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Recovery in Special Emphasis Populations

Recovery in Special Emphasis Populations Alcohol Res. 2020;40(3):05 ● https://doi.org/10.35946/arcr.v40.3.05 Published: 10 December 2020 RecoveRy in Special e mphaSiS p tionS opula 1 2 Eric F. Wagner and Julie A. Baldwin Robert Stempel College of Public Health & Social Work, Community-Based Research Institute, and National Institute on Minority Health and Health Disparities (NIMHD) Research Center in a Minority Institution (RCMI), Florida International University, Miami, Florida Center for Health Equity Research and NIMHD RCMI Southwest Health Equity Research Collaborative, Northern Arizona University, Flagstaff, Arizona Special emphasis populations in the current context can be defined as groups experiencing health disparities resulting in elevated risk to health, safety, and well-being from drinking alcohol. Individuals from marginalized minority populations often encounter barriers to accessing and receiving effective alcohol treatment due to social inequities and disadvantaged life contexts, which also may adversely affect recovery from alcohol use disorder (AUD). Recovery from AUD often involves the adoption of a stable non-drinking lifestyle (sobriety), increased health and well-being, and increased social connection. Although there has been considerable work on AUD epidemiology among special emphasis populations, little research exists directly examining recovery among racial/ethnic minority populations and/ or sexual and gender minority populations. The current narrative review hopes to spark scholarly interest in this critically neglected area. This article opens with a review of special emphasis populations and their alcohol-related risks. Next, definitions of recovery, Alcoholics Anonymous, and culturally adapted recovery models for racial/ethnic minority populations are explored. This is followed by a discussion of factors that may particularly influence recovery among marginalized minority populations. This narrative review concludes with a discussion of research priorities for promoting health equity through studies focused on understanding and supporting recovery from AUD among marginalized minority populations. KEY WORDS: alcohol-related disorders; alcoholism; minority health; health status disparities; Alcoholics Anonymous; social justice; alcohol; sexual and gender minorities INTRODUCTION The National Institute on Alcohol Abuse and youth, emerging adults (ages 18 to 28), older Alcoholism (NIAAA) defines special emphasis adults (age 65 and older), women, individuals populations as “groups who face particular experiencing co-occurring disorders, and ethnic risks from drinking alcohol based on personal and racial minorities are special emphasis Underage characteristics such as age or gender.” populations highlighted by NIAAA. Additional Alcohol Research: Current Reviews 1 Vol 40 No 3 | 2020 special emphasis populations at heightened risk for Individuals With Co-Occurring 2-4 individuals with AUD include sexual minorities, Disorders 5-10 11 homeless persons, Co-occurring disorders alongside AUD are justice system involvement, and former foster care emerging adults. common, and individuals with co-occurring disorders are a special emphasis population given Underage Youth the complexities associated with treating AUD Underage youth are a special emphasis population alongside other disorders. People with drinking given the ubiquity and inherent danger of problems are at heightened risk for psychiatric problems (i.e., anxiety disorders, depressive underage drinking, as well as the status illegality disorders, bipolar disorders, attention-deficit/ of drinking among minors. By 12th grade, most Americans will have consumed alcohol, half will hyperactivity disorder, borderline personality have consumed alcohol in the past year, and 1 disorder, antisocial personality disorder, out of 7 will have had v fi e or more drinks in a schizophrenia); problems with the use of other row in the past 2 weeks. Underage drinking is drugs in addition to alcohol; and physical problems remarkably dangerous, carrying with it substantial and conditions (e.g., liver disease, HIV/AIDS, risk to the health, safety, and well-being of alcohol-related cancers). This comorbidity is a teenagers and those around them. product of genetic vulnerabilities, epigenetics, neurobiology, environment, exposure to stress, Emerging Adults and trauma. As highlighted by NIAAA, having Emerging adults are distinguished by the highest co-occurring disorders is associated with moreover, it risk for alcohol and drug use problems of any greater alcohol problem severity; More than a third of emerging adults age group. complicates the treatment of AUD, which for report binge drinking during the past 2 weeks; optimal effectiveness must be integrated with those attending college are at higher risk for treatment(s) for co-occurring disorders. drinking problems than those not attending Women college, and collegians who participate in Greek NIAAA regards women as a special emphasis letter organizations (“Greek life”) are at especially high risk. population given the higher risk of certain alcohol- related negative consequences compared to men, Older Adults such as liver damage, heart disease, brain damage, NIAAA considers older adults (age 65 and older) Moreover, women are a special and breast cancer. a special emphasis population because many drink emphasis group due to the issues of drinking despite (1) age-related increases in sensitivity during pregnancy and fetal alcohol exposure. In to alcohol, (2) health problems complicated by general, women report more problems related to drinking, and (3) using medications that interact physical and mental health as well as more past Moreover, drinking poorly with alcohol. trauma and abuse (physical and sexual). Notably, problems among older adults often are associated women are more likely than men to begin using with factors unique to senior adulthood, such alcohol and drugs after a specific traumatic event as aging-related health worries, boredom after and to suffer from post-traumatic stress disorder. retirement, the death of friends and loved ones, Key principles in women’s recovery include shame about drinking, and the justica fi tion that addressing any experiences of trauma, including drinking is harmless to others. incest and rape, fears of losing their children, and 20-23 parenting challenges and efficacy. Alcohol Research: Current Reviews 2 Vol 40 No 3 | 2020 Racial and Ethnic Minorities essential elements for defining recovery from NIAAA points out “certain ethnic and AUD has proved challenging. The Substance racial minorities as well as other underserved Abuse and Mental Health Services Administration populations experience more negative (SAMHSA) defines recovery as “ a process of consequences of illness and premature death change through which individuals improve than other groups,” noting disparities affecting their health and wellness, live a self-directed (1) Hispanics/Latinx, (2) Blacks, and (3) Native life, and strive to reach their full potential.” Americans. The life contexts of racial and ethnic Moreover, SAMHSA conceptualizes recovery minority individuals with AUD are likely to along four dimensions: health, home, purpose, include more economic hardship, stress, systemic and community relationships/social networks. discrimination and prejudice, and compounded The Betty Ford Institute Consensus Panel disadvantage, as well as fewer recovery resources defines recovery as “a voluntarily maintained and supports, compared to the life contexts of lifestyle” characterized by sobriety (abstinence non-Hispanic White individuals with AUD. The from alcohol and nonprescribed drugs), personal marginalization associated with racial/ethnic health (improved quality of personal life), and William White minority status produces enduring and signica fi nt citizenship (respect for others). challenges to recovery for such individuals. defines recovery as “the experience (a process The remainder of this narrative review focuses and a sustained status) through which individuals, on individuals from marginalized minority groups families, and communities impacted by severe in the recovery phase of their drinking careers, alcohol and other drug (AOD) problems utilize with particular attention to what may distinguish internal and external resources to voluntarily recovery challenges experienced by minority resolve these problems, heal the wounds inflicted populations from those experienced by majority by AOD-related problems, actively manage their populations. It should be noted that rigorous continued vulnerability to such problems, and empirical studies directly investigating recovery develop a healthy, productive, and meaningful Despite considerable overlap among these among any marginalized minority population(s) life.” are absent from the literature; in contrast, three inu fl ential recovery definitions, they differ in considerable research has been conducted on the meaningful ways with one another (e.g., whether epidemiology of AUD and alcohol-related negative recovery is voluntary; whether recovery means consequences among minority populations. The enduring vulnerability). current narrative review draws heavily on that Kaskutas et al. reached out to adults in recovery = 9,341) and asked them how they defined epidemiological work and extends it to recovery (n recovery. Responses revealed three factors: by: (1) examining what is known about recovery among minority populations; (2) identifying (1) “abstinence” (no use of alcohol); (2) “essential factors and mechanisms that especially may recovery” (being honest with oneself, handling impact recovery among minority populations; and negative feelings without drinking or using, (3) suggesting avenues for additional research. enjoying life without drinking or using); and (3) “enriched recovery” (ongoing growth and development, reacting to life in a more balanced DEFINING RECOVERY way, taking responsibility). In post hoc analyses, AMONG SPECIAL Kaskutas et al. examined possible variation by EMPHASIS POPULATIONS race/ethnicity and education in definitions of Despite widespread common usage of the term recovery, and found almost none. Notably, adults “recovery,” obtaining expert consensus on the in recovery with less than a college degree or Alcohol Research: Current Reviews 3 Vol 40 No 3 | 2020 from racial/ethnic minorities were less likely than AA Special Emphasis Group their counterparts to emphasize abstinence in Adaptation: The Native American defining recovery, and more likely to emphasize Wellbriety Movement Some minority populations have adapted AA the essential recovery and enriched recovery factors. Overall, these differences were slight, literature, rituals, and materials to increase suggesting considerable overlap in definitions of AA’s appeal, as well as cultural and linguistic recovery among and across minority and majority appropriateness, for members of their communities. populations in recovery. Beginning in the 1960s, AA has been steadily adapted by American Indian communities, culminating in the Wellbriety movement. PARTICIPATION IN Wellbriety frames AUD from an American Indian ALCOHOLICS ANONYMOUS perspective, where all things are holistically BY MINORITY POPULATIONS connected, and there is no separation between the Participation in formal alcohol treatment individual, family, and tribe. Moreover, the fourth typically precedes entering recovery. Kaskutas edition of the Big Book of Alcoholics Anonymous et al. found that 96% of adults self-identifying has revised and updated its depictions of Native as being in recovery had received treatment American culture, and a growing number of Native The overwhelming majority of for AUD. American meetings are registering with the AA alcohol treatment programs in the United States General Services Office ( https://naigso-aa.org/). incorporate 12-step elements and promote Despite the advances of the Wellbriety participation in Alcoholics Anonymous (AA) Movement, the relative dearth of AUD treatment as an aid to recovery. AA was founded by and aftercare approaches congruent with Native non-Hispanic White men in the 1930s, and American cultural values, beliefs, and traditions historically most AA members in the United remains a major barrier to recovery from AUD 32,33 Tradition-based Native States have been non-Hispanic White; over time, for Native Americans. AA members have become much more diverse, American practices that may be incorporated ree fl cting the increasing demographic diversity of into AUD treatment and recovery include: the U.S. population. Sweat ceremonies, a cultural practice usually Concerned that AA’s non-Hispanic White performed in a lodge that uses heat and steam to origins might be a barrier to AA participation for cleanse toxins from the mind, body, and spirit; minority populations, Tonnigan, Connors, and smudging or the burning of sacred herbs to purify Miller reviewed the literature and concluded: people and places; the use of ceremonial drums (1) AA is well known and well liked among and songs; Talking Circles; traditional healers; Additionally, historical minority populations; (2) minority populations and Elder teachings. are less likely to avail themselves of AA trauma impinges upon Native Americans’ compared to nonminority populations; and, successful recovery from AUD. Brave Heart (3) minority populations are as likely to benefit notes: “Historical trauma, also referred to In the 2 from AA as nonminority populations. as a cumulative trauma, soul wound, and decades since the published review by Tonnigan intergeneration trauma, refers to the cumulative et al., AA has grown substantially in the number emotional and psychological harm experienced of interest groups, meetings, conventions, and throughout an individual’s life span and through Historical trauma is program resources designed especially for subsequent generations.” minority populations in recovery from AUD (e.g., the cumulative result of centuries of subjugation, http://gal-aa.org/ for gays and lesbians; https:// racism and discrimination, genocidal violence, naigso-aa.org/ for Native Americans). segregation, and systemic oppression inflicted Alcohol Research: Current Reviews 4 Vol 40 No 3 | 2020 upon Native Americans. Incorporating tradition- minority populations are likely to include more based practices, and holistic concepts of wellness pervasive and enduring hardships, stresses, and and community-based recovery support, can disadvantages compared to the life contexts of 40-47 Among marginalized help contextualize and ameliorate the impact of majority populations. historical trauma on recovery from AUD among minority groups, disadvantaged life contexts are 32,33 Native Americans. (1) socially determined, (2) a function of social injustices, and (3) the primary causes of health 41,42 AA Special Emphasis Group This means that inequities and disparities. the long-term elimination of health disparities, Adaptations: African American including those associated with recovery from and Hispanic In African American communities, local church- AUD, is dependent on social change. based drug ministries and mutual aid groups often Research has identie fi d a range of socially are indigenous sources of services for recovery determined disadvantaged life contexts that initiation, stabilization, and maintenance. signica fi ntly impact the course of AUD among 40-47 it is very likely that these Given AA’s Episcopalian roots and its emphasis minority populations; on congregation and mutual aid, AA integrates same social determinants signica fi ntly impact relatively easily with church-based recovery recovery from AUD. Key social determinants support initiatives in African American that may inu fl ence recovery among minority communities. In immigrant urban Hispanic/ populations include: Latinx communities in California, anexos are an • Material hardship indigenous adaptation of AA, typically catering to • Residential segregation male, lower-income, Spanish-speaking immigrants • Neighborhood crime and disorder 37,38 Residences literally annexed to and migrants. • Alcohol access through nearby alcohol outlets AA meeting sites, anexos originated in Mexico including bars and liquor stores in 1975 as part of the recovery support “24 Hour • Stigma about having problems with alcohol use Movement” (Movimiento 24 Horas), and since or having AUD have spread to Hispanic/Latinx communities in • Unfair treatment, prejudice, and discrimination the United States. Although strides have been • Disparities in medical care, resulting in more made toward the cultural and linguistic adaptation untreated or undertreated medical conditions of AA by minority groups, these advances have • Housing instability been limited by an emphasis on heterosexual men; • Unemployment and underemployment thus, a critical next step is the adaptation of AA for • Personal demoralization minority women and for intersectional individuals • Lack of culturally and linguistically appropriate with both racial/ethnic and sexual minority status. recovery support services nearby • Stress, from multiple and interacting sources Such inequity in exposure to economically CHALLENGES TO disadvantaged and health-compromising life RECOVERY AMONG contexts is a pressing environmental justice MINORITY POPULATIONS issue. Racial/ethnic minority populations are Marginalized minority groups possess limited marginalized groups living in lower-income economic and social capital. Such limitations areas; residential segregation by income and race/ typically result from social and environmental ethnicity is considered “the most critical distinctive injustices, and often reflect de jure and de social exposure” driving health disparities. Both before and during facto discrimination. Research has shown that the associations recovery from AUD, the life contexts of between environmental risks and AUD are Alcohol Research: Current Reviews 5 Vol 40 No 3 | 2020 stronger in poorer neighborhoods, suggesting that • Examine how (1) minority populations use environmental challenges are a particular threat or adapt AA, (2) AA practices vary among to recovery among individuals with AUD from minority populations, and (3) characteristics of Although successful minority populations inu fl ence the likelihood of low-income communities. recovery from AUD can be difc fi ult and tortuous benefitting from AA. for anyone, successful recovery for someone from • Investigate the critical transition from treatment a marginalized minority population includes an completion to community-based recovery, and added layer of socially determined challenges how that affects long-term recovery trajectories and environmental injustices. Moreover, a sizable among minority populations. number of people in recovery have more than one • Compare the utilization and impact of AA versus minority identity (e.g., a Latinx lesbian, a person other recovery support services (e.g., Wellbriety; of color who is incarcerated); individuals with SMART [Self-Management and Recovery intersectional identities may be especially likely Training], Celebrate Recovery) among minority to encounter socially determined challenges to populations. recovery from AUD. CONCLUSIONS RECOMMENDATIONS Rigorous empirical studies of recovery from AUD NIAAA has identie fi d four research priorities among minority populations are absent from for investigations regarding the dynamics of the literature. Although many individuals from posttreatment recovery. Two of these priorities minority populations respond well to alcohol speak directly to decreasing health inequities and intervention—successfully completing treatment, enhancing knowledge related to recovery from ending drinking, and starting recovery—minority AUD among minority populations. NIAAA notes populations experience numerous challenges that studies are needed on (1) “the neurobiological, and barriers to recovery from AUD. It is very psychological, environmental, and social factors likely social determinants of health disparities that inu fl ence post-treatment recovery” and (2) signica fi ntly impact recovery from AUD among marginalized minority populations (e.g., racial/ “trajectories of recovery in subgroups of people ethnic minorities, sexual minorities), but this has with different cultural and socioeconomic backgrounds, cognitive abilities, and medical yet to be directly examined. Thus, there is an histories.” Keeping these two priorities in mind, urgent need for investigations of recovery among the following recommendations are offered for minority populations. Such research is essential future research on recovery from AUD among for making progress in eliminating alcohol-related minority populations: health disparities impacting minority populations. • Identify modiab fi le drivers of recovery among Acknowledgments vulnerable populations. This research was supported by the Research Centers in Minority • Estimate the contributions of various life context Institutions at Florida International University (U54MD012393) and Northern Arizona University (U54MD012388), which are hardships, stresses, and disadvantages to recovery sponsored by the National Institute on Minority Health and Health trajectories among minority populations. Disparities. The authors thank Jordan Quintana for her help with • Explore the intersections of various minority manuscript preparation. identities (e.g., race, ethnicity, socioeconomic Financial Disclosure status, sex), alongside experiences of The authors declare no competing financial interests or other discrimination and injustice, vis-à-vis recovery conflicts of interest. trajectories. Alcohol Research: Current Reviews 6 Vol 40 No 3 | 2020 13. Miech RA, Johnston LD, O’Malley PM, et al. Monitoring the Publisher’s Note Future National Survey Results on Drug Use, 1975-2018. Volume Opinions expressed in contributed articles do not necessarily I, Secondary School Students. Ann Arbor, MI: Institute for Social reflect the views of the National Institute on Alcohol Abuse and Research, The University of Michigan; 2019. http://search. Alcoholism, National Institutes of Health. 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Recovery in Special Emphasis Populations

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Abstract

Alcohol Res. 2020;40(3):05 ● https://doi.org/10.35946/arcr.v40.3.05 Published: 10 December 2020 RecoveRy in Special e mphaSiS p tionS opula 1 2 Eric F. Wagner and Julie A. Baldwin Robert Stempel College of Public Health & Social Work, Community-Based Research Institute, and National Institute on Minority Health and Health Disparities (NIMHD) Research Center in a Minority Institution (RCMI), Florida International University, Miami, Florida Center for Health Equity Research and NIMHD RCMI Southwest Health Equity Research Collaborative, Northern Arizona University, Flagstaff, Arizona Special emphasis populations in the current context can be defined as groups experiencing health disparities resulting in elevated risk to health, safety, and well-being from drinking alcohol. Individuals from marginalized minority populations often encounter barriers to accessing and receiving effective alcohol treatment due to social inequities and disadvantaged life contexts, which also may adversely affect recovery from alcohol use disorder (AUD). Recovery from AUD often involves the adoption of a stable non-drinking lifestyle (sobriety), increased health and well-being, and increased social connection. Although there has been considerable work on AUD epidemiology among special emphasis populations, little research exists directly examining recovery among racial/ethnic minority populations and/ or sexual and gender minority populations. The current narrative review hopes to spark scholarly interest in this critically neglected area. This article opens with a review of special emphasis populations and their alcohol-related risks. Next, definitions of recovery, Alcoholics Anonymous, and culturally adapted recovery models for racial/ethnic minority populations are explored. This is followed by a discussion of factors that may particularly influence recovery among marginalized minority populations. This narrative review concludes with a discussion of research priorities for promoting health equity through studies focused on understanding and supporting recovery from AUD among marginalized minority populations. KEY WORDS: alcohol-related disorders; alcoholism; minority health; health status disparities; Alcoholics Anonymous; social justice; alcohol; sexual and gender minorities INTRODUCTION The National Institute on Alcohol Abuse and youth, emerging adults (ages 18 to 28), older Alcoholism (NIAAA) defines special emphasis adults (age 65 and older), women, individuals populations as “groups who face particular experiencing co-occurring disorders, and ethnic risks from drinking alcohol based on personal and racial minorities are special emphasis Underage characteristics such as age or gender.” populations highlighted by NIAAA. Additional Alcohol Research: Current Reviews 1 Vol 40 No 3 | 2020 special emphasis populations at heightened risk for Individuals With Co-Occurring 2-4 individuals with AUD include sexual minorities, Disorders 5-10 11 homeless persons, Co-occurring disorders alongside AUD are justice system involvement, and former foster care emerging adults. common, and individuals with co-occurring disorders are a special emphasis population given Underage Youth the complexities associated with treating AUD Underage youth are a special emphasis population alongside other disorders. People with drinking given the ubiquity and inherent danger of problems are at heightened risk for psychiatric problems (i.e., anxiety disorders, depressive underage drinking, as well as the status illegality disorders, bipolar disorders, attention-deficit/ of drinking among minors. By 12th grade, most Americans will have consumed alcohol, half will hyperactivity disorder, borderline personality have consumed alcohol in the past year, and 1 disorder, antisocial personality disorder, out of 7 will have had v fi e or more drinks in a schizophrenia); problems with the use of other row in the past 2 weeks. Underage drinking is drugs in addition to alcohol; and physical problems remarkably dangerous, carrying with it substantial and conditions (e.g., liver disease, HIV/AIDS, risk to the health, safety, and well-being of alcohol-related cancers). This comorbidity is a teenagers and those around them. product of genetic vulnerabilities, epigenetics, neurobiology, environment, exposure to stress, Emerging Adults and trauma. As highlighted by NIAAA, having Emerging adults are distinguished by the highest co-occurring disorders is associated with moreover, it risk for alcohol and drug use problems of any greater alcohol problem severity; More than a third of emerging adults age group. complicates the treatment of AUD, which for report binge drinking during the past 2 weeks; optimal effectiveness must be integrated with those attending college are at higher risk for treatment(s) for co-occurring disorders. drinking problems than those not attending Women college, and collegians who participate in Greek NIAAA regards women as a special emphasis letter organizations (“Greek life”) are at especially high risk. population given the higher risk of certain alcohol- related negative consequences compared to men, Older Adults such as liver damage, heart disease, brain damage, NIAAA considers older adults (age 65 and older) Moreover, women are a special and breast cancer. a special emphasis population because many drink emphasis group due to the issues of drinking despite (1) age-related increases in sensitivity during pregnancy and fetal alcohol exposure. In to alcohol, (2) health problems complicated by general, women report more problems related to drinking, and (3) using medications that interact physical and mental health as well as more past Moreover, drinking poorly with alcohol. trauma and abuse (physical and sexual). Notably, problems among older adults often are associated women are more likely than men to begin using with factors unique to senior adulthood, such alcohol and drugs after a specific traumatic event as aging-related health worries, boredom after and to suffer from post-traumatic stress disorder. retirement, the death of friends and loved ones, Key principles in women’s recovery include shame about drinking, and the justica fi tion that addressing any experiences of trauma, including drinking is harmless to others. incest and rape, fears of losing their children, and 20-23 parenting challenges and efficacy. Alcohol Research: Current Reviews 2 Vol 40 No 3 | 2020 Racial and Ethnic Minorities essential elements for defining recovery from NIAAA points out “certain ethnic and AUD has proved challenging. The Substance racial minorities as well as other underserved Abuse and Mental Health Services Administration populations experience more negative (SAMHSA) defines recovery as “ a process of consequences of illness and premature death change through which individuals improve than other groups,” noting disparities affecting their health and wellness, live a self-directed (1) Hispanics/Latinx, (2) Blacks, and (3) Native life, and strive to reach their full potential.” Americans. The life contexts of racial and ethnic Moreover, SAMHSA conceptualizes recovery minority individuals with AUD are likely to along four dimensions: health, home, purpose, include more economic hardship, stress, systemic and community relationships/social networks. discrimination and prejudice, and compounded The Betty Ford Institute Consensus Panel disadvantage, as well as fewer recovery resources defines recovery as “a voluntarily maintained and supports, compared to the life contexts of lifestyle” characterized by sobriety (abstinence non-Hispanic White individuals with AUD. The from alcohol and nonprescribed drugs), personal marginalization associated with racial/ethnic health (improved quality of personal life), and William White minority status produces enduring and signica fi nt citizenship (respect for others). challenges to recovery for such individuals. defines recovery as “the experience (a process The remainder of this narrative review focuses and a sustained status) through which individuals, on individuals from marginalized minority groups families, and communities impacted by severe in the recovery phase of their drinking careers, alcohol and other drug (AOD) problems utilize with particular attention to what may distinguish internal and external resources to voluntarily recovery challenges experienced by minority resolve these problems, heal the wounds inflicted populations from those experienced by majority by AOD-related problems, actively manage their populations. It should be noted that rigorous continued vulnerability to such problems, and empirical studies directly investigating recovery develop a healthy, productive, and meaningful Despite considerable overlap among these among any marginalized minority population(s) life.” are absent from the literature; in contrast, three inu fl ential recovery definitions, they differ in considerable research has been conducted on the meaningful ways with one another (e.g., whether epidemiology of AUD and alcohol-related negative recovery is voluntary; whether recovery means consequences among minority populations. The enduring vulnerability). current narrative review draws heavily on that Kaskutas et al. reached out to adults in recovery = 9,341) and asked them how they defined epidemiological work and extends it to recovery (n recovery. Responses revealed three factors: by: (1) examining what is known about recovery among minority populations; (2) identifying (1) “abstinence” (no use of alcohol); (2) “essential factors and mechanisms that especially may recovery” (being honest with oneself, handling impact recovery among minority populations; and negative feelings without drinking or using, (3) suggesting avenues for additional research. enjoying life without drinking or using); and (3) “enriched recovery” (ongoing growth and development, reacting to life in a more balanced DEFINING RECOVERY way, taking responsibility). In post hoc analyses, AMONG SPECIAL Kaskutas et al. examined possible variation by EMPHASIS POPULATIONS race/ethnicity and education in definitions of Despite widespread common usage of the term recovery, and found almost none. Notably, adults “recovery,” obtaining expert consensus on the in recovery with less than a college degree or Alcohol Research: Current Reviews 3 Vol 40 No 3 | 2020 from racial/ethnic minorities were less likely than AA Special Emphasis Group their counterparts to emphasize abstinence in Adaptation: The Native American defining recovery, and more likely to emphasize Wellbriety Movement Some minority populations have adapted AA the essential recovery and enriched recovery factors. Overall, these differences were slight, literature, rituals, and materials to increase suggesting considerable overlap in definitions of AA’s appeal, as well as cultural and linguistic recovery among and across minority and majority appropriateness, for members of their communities. populations in recovery. Beginning in the 1960s, AA has been steadily adapted by American Indian communities, culminating in the Wellbriety movement. PARTICIPATION IN Wellbriety frames AUD from an American Indian ALCOHOLICS ANONYMOUS perspective, where all things are holistically BY MINORITY POPULATIONS connected, and there is no separation between the Participation in formal alcohol treatment individual, family, and tribe. Moreover, the fourth typically precedes entering recovery. Kaskutas edition of the Big Book of Alcoholics Anonymous et al. found that 96% of adults self-identifying has revised and updated its depictions of Native as being in recovery had received treatment American culture, and a growing number of Native The overwhelming majority of for AUD. American meetings are registering with the AA alcohol treatment programs in the United States General Services Office ( https://naigso-aa.org/). incorporate 12-step elements and promote Despite the advances of the Wellbriety participation in Alcoholics Anonymous (AA) Movement, the relative dearth of AUD treatment as an aid to recovery. AA was founded by and aftercare approaches congruent with Native non-Hispanic White men in the 1930s, and American cultural values, beliefs, and traditions historically most AA members in the United remains a major barrier to recovery from AUD 32,33 Tradition-based Native States have been non-Hispanic White; over time, for Native Americans. AA members have become much more diverse, American practices that may be incorporated ree fl cting the increasing demographic diversity of into AUD treatment and recovery include: the U.S. population. Sweat ceremonies, a cultural practice usually Concerned that AA’s non-Hispanic White performed in a lodge that uses heat and steam to origins might be a barrier to AA participation for cleanse toxins from the mind, body, and spirit; minority populations, Tonnigan, Connors, and smudging or the burning of sacred herbs to purify Miller reviewed the literature and concluded: people and places; the use of ceremonial drums (1) AA is well known and well liked among and songs; Talking Circles; traditional healers; Additionally, historical minority populations; (2) minority populations and Elder teachings. are less likely to avail themselves of AA trauma impinges upon Native Americans’ compared to nonminority populations; and, successful recovery from AUD. Brave Heart (3) minority populations are as likely to benefit notes: “Historical trauma, also referred to In the 2 from AA as nonminority populations. as a cumulative trauma, soul wound, and decades since the published review by Tonnigan intergeneration trauma, refers to the cumulative et al., AA has grown substantially in the number emotional and psychological harm experienced of interest groups, meetings, conventions, and throughout an individual’s life span and through Historical trauma is program resources designed especially for subsequent generations.” minority populations in recovery from AUD (e.g., the cumulative result of centuries of subjugation, http://gal-aa.org/ for gays and lesbians; https:// racism and discrimination, genocidal violence, naigso-aa.org/ for Native Americans). segregation, and systemic oppression inflicted Alcohol Research: Current Reviews 4 Vol 40 No 3 | 2020 upon Native Americans. Incorporating tradition- minority populations are likely to include more based practices, and holistic concepts of wellness pervasive and enduring hardships, stresses, and and community-based recovery support, can disadvantages compared to the life contexts of 40-47 Among marginalized help contextualize and ameliorate the impact of majority populations. historical trauma on recovery from AUD among minority groups, disadvantaged life contexts are 32,33 Native Americans. (1) socially determined, (2) a function of social injustices, and (3) the primary causes of health 41,42 AA Special Emphasis Group This means that inequities and disparities. the long-term elimination of health disparities, Adaptations: African American including those associated with recovery from and Hispanic In African American communities, local church- AUD, is dependent on social change. based drug ministries and mutual aid groups often Research has identie fi d a range of socially are indigenous sources of services for recovery determined disadvantaged life contexts that initiation, stabilization, and maintenance. signica fi ntly impact the course of AUD among 40-47 it is very likely that these Given AA’s Episcopalian roots and its emphasis minority populations; on congregation and mutual aid, AA integrates same social determinants signica fi ntly impact relatively easily with church-based recovery recovery from AUD. Key social determinants support initiatives in African American that may inu fl ence recovery among minority communities. In immigrant urban Hispanic/ populations include: Latinx communities in California, anexos are an • Material hardship indigenous adaptation of AA, typically catering to • Residential segregation male, lower-income, Spanish-speaking immigrants • Neighborhood crime and disorder 37,38 Residences literally annexed to and migrants. • Alcohol access through nearby alcohol outlets AA meeting sites, anexos originated in Mexico including bars and liquor stores in 1975 as part of the recovery support “24 Hour • Stigma about having problems with alcohol use Movement” (Movimiento 24 Horas), and since or having AUD have spread to Hispanic/Latinx communities in • Unfair treatment, prejudice, and discrimination the United States. Although strides have been • Disparities in medical care, resulting in more made toward the cultural and linguistic adaptation untreated or undertreated medical conditions of AA by minority groups, these advances have • Housing instability been limited by an emphasis on heterosexual men; • Unemployment and underemployment thus, a critical next step is the adaptation of AA for • Personal demoralization minority women and for intersectional individuals • Lack of culturally and linguistically appropriate with both racial/ethnic and sexual minority status. recovery support services nearby • Stress, from multiple and interacting sources Such inequity in exposure to economically CHALLENGES TO disadvantaged and health-compromising life RECOVERY AMONG contexts is a pressing environmental justice MINORITY POPULATIONS issue. Racial/ethnic minority populations are Marginalized minority groups possess limited marginalized groups living in lower-income economic and social capital. Such limitations areas; residential segregation by income and race/ typically result from social and environmental ethnicity is considered “the most critical distinctive injustices, and often reflect de jure and de social exposure” driving health disparities. Both before and during facto discrimination. Research has shown that the associations recovery from AUD, the life contexts of between environmental risks and AUD are Alcohol Research: Current Reviews 5 Vol 40 No 3 | 2020 stronger in poorer neighborhoods, suggesting that • Examine how (1) minority populations use environmental challenges are a particular threat or adapt AA, (2) AA practices vary among to recovery among individuals with AUD from minority populations, and (3) characteristics of Although successful minority populations inu fl ence the likelihood of low-income communities. recovery from AUD can be difc fi ult and tortuous benefitting from AA. for anyone, successful recovery for someone from • Investigate the critical transition from treatment a marginalized minority population includes an completion to community-based recovery, and added layer of socially determined challenges how that affects long-term recovery trajectories and environmental injustices. Moreover, a sizable among minority populations. number of people in recovery have more than one • Compare the utilization and impact of AA versus minority identity (e.g., a Latinx lesbian, a person other recovery support services (e.g., Wellbriety; of color who is incarcerated); individuals with SMART [Self-Management and Recovery intersectional identities may be especially likely Training], Celebrate Recovery) among minority to encounter socially determined challenges to populations. recovery from AUD. CONCLUSIONS RECOMMENDATIONS Rigorous empirical studies of recovery from AUD NIAAA has identie fi d four research priorities among minority populations are absent from for investigations regarding the dynamics of the literature. Although many individuals from posttreatment recovery. Two of these priorities minority populations respond well to alcohol speak directly to decreasing health inequities and intervention—successfully completing treatment, enhancing knowledge related to recovery from ending drinking, and starting recovery—minority AUD among minority populations. NIAAA notes populations experience numerous challenges that studies are needed on (1) “the neurobiological, and barriers to recovery from AUD. It is very psychological, environmental, and social factors likely social determinants of health disparities that inu fl ence post-treatment recovery” and (2) signica fi ntly impact recovery from AUD among marginalized minority populations (e.g., racial/ “trajectories of recovery in subgroups of people ethnic minorities, sexual minorities), but this has with different cultural and socioeconomic backgrounds, cognitive abilities, and medical yet to be directly examined. Thus, there is an histories.” Keeping these two priorities in mind, urgent need for investigations of recovery among the following recommendations are offered for minority populations. Such research is essential future research on recovery from AUD among for making progress in eliminating alcohol-related minority populations: health disparities impacting minority populations. • Identify modiab fi le drivers of recovery among Acknowledgments vulnerable populations. This research was supported by the Research Centers in Minority • Estimate the contributions of various life context Institutions at Florida International University (U54MD012393) and Northern Arizona University (U54MD012388), which are hardships, stresses, and disadvantages to recovery sponsored by the National Institute on Minority Health and Health trajectories among minority populations. Disparities. The authors thank Jordan Quintana for her help with • Explore the intersections of various minority manuscript preparation. identities (e.g., race, ethnicity, socioeconomic Financial Disclosure status, sex), alongside experiences of The authors declare no competing financial interests or other discrimination and injustice, vis-à-vis recovery conflicts of interest. trajectories. Alcohol Research: Current Reviews 6 Vol 40 No 3 | 2020 13. Miech RA, Johnston LD, O’Malley PM, et al. Monitoring the Publisher’s Note Future National Survey Results on Drug Use, 1975-2018. Volume Opinions expressed in contributed articles do not necessarily I, Secondary School Students. Ann Arbor, MI: Institute for Social reflect the views of the National Institute on Alcohol Abuse and Research, The University of Michigan; 2019. http://search. Alcoholism, National Institutes of Health. 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Alcohol Research : Current ReviewsPubmed Central

Published: Dec 10, 2020

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