Welcome and good evening to the APA webinar series, Looking Beyond. Tonight, our webinar is titled Addressing Alcohol and Substance Use Disorder in the Hispanic Community, Unpacking Social Cultural Risks and Resilience. So it's going to be very, very exciting. We have some excellent panelists. My name is Dr. Regina James. I'm the Chief for the Division of Diversity and Health Equity and Deputy Medical Director here at the American Psychiatric Association. In this webinar series, Looking Beyond, we'd like to take an interdisciplinary lens to really examine issues and propose solutions to some of the problems that are facing the various marginalized and minoritized communities. And tonight, we're going to gain perspectives from psychiatrists and those with a background in public health, as well as social work. So to get us started on this journey, I'd like to introduce my esteemed moderator, Dr. Hector Colon Rivera. Dr. Colon Rivera is a Distinguished Quadruple Board Certified Adolescent, Adult and Addiction Psychiatrist. He's Medical Director at the Association of Puerto Ricans on the Move and Co-Founder of Crear Con Salud Incorporated, which happens to be a grantee of one of our programs, the APA More Equity in Mental Health Community Grants Program. So welcome, Dr. Colon Rivera. I'm so looking forward to this conversation. And thank you for the introduction, Dr. James. So yeah, so this is going to be an exciting discussion and a little bit of background. I mean, we know substance use rates in Hispanic middle, the general population, although certain factors increase risk for addiction to certain substances. And according to some data, I mean, millions of Hispanics adults ages 12 and above had a past year substance use disorder. Approximately 7% of Hispanic adults age 18 and older have a co-occurring substance disorder with a mental illness in the past year. And while some of us believe that substance use disorder impact those living with the condition in similar ways, the truth is that due to racial, cultural and ethnic disparity, historically marginalized communities like the Hispanics communities have, in my experience, substance use disorder and access to treatment quite differently. Both acculturation and assimilation have been found to impact substance use disorders and substance use within the Hispanic communities. And today we're having a great discussion between a few of my colleagues here. And the funny part, we're all addiction psychiatrists, plus, I mean, Karina, which is from SAMHSA. I'm just going to introduce you guys. So the first panelist we have is Fabiola Arbelo Cruz, which is an assistant professor of psychiatry at Yale School of Medicine and the Connecticut Mental Health Center in New Haven, Connecticut. Second panelist we have is Caridad Onsen-Martinez, which is an assistant professor of the Department of Psychiatry and Chief of Addiction Psychiatry Section and Program Director of Addiction Psychiatry Fellowship at UMass Chan Medical School. And Karina Aguilar, Dr. Karina Aguilar, which is Assistant Regional Director of the Substance Abuse and Mental Health Service Administration, the DHHS Region 2. The first question from the panelists is, how do heritage and U.S. cultural practices independently contribute to alcohol initiation among Hispanic youth? And how this interplay between each other? So I'm going to start with Dr. Ponce-Martinez with this question. Thank you, everyone, for being here, and to the leadership of this webinar for inviting us to be here and talking about this very important topic. So I think I'll start off by saying first that when we think about Latinos in the U.S., it is far from a monolithic group. We're talking about so much diversity, not only in country of origin, but also immigration history. Did they come here as adults? Did they come here when they are young? Socioeconomic factors, immigration status, language barriers, etc. And so in terms of heritage and U.S. cultural practices, I would say that that influences exactly particularly among youth. So for youth that were perhaps born in another country and have moved here during that transitional age with their families, certainly they might have still a lot of the practices from their countries of origin that will guide a lot of the substance use and initiation that might happen when they are in the U.S. For those that have come here at a younger age, they may be more like their peers, depending on the level of acculturation that can happen. And there's all sorts of factors here in terms of an interplay. What are the family's values? How integrated are they in their society? What are the substances that are now available in the community that perhaps were not available in their country of origin? How does the family feel in relation to the community? Do they feel supported or are they in fact quite isolated? Are the parents working a lot? And so there's less supervision for the youth where substance use or a desire to assimilate to the prevailing culture that's more prevalent. So there's all these factors that I think can play a role in initiation that can be unique according to the different communities. Those are my starting thoughts. I'm sure my colleagues have other thoughts. Dr. Arbetta-Cruz. Thank you, Hector. And thank you, APA, for having me in this space. I'm quite happy. What I would like to add to this question is similar to what Dr. Ponce-Martinez was saying, is that not all Hispanic Latinx youth are equal when it comes to drinking and alcohol use attitudes, even if they are from the same Hispanic or Latinx group. In fact, attitudes to alcohol use have been shown to be sensitive to social variables, like to gender, religion, and acculturation. Additionally, I just want to point out that we also need to be careful in not assuming that ethnic identity alone as a social classification equates to increased drinking, alcohol, or substance use. And what I'm trying to say is that it is important to understand how identifying or being defined as Hispanic Latinx translate to risk factors for alcohol initiation versus how racial and ethnic inequities in access to fair housing, medical care, or even experience of discrimination, for example, contribute to alcohol initiation. We know there are several social determinants that influence substance use and the risk for development of substance use disorder with differential consequences to youth of color. For example, alcohol sales density remains far greater in Black and Hispanic Latinx communities and neighborhoods than for majority white neighborhoods. So that's the thing that I want to point out. Hello, everyone, and I am Dr. Karina Aguilar. I work for SAMHSA. I also thank you for inviting us. I think this is a really important conversation and one that we don't have enough with something that we need to go in all different circles so that we can openly talk about what is impacting our youth. And as you're hearing, we're hearing the complex relationship, our cultural norms from our countries, but also the U.S. And I think that there's a third one there, like the interplay of both heritage, the one you come with, and also the U.S. cultural factors. And as a young person coming in, and you're navigating that by cultural identity, incorporating aspects both from your culture, but also from the U.S., and the different attitudes, what's going on in school, and all those things really do impact the possibility of the initiation to alcohol or other substance uses. And as Dr. Arbelo also mentioned, the community and neighborhood factors that are around us, the accessibility and availability of alcohol in the community, in the neighborhood, I think that's going to be an important aspect of what our young people have access to them, and perhaps start using one of those substance uses or alcohol. Thank you. So great points. And I will say something, Dr. Ponce mentioned that it's really important to emphasize that Latinx communities compromise a number of diverse subgroups, and it's not a monolith. So we need to you know, have that in mind, be mindful about that. And it's also important to know that substance use varies across heritage groups and locations. I mean, most of East Coast guys, but I mean, we talk about Hispanic groups in the West, probably it would look a little bit different in terms of what they're using in terms of location, and ages, and sex, why not. Um, and some studies, I just want to mention to that, have identified that substance use are higher among Latinx people who were born in the United States, okay, live more years in the United States and more recent immigrants. So they have been here for longer, and use English more than they use Spanish as a language. So some, some something to think about. And Dr. Arbelo Cruz, you mentioned discrimination. And I want to ask you, you know, start a second question for you guys. I mean, can you elaborate on the role of perceived discrimination, and the stress that this can cause? Definitely. And just to have a shared language, I think about discrimination is like the experiences or feeling of being discriminated, right? And discrimination is linked to mental health conditions, depression, anxiety, psychological stress, and all that are independently linked to substance use. There's a strong relationship between mental health and substance use that is well documented in literature, and suggests that mental health is an important mediator of discrimination substance use relationships. And also, I would like to jump in here. And, you know, that perceived, our young people already have the typical stressors of being a youth, right? And there is that this discrimination comes up in so many different forms. Sometimes it's racial profiling, sometimes it's stereotyping, or microaggressions. And this can create a feeling of alienation, and develop stress among us. Also, you know, thinking about what pieces of you you want to hold, and you want to navigate in the demands and expectations that you have, perhaps at home, and then in your in your social setting. So it's a lot what Hispanic youth are facing, and balancing in between their culture and the mainstream culture. And I think these are important things that we have to keep in mind of what the young people are feeling. Yes, I agree with both of you. I think the discrimination can play a role in sort of both sides of it, certainly in initiation. Alcohol can be and other substances can can serve as a sort of a social lubricant, feeling alienated, feeling excluded. Alcohol initiation could be a way to fit in with peers certainly earlier than than perhaps they would have been exposed to otherwise. I'd like to point out that this is particularly a risk factor for women, we have seen that women, in particular, so younger adults, that are women are may may use alcohol and other substances in place and be at a higher risk of other risky behaviors during during youth, particularly when in relationships with with older peers, particularly older men and as a as a way to you know, initiate, as I mentioned, a lot of other risky factors. And accompanied with that is is the discrimination that happens in the sense that with that younger initiation of use, come many more consequences for this youth compared to some of their other peers from majority groups, greater rates of involvement with criminal justice system at a young age disproportionate to to what others experience. And so we start seeing more of the consequences really leading to a vicious cycle from a very young age. Yeah, and we see the cycle in different system, right? We talk about family, we talk about society, we talk about the community, school is another system that we can see discrimination when you have a young fellow using alcohol or substance use. So I'm talking about systems. What systemic barriers contribute to treatment disparities among Hispanic communities and Hispanic young with a substance use disorder? Dr. Aguilar, you want to start? Sure. That's a good question. Because treatment disparities for Hispanic people with substance use disorders can arise from various systematic barriers. It's important to know that these barriers are complex, and they're interconnected. They're often influenced by social, economic, cultural and policy factors. Some systematic barriers that contribute to treatment disparities for Hispanic substance use disorders are the one we're very familiar with, language barriers, when you have limited availability of treatment programs in Spanish for people, the lack of bilingual and culturally healthcare professionals, and also materials, educational materials that can help in understanding not just substance use, but the treatment options that people have. Then you have cultural stigma, which really impacts a person's ability and willingness to seek mental health and substance use treatment. We are very familiar with that fear of judgment, being judged by our community, by people discriminating against us if we have a problem. Maybe also some religious or traditional beliefs that may discourage us from disclosing certain things to people outside of our family, outside of our home. Then we have some other disparities, like in access to healthcare, insurance coverage, and access to affordable healthcare. Speaking of access, thinking of the geographic disparities leading to limited access to treatment facilities in certain areas. We have some limited financial resources to afford treatment. It's going back to having insurance. Along with that, it's your employment-related factors, if you have insurance through your employer, or if you're going to be deducted payment if you take time to go see a doctor. Immigration status may have an impact. Again, the cultural competency of treatment providers. We're not just having people who are bicultural or bilingual, but the cultural competence amongst the healthcare professionals that will be there to give you service. It may hinder the effective communication and understanding with the patient's needs. There are other issues, like maybe limited awareness about what treatment options are there. We just know probably of going to the doctor, but really, what are the options? What do they look like? What do we require from me? This is an important conversation because we have to hear from the community. In order to address the systematic barriers, it needs to be comprehensive. It has to be a culturally sensitive approach. It has to be a conversation. Speaking from the policy side, we need to hear what is going on. As it was initially stated, it's not a cookie cutter. It's so diverse. We need to hear the different voices and different needs so that it could be culturally competent, but also something that people can actually use in the communities. Thank you, Dr. Aguilar. You touched on so many important points. The first one that came to mind that you touched on is the healthcare system. As you mentioned, there are many Latino communities that face institutional racism within the healthcare system because there are cultural and linguistic barriers that hinder access to quality and substance use treatment. For example, recent data showed that between 2014 and 2019, the proportion of facilities that offer services in Spanish decreased in 44 states. Another important thing that comes to mind when I think about systemic barriers, actually, the first thing that comes to my mind is the history of policies that criminalize and stigmatize addiction and entreatment. That impacts all racial and ethnic communities, mainly Black, Latinx, Native communities. Those policies pretty much targeted people of color for incarceration. It sent a message that we're trying to change now that addiction is almost different than a medical condition. And we see that in many ways. I know Dr. Aguilar touched base on cultural stigma. I oftentimes see people saying, I don't want methadone, I don't want Suboxone. I can do it alone. I don't want medication. Something else that I hear is, I don't want methadone, I don't want Suboxone. I don't want another drug to substitute what I'm feeling. And a lot of education needs to happen in order to kind of like deconstruct and construct. And one other piece that you mentioned is the US immigration system. Because I think it contributes to hate and impotent ability to substance use through immigrant related barriers that you mentioned, like limited or no access to insurance, propagating stigma to substance use disorder and perpetuating structural racism. For example, increased risk of deportation for Latinas that use substances or have a substance use disorder. Thank you both for bringing those points up. I'd like to add, when I think about this topic, I almost think about sort of the multiple concentric circles that are addressed. And so from an individual and cultural perspective, for many of the Latinos that we see, Latinx that we see in the US that may be immigrants, how much of them are isolated and work becomes absolutely crucial to their survival, to the survival of their families. And so any deviation, first of all, they might be viewing substance use as less problematic as long as they're able to maintain employment. Because that is really sort of the driving factor. If they're able to maintain employment, able to send money back to their family, is able to support themselves, then all is well. That is such a crucial factor in their lives. And so they might see less of the consequences affiliated or associated with their substance use. When you think about severity of substance use and you're talking about inpatient treatment and moving away from work and they don't have a backup system, they don't have any support and they might even suffer consequences from that. So it's not only loss of employment, loss of income, but also some additional negative consequences from entering treatment, then that becomes another obstacle. We know that Latinos on the whole are much less likely than other groups to be offered medications for treatment of substance use disorder. That may be in part related to their understanding, their acceptance of medications, but there are also systemic issues where medications are not offered. Health literacy in this patient population also matters and is something that needs to be addressed. And so that's another barrier. So it's almost like all of these things that are really affecting the success of treatment, retention of treatment. So not only initiation of treatment, but also having patients remain in treatment, which we know from the larger population is one of the primary indicators of success and eventual abstinence and recovery, really. Wow, so many barriers. And I hear you guys talking, so many stories come to mind, I mean, about patients and probably it happens to you guys too. So many stories come to mind and it's harder when you have kids and the youth using, right? Because there's not a lot of child psychiatrists, a lot of child addiction experts out there to take care of them. And there is a transition of youth where they get lost between the pediatrician, internal medicine, and it's just the transitional is pretty bad and lacking of transition between services. And we're talking about barriers, but I wonder if you guys can show some insight on solutions in a systemic framework about counteracting these barriers that we're talking about. And I always look for a solution for SAMHSA. SAMHSA, do we have solutions? Yes, some of the solutions that we see is, that I was thinking as we were having this conversation was coming to mind was the national class standards that you may be familiar with. And I think those are very important. It's a blueprint that was developed by the Department of Health and Human Services for any organization that's trying to be, implement their culturally competent health literacy culturally competent health literacy approach. And it's free, it's available. So perhaps in a minute, I could put it in the chat, the national class standards. We also have programs like the, we utilize a lot of community health workers and peer recovery workers. And I think people may be familiar with them. At SAMHSA, what we do is we have, one of the things we do is fund our providers. So we have a whole section. So besides the funding that we give to the states, we have all this whole bucket of services for the providers. How do we help you be more informed? How do we help you where you're at? You are experts. However, there may be an area where you need some assistance. And so this is where we house our centers of excellence, where we house the, something like the peer recovery center of excellence that can help solve this, help with this problem. We also have centers of excellence in different populations. For example, African-American, Native American, Pacific Islanders, and obviously Hispanic, Latino. And so that's also an area where if you wanted to focus and put some effort, any topic, any topic, would, our centers of excellence can support. I'll give you an example. A few years ago, we, the other company children were coming into the border and it was very, very difficult. It was creating a stress on the border patrol personnel. And they felt like they just could not understand certain aspects of it. And a few of our centers of excellence that focus in family, children, Hispanic, worked with some of the people from the indigenous groups that were coming from Central America. They all came together and they developed some really good material. And that way they were able to support the personnel working at the border. So in that way, they can be better trained and they can provide a better service. So that was just an example of the way that we can come together with our resources. Another thing that came to mind for me was attention to hiring practices. Like ensuring that there's racial and ethnic and linguistic workforce that is similar to the patient that is being served. And Dr. Aguilar, I really like you touched on the community health workers because these are people that are lay members of the community who usually share the racial ethnic heritage of the community, the language, the socioeconomic status, life experiences. And they become people that are really more accepted for some members of our underserved communities. And they're found to be more accessible than traditional clinical behavioral health services and workers. Yes, I think we've all talked about really social determinants of health affecting the acceptance of treatment, the participation treatment, the quality of treatment that is offered for Latinos. So I think the solution comes in addressing those, really being able to provide comprehensive treatment, understanding that treatment does not happen in isolation and ideally should not happen in a single instance of care, but developing a relationship with communities and with individuals and understanding and accepting. So similar to the acculturation that Latinos have to make up on by living in the U.S., incorporating parts of their native cultures with the mainstream culture. I think treatment can also do that as well. And so it is not replacing cultural, religious beliefs that they might have about the origin of their illness, but introducing new concepts, introducing education about efficacy of medications, efficacy of treatment, in addition to whatever they're doing, really creating that trust in the community to allow for better outcomes. Great examples. Do you guys know of any public health programs that are culturally tailored? Just wondering about that. No, okay. I don't know of anything that is system-wide, but I work in Massachusetts and particularly at UMass. One of the sites that I practice in is called Hector Reyes House. It's a residential treatment program that was actually founded by a Latino man with substance use disorders, and it provides treatment primarily to Latino men that are with substance use disorders. What has been fascinating about the program in my work there is seeing that it's not just me providing addiction psychiatry consultations. It is a clinician providing primary care that can speak Spanish. It is a house that's run, that is following a lot of the cultural norms for the patients or the residents that are there, the clients that are there. It is providing employment training so that patients are able to think about something else once they leave there, help with any legal matters that they have, parenting classes. So it is this comprehensive way of providing treatment that I hadn't seen before. So I think this is one example. I think there are others across the country. I don't think we do a lot of work studying them to understand what aspects there are actually successful, but certainly there are things like that that could be replicated. Because I can speak about nonprofit organizations that are tailored to Hispanic communities. Like the one I work, APM, which is Asociación Puerto Ricana en Marcha. We started by Puerto Ricans for Puerto Ricans and 95% of our patients are Puerto Rican. And we try to touch on all social determinants of health. I mean, credit union, education, mental health, housing and foster home. We have all of those departments and it's tailored for Puerto Ricans. So, I mean, I know about those programs, but I was thinking more about public health programs and that we can apply, we're interested in things like that. But, because I think we need to think about, I mean, we need to work in a big team, right? We need the help of the private, public and also nonprofit organizations for sure. I want to jump in on the questions from the Q&A. Is that okay with you guys? Because we have a lot of questions I want. Yeah, can I say something quick? Sure, please. Just to pinpoint stuff. The fact that you asked that question and there was some seconds of silent, it's a problem. Also an opportunity, but I just want to highlight that. It's a problem and opportunity, right? The second thing that I wanted to say is I work in Connecticut and there's this clinic, which I think it's also a great examples of how to do things right. And it's the Hispanic Clinic of the Connecticut Mental Health Centers. And some key ingredients that this place has is the availability of bilingual and bicultural team. I'm talking about the front desk staff. I'm talking about the therapist, social worker, psychologist. I'm talking about the case manager and the psychiatrists that work there as well. And that in itself just leads to changes that are so important in that clinic. And they target not only the psychiatric and addiction piece but having that case manager that tackles other important areas like social problem. I think that's unique. And something that I have mentioned before in other presentations that I have given that I think is important to me to point out is that even me as a provider to have that space, even if I work there or don't work there, having that Latino Hispanic place just brings joy, brings something, right? So I just wanted to say that. I know you wanna go to the Q&A. Yeah, no, it's true. And thank you for the observation about the silent. I think that's a great observation that we need to think about. I mean, cause we're here to not only talk about barriers but also solutions. And I think we need to talk more about ways of creating programs, of course. So there are a few questions. So I'm gonna start in order, okay? Get to all of them. So I'm gonna read the questions, okay? This is from one of the participants. Let's see, Crystal Do. So the question is, aside from perceived discrimination and other stressors in the US, do you think there might be a cultural aspect contributing to less drinking in Hispanics living outside the US? She's thinking more about the legal age of drinking alcohol. Also, there may be more support from family, their communities, and less isolation. We wanna comment on that. I think we kind of, when we were saying how we all like are different in the cultural, from our cultural home, I think that that kind of leans into that question because it kind of depends how the relationship we have with alcohol, right? Like we use it for celebrations, because we're having like a party and it's a custom that we do it. So, and it varies, it varies from family to family, from area to area of how this is perceived. So, and I'm from Ecuador and there's never a conversation of like the legal age of drinking, for example, right? It's very loose, it's very okay. It's very, and for new years and, or birthday or something. So, I think that that kind of, that cultural perspective is really important to take into account. That's really interesting. So, I'm from Honduras, came here as an adult, came to the US as an adult for my training, but it was similar. So, the legal age for drinking in Honduras, and I think across Central America is 18, not 21 like here. And I think most of my peers and sort of the cultural norm is actually introduction to alcohol younger than 18. But the way in which alcohol is used is very different in Central America. Very often it is done, alcohol is used within families, social gatherings, and so there's much more of a community feel. So, I was shocked when I came to the US for college and started seeing peers in college with alcohol intoxication. I had never seen it before in my life, even though I had been around alcohol from a younger age. And so, I think there are some of those norms that are different, and I think that absolutely matters. And so, when you think about that, I think it matters for when Latinos have come to the US, the age in which they came in. And in addition to that, even if they came in as adults and they are more likely to maintain their cultural norms, the isolation that they might experience here where they don't have a sense of community, they don't have other peers might be more likely to start to lead to initiation of binge drinking and heavy alcohol use that then develops into an alcohol use disorder. Thank you for all the great information. And I feel it as well. In Puerto Rico, the legal drinking age is 18 as well. And something that at least happened to me, and I know every family is different, but I know it influenced me, and I see how here the social disconnect could be not present and be a vulnerability. Growing up, as Dr. Ponson mentioned, I was introduced to alcohol by my family and they spoke to me about it. They told me, you need to just drink a little bit or da, da, da. If I would drink too much, there will be a vecina, meaning a neighbor, say, you're drinking too much. And there will be like commenting and it will be like a shared communication in parties, gathering. And it makes me think about when there's a disconnect with immigration and those social connections are like more fragmented, how that makes an impact. Definitely, definitely. Family, I think family is a huge factor here. I'm from Puerto Rico too, so drinking age is 18. We drink before that, for sure. And it's loose, as Karina mentioned. So next question from Anel Prim, Dr. Prim. Hello? I'm a fan of Dr. Prim, so I need to say hello. So the question is, why is that the immersion in one's cultural origin among Hispanic youth is protective against mental health and substance disorder compared to U.S. cultural? One thing that has been going through my mind that we haven't mentioned is in the mainstream culture of the U.S., how we perceive alcohol probably, sort of like what Dr. Ponce was sharing when you go to college and you have all this binge drinking and it's kind of like people kind of look forward to that. Alcohol kind of like, you know, it's a thing to do and it also makes you be cool and it's I think media also makes it sound cool and something that you want to do. So as I was saying before, when you navigate both cultures and you kind of like pick one or the other, I think as a young person, if you are closer to your home, like your cultural support system, right, you probably be a protective factor versus when you are trying to a culture, trying to fit in to the new place, to your new culture. I think that that's something that we probably saw that with cigarette smoking also. I think that was one of the comments, you know, back in the day when we talked about why would people start smoking? Because it was cool, you know. So I think same thing with other substances. I feel like this can be a sort of a double edged sword. I think there is a lot of stigma. Again, we're not a monolithic group, but in Latinos in general against diagnoses of mental health disorders and substance use disorders. And so on the one hand, what we all described with this shared sense of community, greater family, just this sense of extended family, extended community that can be protective. I think those similar things can lead to a lot of stigma about a diagnosis, about seeking help. And so it might be that symptoms of depression, symptoms of anxiety and problematic use of alcohol and other substances, undetected, untreated for a longer time in youth that is very immersed in sort of their, you know, their cultural groups. I think it also depends on how well that acculturation is going for that family. Certainly for a family that is very immersed in its culture of origin, but they're in the U.S. and haven't really assimilated well and are experiencing a lot of stress from that lack of assimilation, they could be experiencing other stressors in the family that could then also lead to substances. So I think there can be both protective and risk factors there and certainly the possibility of things going undetected. I agree with both of my colleagues here. That's true. That's true. I mean, I mean, I think Dr. Ponce mentioned something really interesting, which could be a double sword there. And especially with mental health, when we're talking about mental health and substance use disorder, a lot of, there's a lot of stigma in Hispanic communities about mental health. And talking about it is, it's not easy. It's not easy, especially between men. And probably you guys agree or not agree. I mean, the machismo is huge in Hispanic communities when we're talking about mental health and we need to, you know, to swallow the pride and just men don't cry situation. So, and if I can add something to that, what do we do with that? What do we do with that attitude or thinking? Because I have also seen like many people come to me and said, I think as Dr. Ponce mentioned earlier, like, oh, I'm able to work. I'm able to bring money home. I can attend to the needs of my family. I'm okay. And how do you go about it? Like trying to, to, to, to ask question, be curious to, to have them see what's going on. And something that we have recommended is like, asking about what family members think like, hey, so I know you're working and you're able to bring money home and you're able to attend to your family's needs. If I will ask your spouse or your kid, if they're worried about your drink, what do you think they will say? And just let them explain, right? I think when I think about cultural stigma, something else that comes out is delay or avoidance of treatment. And it can look like some people try to first seek support from their local church or priests, right. Or trying to manage with family support only first. Also with cultural stigma comes the faulty understanding of substance use disorder in general, thinking that one can control it. As I mentioned earlier, that treatment can be replaced as one drug with another. And we need to do a good job at knowing how to have comebacks for those kinds of, of attitudes or, or, or thinking. Yeah, we have a lot of work to do. There is an interesting question on the chat. So the question is from Yves Sari. Is there a difference between abuse substances among communities? From my perspective, since marginalized communities will have less economical freedom, it will be tending to use cheaper and lower quality, riskier substances. Does that cause difference in medical approach? That's a pretty interesting question. I think yes, there is a difference among the communities. One of the things that I've, that I have seen in my clinical practice has been sort of the patterns of use. And so for some communities, there may be, there may be less of a pattern of, of kind of gateway drugs than the leading, or what we think about the gateway drugs, then leading to greater substance use. So for example, because of less availability of prescription opioids, there may be a greater tendency of some communities who begin with intranasal or insufflated heroines directly, rather than, than prescription opioids that would be available to patients, to people with, with greater means. There can be an issue, you know, in some of the populations, greater initiation with alcohol that then leads to experimenting with, with other substances. And in terms of, of sort of cheaper, lower quality or riskier substances, I think I'll speak about the Northeast, because that's where I practice. Fentanyl is, is everywhere. I think regardless of, of, of how, where it is purchased. And so I think it is equally risky, no matter what the substance, including stimulants, et cetera. So anything that is, that is being purchased illicitly now has such a high likelihood of, of, of being contaminated with, with fentanyl and any other adulterants. Maybe the risk there is, is access in treatment, access to, to naloxone and other, and other rescue medications. Thank you, Dr. Ponce for, for your response. I, I feel like I should add here that for, for psilocin, SAMHSA has approved some of the funds for test strips, because as we know, this is one drug that is not an opioid. And it's also been laced in with the other opioids and fentanyl. So it's, it's important for people who are using to, you know, we have to think about, you know, out of the box. And this is what we have heard from the community, the harm reduction community. That is one way to, to help and assist. And I know it's a controversial, controversial subject, but it's one where we are at, right? So some of the funds that we already are, are using test strips for other things. So this, this is going to be something new for psilocin. Also with, with the opioid and naloxone, all the states are like hands-on when it comes to having a saturation plan that they're working with. SAMHSA is, is, is supporting all states with their naloxone saturation plan. So it's something that we want to, everyone to have availability for you, for, for someone, you know, places where they're high risk. It's going to be, although it's not over the counter, it doesn't mean that we stopped, you know, working on it because there's still a huge population that will probably still need support for naloxone to be able to access it. Thank you. Something I would like to add is that in terms of knowing more about substance use disorder in every Latinx subgroup, we have more questions because we need to be better at studying it. And I think this, it comes to the point that there needs to be more attention at disaggregating data for Hispanic Latinx subgroups, right? Because more, many, much data just look the Hispanic Latinx group as one. So when I think about studies that have done so, I can think about on one study looking at U.S. drug overdose mortality from 2015 to 2019 across different Latinx subgroups. And one of the main findings was that drug overdose mortality rates in the Puerto Rican group compared to Mexican, Cuban, Dominican, Central American, South American, non-Hispanic white, non-Hispanic black were higher. So that was an example of how they disaggregate data. So bottom line, I think we need to aim for more studies that do studies in Latinx communities in subgroups. Definitely. And in the social determinants of health, I mean, they find a lot of these barriers too. I mean, we, and there is a few comments on the chat about also how LGBTQ communities, I mean, we see the same, I mean, all marginalized communities will see similar barriers and similar difficulties of finding assessment and treatment and depending location and the drug they're using and cheaper drugs versus, you know, higher social, economical groups. I mean, they have an easier way of treating these substance use disorders. So I'm going to try to make some questions so we can touch base on some of the topics. Okay. So there are a few questions about if we know about any data on what schools are doing, and I'm guessing to prevent substance use disorder in kids and to serve as safer spaces for kids so they don't use substances. Any comments on that? I, I'm not so sure if I'm understanding the question correctly, but SAMHSA has a prevention technology transfer center that, and also an addictions technology transfer center. And perhaps that could be a place where the person interested in learning more can visit. I'll put the link in the chat. This, this is a, again, this is a, this, this is a, again, a prevention technology transfer center is a, think of it as a, as an agency, a consultant for, for anyone. It could be a university, it could be a community-based organization. It could be a state, it could be a civic group that's interested in addressing a problem in their community. And our PTTC, that's how we call them, they are throughout the United States. We have them in each, each region. So for example, I, I am in New York, and so the, the prevention technology transfer center will be the one that covers New Jersey, New York, Puerto Rico, and the U.S. Virgin Islands. And then, you know, region one, which is the New, New England states will have their own, and consequently, right? So I will add that link. Perhaps that could be a place to get more, more assistance. And all the services that SAMHSA provides, all this type of consultant services are of no cost to anyone. That's great. I also want to make, yeah, I want to mention the APA Foundation program, the APA program, the Notice, Talk, and Act program they have, and it's to, to train people that actually, you know, work with kids, like anyone that work with kids, they teach you how to identify signs, symptoms of mental health, and how to look for help. So it's Notice, Talk, and Act at school. Okay. That's, that's a great program, the APA Foundation, and I think they have a grant now that they're training for free. So look at it at the APA Foundation, Notice, Talk, and Act program. It's great for schools and prevention. And another question here that I want to touch base is, and this is a important question, is, is there an association between trauma and substance use disorder? Absolutely. Yes. For every, every patient population, I think, what I would say is, is that particularly for, for Latinos, this is something that is so stigmatized, and that there is such reluctance in talking about, especially among men. But if we think about immigration journeys, those can be traumatic experiences that people have had in their countries of origin, based on situations there, and poverty and violence, that can be a source of trauma as well, the lifestyle related to substance use, that can be a source of trauma. And it very frequently, there's a lot of reluctance in talking about it. So I think normalizing, asking questions in a way that is, that is less confrontational, that is less judgmental, I think can play in a very important role. And one of the things that I've actually found, and so this was, this was interesting learning experience for me, I mentioned, working in this part-time in this residential program for Latino men as a woman. And so I'm asking about trauma, but actually being able to label an experience and saying what happened to you is not normal, that was traumatic, and the symptoms that you're experiencing right now, the nightmares, the flashbacks, the avoidance, the hypervigilance, and actually linking that to their use of substances to be able to reduce those symptoms, has been a wonderful source of education for the patients to really understand kind of the why, or one of the why's behind the substance use and be able to treat it. So I think that's where health literacy, and that's where we can become effective, even if we don't have, you know, that exact shared experience. So I think that's an important part, but absolutely trauma is very important in this patient population. Something that came to mind is when you asked a question about systemic barriers, and I pointed out the history of policies that criminalize and stigmatize addiction and its treatment, and the legacy of these policies is that incarceration rates for drug-related offenses are six times higher for Black and three times higher for Latinx communities, right? And I think about all the Latinx Hispanic folks that have been incarcerated because of this, Latinx Hispanic folks that have been incarcerated because of this, and as a result of this, these children that didn't have the parent and the negative experiences they had because of that, you lead to trauma. We increase the risk of substance use. Yeah, trauma, trauma, trauma, and of course substance disorder and mental health, having trauma and meeting criteria for PTSD, post-traumatic stress disorder, put you at higher risk of using a substance, and then using that substance, put you at higher risk of using a second substance. So it's just, and when you talk about the ACEs and the number of trauma you have, I mean, that's another story. I mean, the more you have, the more at risk you are. And there's a question about churches and the clergy, and I think, yes, churches can help Hispanic communities to de-stigmatize and join forces. I mean, there's a lot of programs in the APA talking about churches and bringing people to churches to increase access and treatment of substance use disorders. I want to be mindful of the time. We are running out of time, so I want to invite Fatima Reynos to say some words. Thank you, Hector. Thank you all for joining us this evening, and thank you to our esteemed panelists. Please complete our survey. We've dropped the link in the chat. It will provide information on claiming your CME credits, and join us on April 3rd for our next webinar in the Addiction Series titled Navigating the Virtual Crisis, Enhancing Awareness of Technology Addiction and its Impact on Suicidality in Youth of Color. You can find more information at psychiatry.org slash looking beyond. Enjoy the rest of your night. Buenas noches. And don't forget to check LaSaludMental.org, APA website in Spanish, LaSaludMental.org. Check it out, guys. You will love it. Thank you, guys. Thank you for joining.

APA webinar series

alcohol and substance use disorders

Hispanic community

cultural risks and resilience

diverse panelists

treatment disparities

cultural competence training

community health workers

trauma and substance abuse