Equity Considerations

By reviewing this section of the guide first responders will be able to: 

  1. Recognize the disproportionate impact of the War on Drugs and the opioid epidemic on racial and ethnic minorities.
  2. Develop strategies to address barriers to treatment and access, and work towards rebuilding trust with communities of color through deflection and diversion programs.

Any guide proposing best practices around deflection and diversion programs would be incomplete without dedicating discussion to the disproportionate impacts the War on Drugs and the opioid epidemic have had on racial and ethnic minorities. For example, in the year 2020, overdose death rates in older Black men were at rates nearly seven times higher than those in older white men. Additionally, overdose death rates for younger American Indian and Alaska Native (AI/AN) women were nearly two times those of younger white women, and in counties with higher amounts of income inequality, overdose death rates for Black individuals were more than two times higher than in counties with less income inequality.[70] Though tragic, research has shown that racial and ethnic minority groups have barriers to effective substance use treatment often due to lower socioeconomic status, lower employment opportunities, unstable housing, unreliable transportation, and a lack of adequate health insurance.[71] All of these barriers are then exacerbated by distrust of the healthcare system, stigma, and bias.[72] Despite African Americans and white Americans having similar rates of drug use, African Americans are imprisoned for drug charges at six (6) times the rate of white Americans. Further, while only making up 5% of illicit drug users, African Americans make up 29% of those arrested and 33% of those incarcerated for drug offenses.[73]

Importantly, deflection and diversion initiatives that are intentional about their approaches can help to remedy some of these disproportionate impacts that will not only improve health outcomes and diminish harmful criminal justice involvement, but will also help to rebuild relationships and trust with both at-risk groups and the community at large. Though this section of the guide will not be exhaustive in its recommendations, it will provide some concepts that should inform decision-makers on how to structure programs to make sure they are serving all members of the community equitably.

Section A: Address Barriers To Treatment And Access

A community that has a high capacity to provide care does not always produce equal health outcomes across a community. For example, in communities with high capacities to provide care, Black and AI/AN people had steeper death rates than the general population.[74] Though adequate resources may exist in a community, barriers like lack of housing, transportation, childcare, and insurance can prevent individuals from accessing treatment and services when they need it.

The HUB/Situation Table Model considers individuals on a holistic basis and works to address any number of issues an individual may have, including common barriers to seeking and accessing treatment such as housing, insurance coverage, and food insecurity. Invite trusted community leaders to these meetings to expand reach (more below).

Create partnerships with trusted community leaders and figures. In Communities of Color, these may be religious leaders from church and faith-based groups, Indigenous leaders, prominent figures from barber shops and beauty salons, etc. who may know those who need assistance within the community.[75],[76] Partnering with them and integrating them into the care continuum can help individuals gain access to necessary resources. 

Conduct community-led needs assessments that incorporate minority voices. These can help identify gaps in services and resources that act as barriers to entering into treatment and recovery for the entire community.

Create policies and systems that diminish biases in the field that lead to criminal justice involvement instead of treatment and recovery options. For example, allow for post-arrest diversion of individuals that have been arrested due to low-level crimes related to drug use by law enforcement administrative staff or the District Attorney’s Office.

Increase access to buprenorphine. Buprenorphine is generally a less stigmatizing treatment compared to methadone, especially in Communities of Color. [77] Fostering partnerships with appropriate agencies that can provide these treatments, using mobile units, and reducing barriers like transportation and inadequate health insurance coverage, can help link people with this effective treatment option that is minimally accessible in low-income and minority communities.

Mobile Outreach Units can bridge the gaps in access to treatment that exist for at-risk communities. By meeting community members where they are, both physically and figuratively, trust and goodwill can be built when they are provided with linkages to resources and treatment  through genuine interactions that show care and compassion.[78],[79]

In 2019, the U.S. Census Bureau conducted the American Community Survey which found that nearly thirteen percent of people in the United States over the age of five speak English “less than well,” with six percent who speak English “not at all.”[80] In order for all community members to receive equitable access to resources provided by their outreach programs, departments should consider adopting effective language justice programs like the one implemented by the Portland Police Bureau.

Section B: Rebuilding Trust Between Law Enforcement and Communities of Color

As a result of harmful past policies like the Anti-Drug Abuse Act of 1986 that disproportionately incarcerated People of Color, genuine fears exist, particularly among black/African American men, that seeking treatment for substance use disorder may result in severe sentencing and incarceration.[81],[82] This fear is in addition to a growing distrust in police generally, with nearly half of Black American adults (and two-thirds of Black men) having reported that they felt unfairly stopped by police due to their race.[83] Law enforcement can take steps that will hopefully alleviate these fears and rebuild trust over time.

Engage in activities and outreach that prioritize relationship-building. Reaching out to minority communities, whether through post-overdose programs, mobile unit visits, street outreach, etc., and focusing on positive interactions without criminal justice system involvement, can build rapport and trust. Time and dedication to improving these relationships through deflection and diversion programming can, over time,  demonstrate law enforcement’s commitment to helping minority communities.

Peer recovery coaches can help build trust between law enforcement and people who use drugs. Additionally, they have been shown to be effective in helping people access treatment because of shared experiences.[84],[85] Boston’s Project RECOVER uses peer recovery coaches of diverse backgrounds to help individuals connect with them on a deeper level and provide them access treatment and resources with cultural awareness.[86]

Diversify the police force.  A recent study has shown that diversifying police forces can lead to better outcomes for minorities, with Black and Hispanic officers making far fewer arrests and stops than white officers, especially against Black civilians.[87] Although that study applies to arrests and stops, the benefits of a diverse police force and being able to enter Communities of Color with officers who look like the people they are trying to serve can help to diminish unnecessary arrests and help build community trust.

Community Responder Models discussed Section II should be considered when developing a deflection response in your community. Also, training and equipping trusted members of communities with naloxone can save lives. These groups may include Indigenous leaders, faith-based organizations, religious leaders, community health workers, and family members. For example, the African American Engagement Workgroup in Hamilton County, OH engages the faith -based community, harm reduction resources, and community partners to provide tailored support for the youth and adult African American community to reduce stigma of addiction and connect with recovery resources.[88] 

You can learn more about the efforts of the Hamilton County, OH African American Outreach team in this PAARI Spotlight Series: 

Section C: Use Data To Analyze Patterns That May Reveal Inequities

In 2020, overdose deaths increased by 44% for Black Americans and by 39% for American Indian and Alaska Native (AI/AN) people compared to rates from 2019.[89] As discussed previously, Black Americans make up a significantly larger portion of those incarcerated for drug-related crimes, despite having similar rates of drug use as white Americans. Data can help determine not only when particular groups within communities need more targeted intervention, but also patterns of racial bias in policing, if and when they arise.

Promising Practice Recommendations

1. Document, monitor, and report the racial makeup of your program participants. We recommend that deflection initiatives document the race of program participants (among other demographic information), and regularly review this information. To understand whether your program is equitable, you can compare your program demographics to local census data (overall population), to overdose fatality demographics (for a post-overdose follow up program), or to jail demographics (for other deflection programs).
2. Utilize data to compare fatal and non-fatal overdoses with specific community demographics and develop interventions accordingly. For example, if your community is 10% Black, and yet, Black members of your community make up 20% of fatal overdoses, they are fatally overdosing at disproportionate rates and further inventions should be examined.

3. Utilize data to examine criminal justice involvement by race and determine patterns. For example, determine if there are any patterns or differences related to diversion and deflection from the criminal justice system among at-risk and minority group groups in your community.