Harm Reduction Treatment for Substance Use E-Book

Susan E. Collins

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Serie: Advances in Psychotherapy - Evidence-Based Practice
• Sprache: Englisch
• Veröffentlichungsjahr: 2023

Seitenzahl: 263

Beschreibung

Harm reduction approaches are effective, patient-driven alternatives to abstinence-based treatment for people who are not ready, willing, or able to stop using substances. This volume outlines the scientific basis and historical development of these approaches, and reviews why abstinence-based approaches often do not work. The authors then share their expertise about harm reduction treatment (HaRT), an empirically based approach co-developed with community members impacted by substance-related harm – a first of its kind. The reader learns in detail about the pragmatic mindset and compassionate heartset of HaRT and the three treatment components: measurement and tracking of patient-preferred substance-related metrics, harm-reduction goal setting and achievement, and discussion of safer-use strategies. This volume walks practitioners through all components, provides example scripts for use in daily practice, and illustrates the work through case studies and input from community members. Handouts are available for use in daily practice. This is essential reading for clinical psychologists, psychotherapists, and researchers who encounter people who have substance-use problems.

Leseprobe

Advances in Psychotherapy – Evidence-Based Practice, Volume 49

Harm Reduction Treatment for Substance Use

Susan E. Collins

HaRRT Center, Department of Psychiatry and Behavioral Sciences, University of Washington, School of Medicine, Seattle, WA

Department of Psychology, Washington State University, Pullman, WA

Seema L. Clifasefi

HaRRT Center, Department of Psychiatry and Behavioral Sciences, University of Washington, School of Medicine, Seattle, WA

About the Authors

Susan E. Collins, PhD, (she/her) is a licensed clinical psychologist, faculty at the University of Washington School of Medicine and Washington State University, co-director of the Harm Reduction Research and Treatment (HaRRT) Center, and co-founder of the social purpose corporation, HaRT3S. Dr. Collins has been involved in substance use research, assessment, and treatment for over 25 years and has disseminated this work in over seven dozen book chapters, abstracts, and peer-reviewed articles. Dr. Collins also brings her own lived experience as a person in recovery from addictive behaviors and as a woman embedded in families with the intergenerational experience of addictive behaviors, substance use disorder, and substance-related harm.

Seema L. Clifasefi, PhD, is a licensed clinical social worker, an associate professor and co-director of the Harm Reduction Research and Treatment (HaRRT) Center at the University of Washington – Harborview Medical Center, and co-founder of the social purpose corporation HaRT3S. Her research lies at the intersection of substance use, mental health, criminal justice, and housing policy. For the past nearly two decades she has been part of several collaborative academic/community-based research partnerships focused on the development and evaluation of individual and community-level harm reduction programs and interventions designed for and with people who have lived experience of homelessness and substance use problems.

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, Professor Emeritus, University of Missouri–Saint Louis, MO

Associate Editors

Jonathan S. Comer, PhD, Professor of Psychology and Psychiatry, Director of Mental Health Interventions and Technology (MINT) Program, Center for Children and Families, Florida International University, Miami, FL

J. Kim Penberthy, PhD, ABPP, Professor of Psychiatry & Neurobehavioral Sciences, University of Virginia, Charlottesville, VA

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a reader-friendly manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work and an ideal educational resource for students as well as for practice-oriented continuing education.

The most important feature of the books is that they are practical and easy to use: All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Continuing Education Credits

Psychologists and other healthcare providers may earn five continuing education credits for reading the books in the Advances in Psychotherapy series and taking a multiple-choice exam. This continuing education program is a partnership of Hogrefe Publishing and the National Register of Health Service Psychologists. Details are available at https://www.hogrefe.com/us/cenatreg

The National Register of Health Service Psychologists is approved by the American Psychological Association to sponsor continuing education for psychologists. The National Register maintains responsibility for this program and its content.

Library of Congress of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2023933421

Library and Archives Canada Cataloguing in Publication

Title: Harm reduction treatment for substance use / Susan E. Collins (HaRRT Center, Department of

Psychiatry and Behavioral Sciences, University of Washington, School of Medicine, Seattle, WA,

Department of Psychology, Washington State University, Pullman, WA), Seema L. Clifasefi (HaRRT

Center, Department of Psychiatry and Behavioral Sciences, University of Washington, School of

Medicine, Seattle, WA).

Names: Collins, Susan E., author. | Clifasefi, Seema L., author.

Series: Advances in psychotherapy--evidence-based practice ; v. 49.

Description: Series statement: Advances in psychotherapy--evidence-based practice ; volume 49 |

Includes bibliographical references.

Identifiers: Canadiana (print) 20230194028 | Canadiana (ebook) 20230194087 | ISBN 9780889375079

(softcover) | ISBN 9781613345078 (EPUB) | ISBN 9781616765071 (PDF)

Subjects: LCSH: Substance abuse—Treatment. | LCSH: Substance abuse—Social aspects. | LCSH: Harm

reduction. | LCSH: Psychotherapy.

Classification: LCC RC564 .C65 2023 | DDC 616.86/06—dc23

© 2023 by Hogrefe Publishing

www.hogrefe.com

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

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Cover image: © HaizhanZheng – iStock.com

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|v|Acknowledgments

We would like to acknowledge our longtime community partners and collaborators who have unwaveringly supported the research that forms the foundation of this book, including our friends and colleagues at the Downtown Emergency Service Center, Evergreen Treatment Services – REACH program, the People’s Harm Reduction Alliance, Pioneer Human Services at the Dutch Shisler Sobering Support Center, Seattle/King County Public Health, Seattle/King County Behavioral Health and Recovery Division, Catholic Housing Services, among others. We also acknowledge the support of our institutions, the University of Washington School of Medicine and Washington State University, as well as our funders at the National Institutes of Health and the Alcohol and Drug Abuse Institute.

We would also like to thank our longtime consultants, colleagues, and collaborators in this research, including Dr. Patt Denning, Dr. Mark Duncan, Dr. Bonnie Duran, Noah Fay, T. Ron Jackson, Shilo Jama, Dr. Mary Larimer, Jeannie Little, Daniel Malone, Dr. Joseph Merrill, Dr. Lonnie Nelson, Dr. Michele Peake-Andrasik, Dr. Richard K. Ries, Dr. Andrew Saxon, and Dr. Brian Smart. We thank our staff, students, and trainees at the Harm Reduction Research and Treatment (HaRRT) Center, without whom we could not have conducted the research that has informed this book. We especially thank Emily Taylor, our senior research coordinator, for her hard work and dedication coordinating multiple treatment trials over the past decade. We also acknowledge the work of the clinicians and administrators of the harm reduction treatment (HaRT) track at Harborview Medical Center many of whom kindly reviewed this manuscript.

We honor the memory of the late Dr. G. Alan Marlatt, who entrusted us with some projects he held dear, whose trailblazing work inspired our efforts, and for whose mentorship we will always be grateful. We also thank Dr. William R. Miller for his work on the spirit of motivational interviewing, which has deeply informed our work as clinicians, and for his help in drawing parallels and distinctions between motivational interviewing and harm reduction treatment. We thank Dr. Linda Sobell for her astute editorial help. We are also deeply grateful to her and Dr. Mark Sobell for their early and courageous work in non-abstinence-based treatment, natural recovery, guided self-change, and more nuanced measurements of substance use, all of which likewise formed a strong foundation for this book.

We acknowledge and hope to honor in this work the immeasurable contributions of our various community advisory board members and community consultants over the years, as well as the hundreds of patients, clients, and research participants that contributed their experiences to this work. We especially honor the memory of Joey Stanton, beloved community consultant and mentor, whom we cite in this book. We thank Lovella Black Bear and Grover “Will” Williams, who are longtime community advisory board members who contributed their words and to whom we are grateful for every |vi|co-learning moment. Many community members – research participants, clients, community advisory board members – have told us over the years that they simply hoped their own experiences could help someone else in need and could help their communities heal. We believe they have.

Finally, we dedicate this book to our families, who have their own long and complicated histories with substances, substance use and SUD, and for whose future we are fighting.

Contents

Acknowledgments

Preface

1  Description

1.1  Terminology and Definitions

1.1.1  Harm Reduction Heartset Is Foundational

1.1.2  Harm Reduction Mindset Is Pragmatic

1.1.3  Harm Reduction Across Ecological Systems

1.2  Applying Harm Reduction in Clinical Work

1.2.1  Accepting Substance Use Is Here to Stay

1.2.2  Acknowledging Reasons for Clients’ Use

1.2.3  Recognizing Substance-Related Harm Is Shaped by Systems

1.2.4  Supporting Clients’ Own Steps Toward Harm Reduction

1.2.5  Working Toward Social Justice and Racial Equity

1.3  Rationale for Harm Reduction

1.3.1  Abstinence-Only Approaches Are Disempowering

1.3.2  Abstinence-Only Approaches Do Not Consistently Engage

1.3.3  Harm Reduction Approaches Are Effective

1.4  The Harm Reduction Treatment Model

1.5  Related and Foundational Treatment Models

1.5.1  “Controlled Drinking”

1.5.2  Brief Interventions in Health Care Settings

1.5.3  Personalized Normative Feedback Interventions

1.5.4  Motivational Interviewing

1.5.5  Guided Self-Change

1.5.6  Harm Reduction Psychotherapy

1.6  Conclusions

2  Theories and Models

2.1  Pharmacological Treatment for Harm Reduction

2.2  Behavioral Harm Reduction Treatment

2.2.1  HaRT Mindset

2.2.2  HaRT Heartset

2.2.3  HaRT Components

2.3  What HaRT Is Not

3  Assessment and Treatment Indications

3.1  Treatment Indication

3.2  Preparation for HaRT

3.2.1  Reflecting On and Readying Your Practice Setting

3.2.2  Preparing to Navigate Systems For and With Clients

3.3  Assessment of HaRT Efficacy on Key Outcomes

3.3.1  Assessment of Safer-Use Strategies and Harm Reduction Goal Setting

3.3.2  Assessment of Substance Use Outcomes

3.3.3  Lab Testing and Biomarkers

3.3.4  Measures of QoL Outcomes

3.3.5  Measures for Utilization and Cost Analysis

3.3.6  Treatment Integrity Materials and Measures

4  HaRT Implementation

4.1  Method of Approach

4.1.1  HaRT Mindset

4.1.2  HaRT Heartset

4.1.3  HaRT Components and Their Integration in Initial and Follow-Up Sessions

4.1.4  Auxiliary HaRT Components

4.2  HaRT Efficacy and Prognosis

4.2.1  Behavioral Harm Reduction Treatment for AUD

4.2.2  Combined Pharmacotherapy and Behavioral Treatment

4.3  Problems in Carrying Out the Approaches

4.4  Diversity Issues

5  Afterword

6  Case Vignettes

7  Further Reading

8  References

9  Appendix: Tools and Resources

|ix|Preface

We are writing this preface over 2 years into the global COVID-19 pandemic, which hit the US with force in early 2020. The past 2 years have been both a harrowing and a heady time in our nation’s history, full of seismic shifts toward healing and justice, as well as heartbreaking losses and setbacks. The field of substance use treatment and research has been a part of this picture. The pandemic ushered in record-breaking rates of morbidity and mortality, disproportionately impacting communities of color, people with disabilities, and older people. For many, however, the toll went beyond the infection and its proximal sequelae. As the psychological impacts of the pandemic took hold, overdose deaths and alcohol-related deaths due to accidents and liver disease spiked in unprecedented ways.

Fortunately, just in time to meet this challenge, high-ranking government officials in the US have warmed to harm reduction as national policy. For the first time in history, the White House has formally embraced harm reduction: The Biden–Harris administration’s inaugural National Drug Control Strategy centers harm reduction as essential to “keep people alive” and “engage and build trust with people who use drugs” (White House et al., 2022). The definition of “recovery” from the National Institute on Alcohol Abuse and Alcoholism was recently expanded beyond abstinence to include remission from symptoms of alcohol use disorder, cessation of “heavy drinking,” and improvements in biopsychosocial functioning and quality of life (Hagman et al., 2022). National leaders in substance use treatment, policy, and research funding recently defined the concept of preaddiction to introduce more nuance into the diagnosis of substance use disorder and more approachable pathways for primary and secondary prevention (McLellan et al., 2022). As harm reduction researchers and clinicians, we appreciate these steps.

Of course, people who use substances, and their families and their communities, have been engaging in ways to reduce harm long before these recent steps, often in the face of government inaction and even persecution. The specific term “harm reduction” has, over the past 4 decades, come to be most closely associated with grassroots activism and public health efforts to reduce harm associated with substance use and sexual behaviors, particularly in response to the HIV/AIDS crisis of the 80s and 90s. We acknowledge the importance of the vast and diverse harm reduction work done in communities, across professional disciplines, and around the world. For this reason, we want to be clear that this book will address just one narrow aspect of the larger field of harm reduction. Namely, we are US-based and Western-trained substance use treatment clinicians who are writing a psychotherapeutic manual on an evidence-based harm reduction treatment practice developed with and for people who use substances.

With this focus in mind, harm reduction for substance use is a set of compassionate and pragmatic approaches to reduce substance-related harm and improve quality of life for people who use substances, their families, |x|and their communities. The modern harm reduction movement has been underpinned by strong grassroots efforts that have often been led by people who use substances and have been marginalized within the system. In our roles as researchers and clinicians, we have sought to positively contribute to harm reduction, while being mindful of the concerns about governmental, public health, and academic appropriation of the work. We have engaged in long-term collaborations with community members and community-based agencies to share resources, co-learn, cocreate, implement, evaluate, and disseminate the work you are reading about here.

This book, Harm Reduction Treatment for Substance Use, is laid out similarly to others in the Advances in Psychotherapy – Evidence-Based Practice series. In Chapter 1, we provide definitions, scientific rationale, and historically relevant models that informed the development of HaRT, and in Chapter 2, we detail its underpinning theoretical tenets. In Chapter 3, we review treatment indications and practice preparation for HaRT. We also review psychometrically sound assessment tools we have used in research trials and clinical practice to inform, guide, and evaluate our application of HaRT. Early in Chapter 4, we describe the implementation of HaRT in outpatient psychotherapy and community-based settings. Then we share HaRT’s evidence base, challenges in its application, and its placement in cultural context. We close with two case vignettes in Chapter 5 and provide further readings that expand on harm reduction treatment in Chapter 6. In the Appendices, we have provided measures and worksheets to facilitate application of HaRT in clinical practice.

As we share information about HaRT for your consideration, we want to acknowledge and thank the grassroots activists and thought leaders who have spent decades fighting for harm reduction treatment, programming, and policy, often at great risk to themselves, to help their communities survive and thrive. We are thus donating any royalties we receive from this book to community-based harm reduction agencies, from whom we have learned so much.

|1|1Description

We did not start out as harm reductionists. Seema L. Clifasefi was originally trained, not as a clinician, but as a cognitive and experimental psychologist, designing experiments to manipulate participants’ memories and experiences. These studies were undergirded by researcher-driven theories about others’ realities, testing the effects of alcohol and alcohol placebos on cognitive and perceptual processes, such as eyewitness memory, inattentional blindness, and false memories. Susan E. Collins, with a recovery history of her own and the intergenerational experience of substance use disorder (SUD), spent time in the 12-step community, diligently learned the pantheon of treatments that encourage people to change in counselor-sanctioned ways, and stood in bathrooms with rubber gloves on, collecting drug toxicology samples, and writing letters to judges.

Instead, the harm reduction movement changed us slowly over time, reshaping our practices, our careers, and our lives. We were changed by conversations with our mentors, including G. Alan Marlatt, PhD, Mary Larimer, PhD, Patt Denning, PhD, Jeannie Little, LICSW, and Linda Sobell, PhD, trailblazers in drinking moderation and harm reduction approaches. We were changed by the teachings of community members who had to “bang on the table” to be heard in service settings (Collins et al., 2018), of front-line case managers who told us that harm reduction is the “only thing that works” (Collins, Clifasefi, Dana, et al., 2012), of activists organizing for users’ rights and providing services to their own communities – the Junkiebond, VOCAL, National Harm Reduction Coalition, Chicago Recovery Alliance, People’s Harm Reduction Alliance, Urban Survivor’s Union, among others. These teachings made us deeply reflect on our own frustrations with our belief systems, our institutions, our research, and our clinical practices.

We believe this change for us is also happening for many others in our field. Perhaps it reflects a larger sea change that is sweeping across our scientific disciplines, our clinical practices, and the larger collective culture in the US. In substance use and mental health counseling, more narrowly, clinicians, therapists, and counselors are increasingly aware of and learning from grassroots harm reduction movements and from their own clients (Collins, Clifasefi, Andrasik, et al., 2012; Hawk et al., 2017). As harm reduction clinicians, we must support these grassroots efforts without co-opting them, and we need to ask ourselves what we, in our professional identities, can offer to this movement. In response, we wrote this book to describe the evidence-based harm reduction treatment modality we have spent the last decade codeveloping, implementing, and evaluating, together with communities marginalized by substance-related harm.

|2|1.1  Terminology and Definitions

As applied to substance use intervention, the umbrella term “harm reduction” refers to a compassionate stance and a set of pragmatic strategies that minimize substance-related harm and enhance QoL for people who use substances, their families, and their communities (Collins et al., 2011). As its name implies, harm reduction breaks with traditional abstinence-based approaches in that its focus is on minimizing harm, and it does not require or even particularly elevate abstinence or use reduction as ultimate goals (Heather, 2006). While we appreciate the contributions of abstinence-based approaches as important and effective recovery pathways for some, we believe harm reduction approaches are necessary additions to the spectrum of care to ensure greater treatment reach, engagement, and effectiveness.

1.1.1  Harm Reduction Heartset Is Foundational

As defined above, harm reduction can be described as a set of strategies; however, it is the culturally humble and compassionate spirit or harm reduction heartset with which strategies are applied that is essential. In fact, this heartset should drive the nature of more concrete interventions and the way they are implemented and thereby received by the community. Of course, we are not the first ones to say this. Dave Purchase, the late and great founding director of the North America Syringe Exchange Network (NASEN) and the Tacoma Needle Exchange noted that harm reduction is more “an attitude” than a fixed set of approaches (Marlatt, 1998b, p. 6). Handing out clean syringes constitutes a fairly concrete harm reduction intervention, but Purchase knew the most important part was how he set up his program to center people who use substances, how he handed out syringes with nonjudgment, and how he was in community with love, humility, and compassion in this work.

1.1.2  Harm Reduction Mindset Is Pragmatic

Adopting a harm reduction mindset is pragmatic for those of us seeking to work with the entire spectrum of people who use substances. After all, it is substance-related harm that drives the diagnosis of substance use disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Pragmatism also drives harm reduction clinicians’ additional focus on QoL. Our research has shown that people who use substances are striving to meet their basic needs and engage in meaningful activities, just as much if not more than changing their substance use (Fentress et al., 2021). This same research has shown that a clinical focus that prioritizes both what people want to leave behind (i.e., substance-related harm) and what they want to move toward (e.g., engaging in meaningful activities, fulfilling basic needs) is associated with positive treatment outcomes (Fentress et al., 2021).

|3|1.1.3  Harm Reduction Across Ecological Systems

Thinking more systemically (Bronfenbrenner, 1979), harm reduction approaches for substance use may be, and are, applied at various levels. Taking the widest lens, macrosystem-level approaches comprise policy changes (e.g., decriminalizing, legalizing, and regulating substance use; Marlatt & Witkiewitz, 2010) or large-scale provision of high-coverage, combined intervention programs (e.g., comprehensive medication for opioid use disorder [MOUD] plus syringe programs plus antiretroviral therapy; Degenhardt et al., 2010). At the population level, harm reduction can take the form of public health messaging and public service announcements (e.g., the 1983 “friends don’t let friends drive drunk” campaign from the Ad Council). At the community level, harm reduction approaches are often applied within higher-risk communities to reduce risks for that community, as well as the surrounding environment (e.g., low-barrier, non-abstinence-based “Housing First,” needle and syringe programs, safer consumption sites). Finally, harm reduction at the individual level encompasses treatment, counseling, or other one-on-one or group healing approaches (Collins et al., 2011).

1.2  Applying Harm Reduction in Clinical Work

Because clinicians, psychotherapists, and counselors are most active in their professional roles on the individual level of intervention, we focus in this book on an evidence-based psychotherapeutic or counseling treatment protocol that we call harm reduction treatment for substance use disorder (HaRT). However, before we focus on that individual level of harm reduction, we will explore the tenets of the broader harm reduction movement and their relevance for our clinical practice.

1.2.1  Accepting Substance Use Is Here to Stay

Substance use has existed for millennia as an essential human behavior (Guerra-Doce, 2015). In our modern societies, one can surmise that most people are engaged in some kind of substance use on a regular basis. (For example, did you have your morning coffee or tea today?) We have thus concluded that it is neither an efficient nor an effective way to spend our time as clinicians trying to eradicate this long-standing human behavior. We are better positioned to do what we can today to help people and their communities reduce substance-related harm.

1.2.2  Acknowledging Reasons for Clients’ Use

In contrast to some abstinence-based ideologies (e.g., Alcoholics Anonymous, 2008), we assert that substance use is not “irrational.” While we acknowledge substance-related harm, we also acknowledge the real and valid reasons our |4|clients use (e.g., attaining and maintaining a sense of physical and psychological safety and comfort, cognitive focus, relaxation, enjoyment, and social benefits; Collins et al., 2013; Collins, Kirouac, et al., 2014; Collins, Taylor, et al., 2018). Our research has indicated that substance use is simply one way people seek to serve their overarching QoL goals (Fentress et al., 2021), which cross-cultural studies show are founded on relatively universal human goals (Grouzet et al., 2005). Recent mainstream books on drug use and harm reduction have served to elevate these perspectives (Hart, 2021; Szalavitz, 2021).

Recognizing the reasons for our clients’ use has important implications for our clinical and counseling work. First off, it just makes sense to understand why our clients use substances; it helps us better understand the full clinical picture. Second, it also shows we accept our clients’ perceived reality and their whole self, which conveys unconditional positive regard and strengthens the therapeutic bond. Next, it creates a safe space for clients to openly discuss their substance use. Creating an environment in which our clients feel comfortable discussing their use is essential so we can conduct an accurate substance use and mental health assessment and envision a safe and helpful treatment plan. Finally, it allows us to fully engage the tools of HaRT but also other psychotherapeutic modalities. For example, if we understand what our clients are getting out of their substance use (e.g., physical relaxation, psychological coping, supporting socializing), we are better positioned to codevelop with them ways to get what they want out of their use while minimizing risk of harm to themselves and their communities. Similarly, we might also help them consider obtaining these perceived benefits in other ways (e.g., sports, mindfulness-based strategies, finding other means of socializing).

The opposite is also true. If we do not acknowledge that people have positive experiences with substances and thus do not ask about what people get out of their substance use, we are missing vitally important clinical information, which will negatively impact our ability to help our clients.

1.2.3  Recognizing Substance-Related Harm Is Shaped by Systems

We often talk about substance use and substance-related harm as if it were fully individually determined. We reify SUD as something that resides within the individual. We must, however, acknowledge that substance use patterns, substance-related harm, and SUD are shaped heavily by larger familial, community, commercial, socioeconomic, and even geopolitical factors. Taking a more sweeping historical view: What substances are used via what modes and for what purpose has changed dramatically across cultures and across time. What is considered socially acceptable or unacceptable use, or what is considered legal or illicit use, are likewise socially and temporally dependent, and yet these social constructs in any given time and place have real consequences that shape individuals’ use and experience of substance-related harm – their social capital, their child custody, their incarceration, their job stability (see Box 1 for an example).

|5|Box 1: The Intersection of Anti-Black Racism, Classism, and Drug Laws

In 1986, Len Bias, a talented Black college basketball player, died of an overdose after using powder cocaine and alcohol. The disinformation spread in the aftermath: the falsehood that Bias’s overdose was due to crack cocaine, the myth that crack cocaine was more dangerous, addictive, and violence-inducing than powder cocaine, and the exaggerated fear that youth and unborn babies were particularly susceptible to its effects. These myths have been debunked. Crack and powder cocaine are pharmacologically the same, but crack is less expensive to produce and was thus more widely available in lower-income urban areas. It is also important to note that, while past-year prevalence of crack cocaine use is more common among Blacks, lifetime crack cocaine use and past-year cocaine use overall (including the more expensive powder cocaine) is more prevalent in non-Latinx Whites. Nonetheless, the media frenzy around Bias’s overdose, the proliferation of fear-based disinformation, and race- and class-based scapegoating propelled the swift passage of the Anti-Drug Abuse Act of 1986, which arbitrarily set minimum federal prison sentences for crack versus powder cocaine to a 100:1 ratio. That means that distribution of 5 g of crack led to the same sentencing as 500 g of powder cocaine. In 2010, this law was changed, but the ratio remains inequitable at 18:1. The upshot? Despite the fact that the prevalence of cocaine use was and continues to be highest among White, non-Latinx people, Black people continue – even 35 years later – to comprise the majority of federal incarcerations for cocaine-related crimes. Anti-Black racism and classism shaped federal drug laws that led to vastly disproportionate and intergenerational harm for Black families and communities, and particularly for those in lower-income urban areas.

Consider even more discretely defined constructs that we clinicians know well, such as the definition of alcohol use disorder (AUD) according to the DSM-5. The definition is clear and adhered to like a checklist, determining treatment access, billable services, and diagnoses that follow clients across health care systems. However, it is important to remember that this definition has changed every decade or 2 since the manual’s first, heavily psychodynamic-flavored first edition. For example, in 2013, everything we knew about the defining aspects of, say, “alcohol abuse” or “alcohol dependence” in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) changed, when the DSM-5’s “alcohol use disorder – mild, moderate, severe” took its place. The fact that such labels can and do shift overnight without our clients’ input and without any change in their actual experiences and behaviors is jolting when we consider how such labels impact clients’ access to help, treatment course, and larger life trajectories from job prospects to child custody. Thus, these larger, systemic factors are deeply impactful in shaping individuals’ experiences with substances and, the research shows us, can be more predictive of individuals’ experiences of substance-related harm than their own individual substance use (Collins, 2016).