiliated methadone maintenance treatment programs, respectively, were analyzed. The organizations’ director and clinical supervisor were surveyed. Fixed-effects linear regression models were fitted with measures of cultural competency, client, and organizational characteristics to assess methadone dosage levels. Culturally-competent units have smaller numbers of methadone clients, greater percentages of clients who receive methadone dosages of less than 40 mg/d, smaller percentages of clients who receive methadone dosages of 80 mg/d or more, and provide a larger number of therapeutic and ancillary services during treatment than non-culturally-competent units. OSAT units with more African Americans are significantly more likely to have clients who receive dosages of less than 40 mg/d and are significantly less likely to have clients who receive dosages of 80 mg/d or more. There is no racial difference among culturally-competent unit clients who receive dosages of less than 40 mg/d, between 40 and 59 mg/d, between 60 and 79 mg/d, and 80 mg/d or more. However, among non-culturally-competent units, a racial difference exists among African Americans and other clients who receive these various dosage levels. Research indicating that African Americans receive lower dosages of methadone than their White and Hispanic counterparts may now be explained by whether these clients receive treatment in culturally competent organizations, rather than solely by arguments related to organizational differences in resources, experience and training of staff, staff bias and/or racism. Culturally competent organizations may seek a method of treatment that dissuades “replacing one drug for another,” while simultaneously treating the root cause of the addiction through the provision of comprehensive therapeutic and ancillary support services. Further research is needed to determine if cultural competency results in better substance abuse treatment outcomes for African Americans.

Keywords

MethadoneDisparityDosageAfrican-AmericansNational drug abuse treatment system survey

Introduction

Results from a national panel study indicate that the percentage of heroin addicts receiving methadone dosage levels less than the recommended 60 milligrams per dose (mg/d) has decreased from 79.5% in 1988 to 35.5% in 2000 (D’Aunno and Pollack 2002), which, on the surface, suggests a significant improvement in treatment practice. There is, however, an ongoing debate regarding what constitutes an appropriate level of methadone dosage and treatment to improve client success (Faggiano et al. 2007; Trafton et al. 2006; Strain et al. 1999). In comparing moderate and high dosages of methadone treatment, Strain et al. (1999) found that both 40–50 mg/d and 80–100 mg/d of methadone were effective in treatment retention and decreasing rates of use among heroin abusers, however, higher doses of methadone were more effective overall. Conversely, Trafton et al. (2006) found that heroin abstinence varied from 1.5 mg/d to 191.2 mg/d of methadone with 38% of their sample remaining heroin abstinent for a month while receiving less than 60 mg/d. The variation in methadone dosage level seems to suggest that treatment should be determined based on individual characteristics such as the presence of co-occurring psychological disorders or illnesses, biology and other drug interactions (Trafton et al. 2006; Marion 2005). Others argue that using methadone dosage levels as an indicator of treatment success is problematic given that for some clients higher doses of treatment can lead to a temporary “zombie” like state, which causes them to behave in a passive, trans-like manner. Moreover, clients may modify their treatment to adapt to the anxieties associated with taking medications, including methadone maintenance therapy. Clients that demonstrate these characteristics are at times said to be “compliant” with treatment protocols (Bourgois 2000; Holt 2007).

Notwithstanding the controversy of methadone dosage level, of relevance to racial disparities in treatment and subsequent health, D’Aunno and Pollack (2002) also indicated that methadone programs with a greater percentage of African American clients were more likely to dispense methadone at dosages lower than the national recommendation of 60 mg/d. More recent data suggests that this disparity worsened in 2005 (Pollack and D’Aunno 2007), which represents a significant public health concern considering that African Americans, who along with Hispanics, make up over one-third of all substance abusers in treatment (NIDA 1999).

Possible explanations regarding the racial discrepancies in methadone dosage levels have crossed organizational, social-cultural, and quasi-political lines. D’Aunno and Pollack (2002) suggest that organizational factors that include poor staffing, the inability to attract and retain well-educated personnel, the limited means to obtain educational or training materials, and the location of facilities in predominantly urban areas may be primary causes of this race disparity in treatment. Studies have also associated variations in dosage with staff’s perception of client’s compliance and behavior. Researchers assert that methadone can be a mechanism of social control for people of color and other disadvantaged populations as some clients in methadone maintenance treatment programs have no autonomy, and the power dynamics of staff over clients can explicitly impact differentials in dosage levels (Bourgois 2000; Kirdorf et al. 1998; Woods 2001). Still others speculate that methadone treatment is part of a conspiracy to aid in the genocide of people of color, by essentially replacing one drug for another (Bourgois 2000; Stancliff et al. 2002). On a similar vein, some African Americans view methadone treatment as a form of slavery, by which the government controls the lives of African Americans through medication dependency (Brown 1985), and are more likely to reject or modify methadone maintenance as a solution to drug abuse (Nurco et al. 1980; Holt 2007).

This study attempts to understand the relationship between cultural competency and methadone dosage levels that may prove important in achieving positive outcomes for African American clients in methadone treatment. Cultural competence is one of the more comprehensive and culturally responsive models used in substance abuse treatment to help dispel disparities in the broader health arena (Betancourt et al. 2003). Substance abuse treatment, when provided in a culturally competent context, is thought to be one of the best strategies for addressing the racial disparities in client services use and clinical outcomes (Howard 2003a, b; Campbell and Alexander 2002; Longshore et al. 1998). Likewise, successful methadone maintenance treatment is associated with several positive outcomes including lower likelihood of relapse, reduced recidivism in the criminal justice system, decreased HIV risk, stable housing and employment, improved quality of life, and better inter- and intra-personal relationships (White and Coon 2003). Such outcomes underscore the significance of ensuring that clients receive proper dosage levels while in treatment and accentuate a critical issue for African Americans who are receiving sub-optimal methadone treatment compared to their white counterparts. Yet, to date no studies have empirically examined the effect of cultural competency on methadone dosage levels given the disparity that African American clients experience in methadone treatment. We sought to determine whether the discrepancy in methadone treatment, in which blacks fare worse, can be explained within the context of culturally competency?

Methods

Data sources and sampling frame

The sampling frame is a composite list developed from five separate lists. These are: the 1992 Substance Abuse and Mental Health Services Administration National Facilities Register; the 1992 National Drug and Alcoholism Treatment Unit Survey; the 1994 American Hospital Association Survey; the 1994 Food and Drug Administration list of licensed methadone providers; and, a complete national database of businesses with a Standard Industrial Classification Code for Drug and Alcohol Treatment Services. These five lists were merged and duplicate listings were removed, resulting in a total of 32,927 facilities that were potentially eligible for the study. The modal reason for excluding a unit was that the majority of its clients were not treated for substance abuse problems. Units operated by the Veteran’s Administration and by jails or prisons were also excluded from eligibility. These procedures ensure that the sampling frame consisted of the most complete list of the nation’s outpatient substance abuse treatment units (Heeringa 1996).

The National Drug Abuse Treatment System Survey (NDATSS) uses a mixed-panel design, which combines elements from cross-sectional and panel designs. Originally, in 1988, 575 randomly selected treatment units agreed to participate in the study, an 86% response rate. For the 1990 survey, participating units from 1988 were re-contacted and of these units, 481 participated (an 88% response rate). From the 1988 and 1990 surveys, 429 units remained eligible for the 1995 survey, and interviews were obtained in 387 of these units (90%). In addition to these 387 units, the panel sample was supplemented with a new randomly selected sub-sample of treatment units (n = 270). Of these 270 units, 231 (86%) agreed to participate; thus, the total nationally representative, stratified sample in 1995 consisted of 618 units. The 2000 NDATSS included a special managed care sub-study that increased the sample size from 618 units in 1995 to 745 units in 2000. These units were retained in the 2005 NDATSS sample. A complete description of the NDATSS development, sampling design, and weighting frame has been published elsewhere (Adams 2005).

The unit of analysis for this study is an outpatient substance abuse treatment (OSAT) unit, which is defined as a physical facility with resources dedicated primarily to treating individuals with substance abuse problems (including alcohol and other drugs) on an ambulatory (non-residential) basis. In 1995, among the 618 OSAT units, only 125 provided methadone maintenance treatment (MMT) programs. Of the 125 units that provided MMT programs, 123 units had non-missing values for the methadone dosage levels. In 2005, among the 566 OSAT units, only 154 provided methadone maintenance treatment (MMT) programs. Of the 154 units that provided MMT programs, 141 units had non-missing values for the methadone dosage levels.

Both the director and clinical supervisor of each participating unit were asked to complete phone surveys. Directors provided information concerning the unit’s ownership, environment, finances, parent organizations, and managed care arrangements. Clinical supervisors provided information about staff, clients, and services. Telephone survey procedures were used that extensive research indicates produce highly reliable and valid data (Groves 1988).

Measures

OSAT unit client characteristics

The percentage of African-American clients in the OSAT unit’s MMT program was used as well as the total number of methadone clients.

OSAT unit organizational characteristics

We created a variable for type of unit ownership. We combined private for-profit ownership and private not-for-profit ownership into one group and called it private ownership. Public ownership was used as the reference group. JCAHO (Joint Commission on Accreditation of Healthcare Organizations) accreditation status was created as a yes/no variable.

For 1995, the 123 OSAT units with MMT programs were divided into two sub-groups: units that espoused a belief that African Americans need a particular treatment approach (n = 97) and units that did not, hereinafter referred to as non-culturally-competent units (n = 24), with 2 units having missing values for this belief system and not being classifiable. For 2005, the 141 OSAT units with MMT programs were divided into two sub-groups: units that espoused a belief that African Americans need a particular treatment approach (n = 114), and non-culturally-competent units (n = 26), with 1 unit having missing values for this belief system and not being classifiable.

This grouping was determined by the supervisor of the unit agreeing or strongly agreeing (based on a 5-point Likert Scale where 1 = strongly agree and 5 = strongly disagree) with at least one of two questions: (a) “Compared to Caucasians, do you agree that African Americans in outpatient substance abuse treatment need treatment by African American staff?” or (b) “Compared to Caucasians, do you agree that African Americans in outpatient substance abuse treatment need treatment by staff educated in the history of African Americans?” These two measures were used to identify whether a treatment unit had a cultural competency belief system based on the preponderance of the literature suggesting the importance of these variables to the provision of culturally competent care (Howard 2003a).

For 1995, the 97 OSAT units with MMT programs that were designated as believing that African Americans need a particular treatment approach were then divided into two sub-groups: units that actualized this culturally competent belief system through attitude, policies, and practices, hereinafter referred to as culturally-competent units (n = 19) and units that did not, hereinafter referred to as culturally-competent/non-actualizing units (n = 78). For 2005, the 114 OSAT units with MMT programs that were designated as believing that African Americans need a particular treatment approach were then divided into two sub-groups: culturally-competent units (n = 5) and culturally-competent/non-actualizing units (n = 109).

This grouping was determined by using variables within the survey that approximated as closely as possible eight of the nine cultural competency practices indicated by Brach and Fraser (2000): 1) Recruitment and retention of African American staff; 2) Immersion into another culture; 3) Training; 4) Interpreter services; 5) Culturally competent health promotion; 6) Use of community health workers1; 7) Inclusion of family and/or community members2; 8) Administrative and organizational accommodation. No variable within the questionnaire approximated the ninth cultural competency practice—coordination with traditional healers (Howard 2003a).

Availability of therapeutic and ancillary support services will be measured in two ways: 1) the aggregate number of therapeutic and ancillary support services provided at the treatment unit (maximum = 27); and 2) the aggregate total of six (6) different types of therapeutic and ancillary support services: (family services which include family therapy, parenting education, domestic violence counseling; life coping services which include employment counseling, financial counseling, entitlement assistance,3 transportation assistance, housing assistance, child care assistance; legal services which include legal services for criminal issues, legal services for domestic problems (see Footnote 3), legal services for child custody; educational services which include health education (see Footnote 3), smoking cessation,4 HIV prevention, women’s issues (see Footnote 3), and family planning; preventive medical care services which include physical examinations, HIV testing, TB screening, screening for hepatitis (see Footnote 4), sexually transmitted disease testing (see Footnote 4), routine gynecological examinations, PAP smears (see Footnote 4) and pregnancy testing; medical treatment services which include routine medical care, TB treatment, HIV acute care, mental health treatment, prenatal care, and postpartum care (see Footnote 3)).

Dependent variables

The percentages of clients in the treatment unit that received methadone dosages less than 40 mg/d, between 40 and 59 mg/d, between 60 and 79 mg/d, and 80 mg/d or more were used. Organizational respondents to the survey were instructed to only include clients that received the same size dose of methadone for at least two weeks when responding to questions pertaining to methadone dosage levels.

Analytic approach

Fixed effects linear regression models were fitted with variables pertaining to cultural competency, JCAHO accreditation, unit ownership type, and total number of methadone clients in the unit as independent variables and receiving methadone dosages of less than 40 mg/d, between 40 and 59 mg/d, between 60 and 79 mg/d, and 80 mg/d or more as the dependent variables. Additional fixed effects linear regression models were fitted with the same independent and dependent variables listed above with the addition of the percentage of African American clients as an independent variable. Only models pertaining to methadone dosages of less than 40 mg/d and 80 mg/d or more are shown. All analyses were conducted using Statistical Analysis System (SAS) Version 9.1 (SAS Institute, Cary, NC).

Results

Table 1 shows the bivariate relationship between the independent and dependent variables and levels of cultural competency in 1995 and in 2005. There are no statistically significant differences in JCAHO accreditation, public/private ownership, or the percentage of African American clients among the OSAT units by level of cultural competency in either year. However, the mean number of methadone clients differs by cultural competency level in 1995 (p = 0.033) and in 2005 (p = 0.015). Non-culturally competent units have significantly more methadone clients than culturally competent units in 1995 (p < 0.05) and culturally competent/non-actualizing units in 2005 (p < 0.05). By 2005, culturally competent units have the highest percentage of African American clients (54.4%).
Table 1

Descriptive statistics of independent and dependent variables by year

Variables

1995 (N = 121)

2005 (N = 140)

P-Valuea (1995)

P-Valuea (2005)

Non-Culturally Competent (N = 24)

Culturally Competent/ non-actualizing (N = 78)

Culturally Competent (N = 19)

Non-Culturally Competent (N = 26)

Culturally Competent/ non-actualizing (N = 109)

Culturally Competent (N = 5)

Independent Variables

JCAHO Accreditedb N (%)

6 (25.0)

24 (30.8)c

7 (36.8)

8 (30.8)c

43 (39.4)c

0 (0.0)

0.7016

0.1737

Private Ownership N (%)

19 (79.2)

49 (62.8) c

10 (52.6)

18 (69.2)c

87 (79.8)c

3 (60.0)

0.1775

0.2258

Mean Number Of Methadone Clients

628.29

377.71

285.79 f,**

943.72 d, **

376.25

551.80

0.0329

0.0147

Mean Percentage Of Clients That Are African-American

27.33

32.96

42.16

23.65

27.24 e,**

54.40 f, *

0.1469

0.0692

Dependent Variables

Mean Percentage Of Clients Receiving Less Than 40 Mg Of Methadone

15.21

20.87

26.95

15.50

13.13

13.00

0.1022

0.6496

Mean Percentage Of Clients Receiving Between 40 Mg And 59 Mg Of Methadone

31.92

30.23

32.63

12.08 d, *

17.54

20.20

0.8472

0.0741

Mean Percentage Of Clients Receiving Between 60 Mg And 79 Mg Of Methadone

24.42

26.69

30.74

25.58

22.42 e,**

38.60

0.4353

0.0373

Mean Percentage Of Clients Receiving More Than 80 Mg Of Methadone

22.54

20.62 e,**

9.16 f,**

46.85

46.82

28.20

0.0320

0.2236

aP-values from differences between the culturally competent groups in are obtained from chi-squared tests of association and F-tests (for means)

bJCAHO (Joint Commission on Accreditation of Healthcare Organizations)

cPercent missing for all variables is less than 4%

dComputed by Tukey-Kramer Honestly Significant Difference Test (for means) or chi-square test of association and compared non-cultural competent units and cultural competency/non-actualizing units

eComputed by Tukey-Kramer Honestly Significant Difference Test (for means) or chi-square test of association and compared cultural competency/non-actualizing units and cultural competent units

fComputed by Tukey-Kramer Honestly Significant Difference Test (for means) or chi-square test of association and compared cultural competent units and non-cultural competent units

*p < .1,**p < .05, ***p < .01, #p < .001, ##p < .0001

There are no statistically significant differences in the mean percentage of clients who received lower methadone dosages of less than 40 mg/d and between 40 and 59 mg/d among the OSAT units by level of cultural competency. However, the mean percentage of clients receiving higher methadone dosages of 60–79 mg/d and 80 mg/d or more differ by cultural competency level in 1995 (p = 0.032) and in 2005 (p = 0.037). Culturally competent units have a larger percentage of clients receiving 60–79 mg/d than culturally competent/non-actualizing units (p < 0.05) in 2005 and smaller percentage of clients receiving 80 mg/d or more than non-culturally competent units (p < 0.05) and culturally competent/non-actualizing units (p < 0.05) in 1995.

Table 2 displays the fixed effects linear regression models pertaining to clients receiving methadone dosages less than 40 mg/d and 80 mg/d or more in 1995 and in 2005, while controlling for JCAHO accreditation, public/private ownership, and the total number of methadone clients. In 1995, culturally competent units are significantly more likely to have clients that receive methadone dosages of less than 40 mg/d than non-culturally competent units (p = 0.024). Moreover, culturally competent units are significantly less likely to have clients that receive methadone dosages of 80 mg/d or more than non-culturally competent units (p = 0.025). In 2005, there is no difference in the clients receiving methadone dosages between less than 40 mg/d and 80 mg/d by level of cultural competency among OSAT units. No other variables are significant in the 1995 and 2005 models. In models not shown, there is no difference in the clients receiving methadone dosages between 40 and 59 mg/d and between 60 and 79 mg/d by level of cultural competency among OSAT units in 1995. In 2005, non-culturally competent units are significantly less likely to have clients that receive methadone dosages of 40–59 mg/d than culturally competent/non-actualizing units (p = 0.014).
Table 2

Linear regression models of methadone dosage levels

Covariates

Dependent Variables: 1995 Dose Levels

Dependent Variables: 2005 Dose Levels

Patients Receiving less than 40 mg/d (95% CIa)

P-Value

Patients Receiving 80 mg/d or more (95% CIa)

P-Value

Patients Receiving less than 40 mg/d (95% CIa)

P-Valuee

Patients Receiving 80 mg/d or more (95% CIa)

P-Valuee

Intercept

13.828 (3.910, 23.75)

0.007

19.823 (9.552, 30.09)

<.001

15.032 (8.575, 21.49)

<.001

43.393 (30.45, 56.34)

<.001

Culturally competent/non-actualizing unitsb

6.1972 (−1.96, 14.35)

0.135

−0.974 (−9.42, 7.470)

0.820

−2.057(−7.49, 3.376)

0.455

−1.556 (−12.4, 9.336)

0.778

Culturally Competent unitsb

12.545 (1.643, 23.45)

0.024

−12.97 (−24.3, −1.68)

0.025

−2.674 (−14.3, 8.960)

0.650

−18.11 (−41.4, 5.209)

0.127

JCAHO Accreditedc

−4.133 (−11.1, 2.875)

0.245

5.2723 (−1.98, 12.53)

0.153

0.1045 (−4.14, 4.351)

0.961

−0.037(−8.55, 8.476)

0.993

Private Ownershipd

5.5746 (−1.30, 12.45)

0.111

2.2391 (−4.88, 9.359)

0.535

−0.478 (−5.44, 4.487)

0.849

6.6646 (−3.29, 16.62)

0.188

Number Of Methadone Clients

−0.003 (−.010, .0040)

0.404

−0.003 (−.010, .0043)

0.430

0.0017 (−.001, .0040)

0.157

−0.002 (−.007, .0027)

0.411

aCI confidence interval

bReference group: Non-culturally competent units

cReference group: Not JCAHO (Joint Commission on Accreditation of Healthcare Organizations) accredited

dReference group: Public ownership

eOverall model F-test was not significant

Table 3 illustrates the fixed effects linear regression models pertaining to clients receiving methadone dosages less than 40 mg/d and 80 mg/d or more, while controlling for JCAHO accreditation, public/private ownership, the total number of methadone clients, and the percentage of African American clients. In 1995, there was no difference in clients receiving methadone dosages of less than 40 mg/d by level of cultural competency among OSAT units. However, culturally competent units are significantly less likely to give 80 mg/d or more of methadone to clients than non-culturally competent units (p = 0.043). In 2005, there is no difference in the clients receiving methadone dosages between less than 40 mg/d and 80 mg/d by level of cultural competency among OSAT units. No other variables are significant in the models in 1995 except the variable percentage of African American clients.
Table 3

Linear regression models of methadone dosage levels with percent African-American clients

Covariates

Dependent Variables: 1995 Dose Levels

Dependent Variables: 2005 Dose Levels

Patients Receiving less than 40 mg/d (95% CIa)

P-Value

Patients Receiving 80 mg/d or more (95% CIa)

P-Value

Patients Receiving less than 40 mg/d (95% CIa)

P-Valuee

Patients Receiving 80 mg/d or more (95% CIa)

P-Value

Intercept

7.9151 (−2.23, 18.06)

0.125

26.051 (15.03, 37.07)

<.001

13.504 (6.812, 20.20)

<.001

51.267 (38.62, 63.92)

<.001

Culturally competent/non-actualizing unitsb

4.2646 (−3.51, 12.04)

0.279

−1.22 (−9.66, 7.223)

0.775

−2.502 (−7.93, 2.928)

0.364

0.7336 (−9.53, 11.00)

0.888

Culturally Competent unitsb

8.0152 (−2.42, 18.45)

0.131

−11.71 (−23.0, −.377)

0.043

−4.811 (−16.7, 7.055)

0.424

−7.099 (−29.5, 15.33)

0.532

JCAHO Accreditedc

−5.653 (−12.2, .9181)

0.091

5.682 (−1.46, 12.82)

0.118

−0.399 (−4.67, 3.869)

0.854

2.5584 (−5.51, 10.63)

0.531

Private Ownershipd

6.0796 (−.413, 12.57)

0.066

0.9837 (−6.07, 8.036)

0.783

0.2281 (−4.79, 5.242)

0.928

3.0255 (−6.45, 12.50)

0.529

Number Of Methadone Clients

−0.005 (−.012, .0014)

0.126

−0.002 (−.009, .0049)

0.539

0.0014 (−.001, .0038)

0.237

−56E-5 (−.005, .0039)

0.805

Percent African-American Clients

0.2693 (.1474, .3913)

<.001

−0.17 (−.302, −.038)

0.012

0.0623 (−.015, .1396)

0.113

−0.321 (−.467, −.175)

<.001

aCI confidence interval

bReference group: Non-culturally competent units

cReference group: Not JCAHO (Joint Commission on Accreditation of Healthcare Organizations) accredited

dReference group: Public ownership

eOverall model F-test was not significant

In 1995, OSAT units with more African American clients are significantly more likely to have clients who receive methadone dosages of less than 40 mg/d (p  <0.001) and are significantly less likely to have clients who receive methadone dosages of 80 mg/d or more (p = 0.012). In 2005, OSAT units with more African American clients are significantly less likely to have clients who receive methadone dosages of 80 mg/d or more (p < 0.001).

In models not shown, OSAT units with more African American clients are significantly less likely to have clients who receive methadone dosages between 60 and 79 mg/d in1995 (p < 0.001) and are significantly more likely to have clients who receive methadone dosages between 40 and 59 mg/d (p = 0.033) and 60–79 mg/d (p < 0.001) in 2005.

Tables 4 and 5 shows linear regression models of the percentage of clients in the OSAT unit who receive methadone dosages of less than 40 mg/d, between 40 and 59 mg/d, between 60 and 79 mg/d, and 80 mg/d or more by level of cultural competency, with only the percentage of African American clients in the OSAT unit as a predictor variable. There is no racial difference among OSAT unit clients who receive methadone dosages of less than 40 mg/d, between 40 and 59 mg/d, between 60 and 79 mg/d, and 80 mg/d or more within culturally-competent units in 1995 or in 2005. However, among non-culturally-competent and culturally-competent/non-actualizing units, a racial difference exists among African American clients and other clients who receive methadone dosages of less than 40 mg/d, between 40 and 59 mg/d, between 60 and 79 mg/d, and 80 mg/d or more. In 1995, African American clients are significantly more likely to receive methadone dosages of less than 40 mg/d (p = 0.032 and p = 0.004, respectively) and significantly less likely to receive methadone dosages of 60–79 mg/d and 80 mg/d or more (p < 0.001 and p = 0.030, respectively). In 2005, African American clients are significantly more likely to receive methadone dosages of less than 40 mg/d and 60–79 mg/d (p = 0.048 and p < 0.001, respectively) and significantly less likely to receive methadone dosages of 80 mg/d or more (p < 0.001, respectively).
Table 4

Linear regression with only percent African-American clients in the model (1995)

1995

Non-Culturally Competent

Culturally Competent/ non-actualizing

Culturally Competent

Model

Dependent Variable

Variables

Regression Coefficients

P-Value

Regression Coefficients

P-Value

Regression Coefficients

P-Value

MODEL1

Less than 40 mg

Percent African-American Clients

0.2411

0.032

0.24

0.004

0.1978

0.349

MODEL2

Between 40–59 mg

Percent African-American Clients

0.1032

0.507

0.1421

0.109

0.1571

0.393

MODEL3

Between 60–79 mg

Percent African-American Clients

−0.076

0.597

−0.241

<.001

−0.268

0.138

MODEL4

More than 80 mg

Percent African-American Clients

−0.385

0.030

−0.104

0.224

−0.089

0.401

Table 5

Linear regression with only percent African-American clients in the model (2005)

2005

Non-Culturally Competent

Culturally Competent/ non-actualizing

Culturally Competent

Model

Dependent Variable

Variables

Regression Coefficients

P-Value

Regression Coefficients

P-Value

Regression Coefficients

P-Value

MODEL1

Less than 40 mg

Percent African-American Clients

0.0176

0.876

0.0782

0.048

0.0834

0.638

MODEL2

Between 40–59 mg

Percent African-American Clients

0.1063

0.093

0.0775

0.067

0.1343

0.622

MODEL3

Between 60–79 mg

Percent African-American Clients

0.1711

0.198

0.1636

<.001

0.4057

0.268

MODEL4

More than 80 mg

Percent African-American Clients

−0.295

0.121

−0.316

<.001

−0.623

0.140

Lastly, Table 6 reveals the bivariate relationship between measures of the mean aggregate number of therapeutic and ancillary support services provided at treatment and the level of cultural competency among OSAT units. There is no statistically significant difference in the mean aggregate total of six different types of therapeutic and ancillary support services within the OSAT units by the level of cultural competency in either year. However, there was a marginally significant difference (p < 0.1) in the mean aggregate total number of therapeutic and ancillary support services within the OSAT unit by cultural competency level in 1995 (p = 0.099) and in 2005 (p = 0.016). Culturally competent units have the greatest mean aggregate number of therapeutic and ancillary support services available among all three cultural competency levels.
Table 6

Ancillary services by cultural competency

Variables

1995

2005

P-Valuea (1995)

P-Valueb (2005)

Non-Culturally Competent (N = 24)

Culturally Competent/non-actualizing (N = 78)

Culturally Competent (N = 19)

Non-Culturally Competent (N = 26)

Culturally Competent/non-actualizing (N = 109)

Culturally Competent (N = 5)

Mean Aggregate Total Of Six Different Types Of Therapeutic And Ancillary Support Services Provided At The Treatmentc

5.04

4.88

5.37

4.73

5.20

5.60

.1984

.1513

Mean Aggregate Number Of Therapeutic And Ancillary Support Services Provided At The Treatment Unit d

17.21

16.92 e,*

20.00

13.80 f, *

16.54

20.20 e,**

.0987

.0163

These variables were in the 1995 dataset, but not in the 2005 dataset: entitlement assistance, legal services for domestic problems, health education, women’s issues and postpartum care. (Total N = 27)

These variables were in the 2005 dataset, but not in the 1995 dataset: smoking cessation, PAP smears, sexually transmitted disease testing, and screening for hepatitis (Total N = 26)

aP-values from differences between the culturally competent groups in 1995 are obtained from F-tests

bP-values from differences between the culturally competent groups in 2005 are obtained from F-tests

cDifferent types of available services include: family services, life coping services, legal services, educational services, preventive medical care services and medical treatment services

dServices available both years include: family therapy, parenting education, domestic violence counseling, employment counseling, financial counseling, transportation assistance, housing assistance, child care assistance, legal services for criminal issues, legal services for child custody, HIV prevention, physical examinations, HIV testing, TB screening, routine gynecological examinations, pregnancy testing, family planning, routine medical care, HIV acute care, mental health treatment, prenatal care, and postpartum care

eComputed by Tukey-Kramer Honestly Significant Difference Test comparing cultural competency/non-actualizing units and cultural competent units

fComputed by Tukey-Kramer Honestly Significant Difference Test comparing non-cultural competent units and cultural competency/non-actualizing units

gComputed by Tukey-Kramer Honestly Significant Difference Test comparing cultural competent units and non-cultural competent units

*p < .1,**p < .05, ***p < .01, #p < .001, ##p < .0001

Discussion

Our study sheds light on the relationship among race, cultural competency, and methadone dosage levels within outpatient substance abuse treatment organizations. National studies show that over 38% of methadone facilities are dispensing methadone below the recommended dosage of 60 mg/d as outlined by the National Institute on Drug Abuse and that African Americans receive lower doses than their white counterparts (D’Aunno and Pollack 2002).

Culturally-competent units have a higher percentage of clients receiving methadone dosages of less than 40 mg/d than non-culturally-competent units as well as having a lower percentage of clients receiving methadone dosages of 80 mg/d or more. On the surface, it could be inferred that cultural competency may be contributing to the racial disparity in treatment as they are providing to their clients, inclusive of African Americans, methadone treatment that could be deemed substandard by national recommended guidelines. However, considering the ongoing debate regarding what constitutes an appropriate level of methadone dosage and treatment to improve client success (Faggiano et al. 2007; Trafton et al. 2006; Strain et al. 1999), this inference could be deemed inaccurate.

Our findings suggest that the racial disparity for African Americans in methadone treatment programs occur within at least two different contexts. The first context can be elucidated under the auspices of providing effective culturally-competent methadone treatment. Howard (2003a) suggests that a culturally competent treatment approach that treats the whole person, rather than solely the addiction, may be more effective for African American substance abusers. The philosophy of cultural competency is the provision of treatment that addresses the underlying ills associated with drug addictions and relapse such as unemployment, homelessness, poverty and other types of social distress that African American heroin clients face (Rosen 2004; Betancourt et al. 2003; Howard 2003b; Holt 2007). Thus, an important element in the discourse of culturally-competent methadone treatment effectiveness is the role of comprehensive therapeutic and ancillary support services. Research on methadone treatment effectiveness, however, has almost exclusively focused on dosage level as the “magic bullet” for heroin addicts. Few studies have emphasized the importance of providing comprehensive support services, within the context of cultural competency, for people of color in methadone treatment (Bourgois et al. 2006; Kayman et al. 2006; Campbell and Alexander 2002; Longshore et al. 1998). A significant finding in our study indicates that culturally-competent units provide more therapeutic and ancillary services than non-culturally-competent units.

Essentially, culturally competent organizations dispense methadone at lower doses to all of their clients than their non-culturally competent counter-parts, but they also provide more therapeutic and ancillary support services to these same clients. For culturally competent organizations, giving lower dosages while creating a stable quality-of-life through the provision of ancillary support service linkages is fundamentally more effective than giving clients high doses of methadone. Such organizations may dispense more conservative amounts of methadone than their non-culturally competent counterparts because they simultaneously work with the client to improve all aspects of his or her life. If treatment is administered within a model that upholds methadone dosage levels as the “magic bullet” for recovery and minimizes the importance of comprehensive support services that are crucial to the overall success of clients in treatment, then minimal change in overall treatment outcomes and relapse may occur. Addressing race disparities in methadone treatment may benefit by universally incorporating the basic tenets of cultural competence practices by enhancing the provision of ancillary support service linkages to better serve all clients.

The second context in which the racial disparity in methadone treatment programs for African Americans occurs may be one of institutionalized inequality precipitated by race and racism. Our findings indicate that African Americans within non-culturally competent units are more likely to receive methadone dosages of 40 mg/d or less and are less likely to receive methadone dosages of 80 mg/d or more than their other client counterparts within the same units. In contrast, there is no racial difference among culturally-competent unit clients who receive dosages of less than 40 mg/d, between 40 and 59 mg/d, between 60 and 79 mg/d, and 80 mg/d or more.

The lack of equitable treatment and limited support services within organizations that fundamentally do not believe in responding to the cultural needs of its clients illuminate systemic problems in methadone treatment relevant to racial disparities in health that cannot be ignored. Such practices are, in part, a manifestation of many factors such as poor training, lack of staff education, limited resources, and negative perceptions that staff may hold toward clients (Bourgois 2000; D’Aunno and Pollack 2002). Dosage levels can at times be determined by staff’s perceptions of clients behaviors and attitudes while in treatment (Bourgois 2000). Some studies show that staff in substance abuse facilities are more likely to view the progress of black clients who withdraw from treatment more negatively than whites and are two times more likely to terminate blacks from treatment compared to their white counterparts (Jacobson et al 2007; Brady et al. 2004). The need for equitable treatment in substance treatment specifically methadone treatment, based on our findings, is evident and imperative.

The medicalization of methadone treatment has been, in part, the source of ongoing tensions between methadone treatment advocates, its opponents and skeptics. Moreover, the ongoing distrust, particularly among the African American community regarding the role of methadone treatment in the community has been exacerbated (Bourgois et al. 2006; Stancliff et al. 2002; Joseph et al. 2000). In light of our findings, coupled with the continued strains within the methadone treatment discourse, substance abuse professionals may want to consider the concerns of clients as well as the sentiment of the African American community at large, as part of the response to addressing the racial disparity in methadone treatment.

Conclusion

Substance abuse treatment, when provided in a culturally competent context, is the best strategy for addressing the racial disparities in client services use and clinical outcomes (Howard 2003a, b; Campbell and Alexander 2002; Longshore et al. 1998). As such, methadone alone may not ensure quality and stability of life or mitigate relapse. Further, methadone alone may not be what some clients want, hence alternative choices and support services may be necessary to increase the likelihood of recovery and to decrease the possibility of relapse. Our work has allowed us to have a better understanding of the race disparity within dosage differentials through the unveiling of roles pertaining to cultural competence and to institutionalized inequalities. However, future studies must continue to examine this relationship and further explicate the differences in race observed in the non-culturally competent organizations in efforts to close the gap. We must also recognize the implications this work has for the broader health disparities literature. As pointed out by several scholars, it is important that we continue to deconstruct the complexities of race differences, and disparities toward its elimination (Bourgois et al. 2006; Rathore and Rumholz 2004; Balsa and McGuirre 2003).

During an era of heightened rhetoric, and an ongoing need for culturally competence in substance abuse treatment and methadone treatment, it seems that there is evidence of a decline in cultural competency, which warrants further exploration. We also observed in comparing methadone units in 1995 and 2005 that significantly less units were practicing culturally competent protocols in 2005 than they were in 1995. Upon further examination, our findings point to a decline over time in culturally competent practices that involve outreach into the community such as community-based programs, faith-based organizations, and treatment that involves family and friends. Lack of resources may be one explanation for the significant decline in community outreach and involvement from 1995 to 2005. In addition, the various controversial perspectives within the community regarding methadone treatment could play a part in the decline of community outreach and involvement, particularly if units are located in areas that are not supportive of its presence (Bourgois et al. 2006; Stancliff et al. 2002; Joseph et al. 2000). To date, we have limited knowledge regarding the impact that community outreach and involvement as well as other criteria of cultural competence have on methadone treatment outcomes.

Research is needed to examine the role of comprehensive support services in improving culturally competent treatment. Studies are needed that focus on personnel and their interactions with clients and its impact on services, including doses of methadone (Kayman et al. 2006). In addition, we need studies to help us better understand the role of cultural competency on methadone treatment outcomes for African Americans. To address the distrust of African Americans, research is needed to develop better mechanisms to educate communities regarding the realities and misconceptions of substance abuse treatment.

Footnotes
1

One of the three variables for this measure, “unit involved churches in follow-up care” was not in the 2005 dataset; no replacement variable was used.

 
2

One of the three variables for this measure, “sought input from community leaders of communities w/ African Americans” was not in the 2005 dataset; it was replaced by the construct of the variables, “number of hours spent making public presentations and appearances in the community” > 0, and if there were African Americans in the surrounding community.

 
3

These variables were in the 1995 dataset, but not in the 2005 dataset. Total n = 27.

 
4

These variables were in the 2005 dataset, but not in the 1995 dataset. Total n = 26.

 

Acknowledgments

This study was funded by the DHHS Agency for Healthcare Research and Quality (R24 HS013353).

Copyright information

© Springer Science + Business Media, LLC 2009