We are very fortunate to have this remarkable team with us today who will be discussing the inequities in substance use disorder care. I am actually so proud to share that I have known Dr. Durham as a trainee, as a colleague, then as a director of the psychiatry residency training program at Boston University, and now as a leader who is advocating the health equity for marginalized communities. She is also a recipient and a PI of multiple grants focusing on cultural competency and health equity in SUD care, while also influencing state as well as the national level professional societies. She is a clinical associate professor. She is also an adult and child psychiatrist with addiction medicine board certification at Boston University Medical Center, and starting February, she will be the chief behavioral health officer at Ibn Sina Foundation in Houston, Texas. So without further ado, Dr. Durham. I'm happy to be here with you all, and thank you, Dr. Desai, for the warm introduction. It's really wonderful. This is my first AAAP meeting, and it's been wonderful to get to know people and see colleagues that I haven't seen in quite some time. I'm really happy that we're going to be able to talk with some great people today on the inequities in substance use treatment for marginalized communities, challenges, and opportunities. Untraded substance use disorders contribute to thousands of deaths each year, as many of us know. Although there are treatments available, many communities have not accessed them. The reasons for this are multifactorial, including stigma, mistrust, discrimination, racism, and the criminalization of substance use. Although many acknowledge substance use as the number one health problem in North America, data reveals the treatment gaps are enormous. For black and Latinx groups in the U.S., about 90 and 92% respectively diagnosed with a substance use disorder did not receive addiction treatment. Data from the 2018 National Survey on Drug Use and Health suggests that substance use patterns reported by LGBTQ plus adults in this particular survey included individuals who described themselves as lesbian, gay, or bisexual are higher compared to those reported by non-LGBTQ communities. The presentation will highlight the inequities in substance use treatment for black, Latinx, and LGBTQ plus populations, discuss approaches for engaging marginalized populations, and provide strategies for assessing, diagnosing, and treating substance use disorder in marginalized communities. Without further ado, I'd love to introduce my colleagues here who will be presenting. To my right, Dr. Daryl Shorter is a diplomat of the American Board of Psychiatry and Neurology and is a board certified in both general and addiction psychiatry. He's a graduate of Rice University and Baylor College of Medicine. Dr. Shorter completed general psych residency at the Ohio State University Medical Center and addiction psychiatry fellowship at New York University. Dr. Shorter is an associate professor in the Mininger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He also serves as a medical director of addictions and recovery services at the Mininger Clinic as well as a program director for the Baylor College of Medicine Addiction Psychiatry Fellowship. Dr. Shorter is the author of numerous peer-reviewed publications and book chapters focusing on medication treatment of substance use disorders and addiction training in graduate medical education and lectures widely on topics related to LGBTQ community health. Ms. Anita Bradley is the founder and executive director of the Northern Ohio Recovery Association. Its acronym is NORA. She's a graduate of Kent State and Cleveland State Universities. She earned her bachelor's degree in criminal justice studies and a master's degree respectively. Ms. Bradley founded the Northern Ohio Recovery Association in 2004 to prevent the use of alcohol, tobacco, and other drugs, utilizing a holistic healing and recovery approach. Ms. Bradley has been in recovery for over 30 years, blending personal and professional knowledge in her approach. She has served as a clinician and administrator, receiving numerous local leadership and volunteer service awards. She's also received the U.S. Presidential Administration of Barack Obama called on her to lend expertise on substance use and prevention. She is the winner of the Smart Business Magazine's Women Who Excel Entrepreneur Award and the Joel Hernandez Community Recovery Award, as well as the 2016 White House Champion for Change. And last but not least, to my left, is Dr. Fabiola Arbelo-Cruz, who's an attending addiction psychiatrist at the Connecticut Mental Health Center in New Haven, Connecticut, an assistant professor of psychiatry at Yale School of Medicine. One of her roles at CMHC includes working with the street psychiatry team, a model of mental health and addiction care delivery that takes physicians and other providers to the streets to provide care primarily to people who are experiencing unsheltered homelessness. Dr. Arbelo-Cruz graduated magna cum laude with a bachelor's in science degree from the University of Puerto Rico and received her medical degree from the Ponce Health Sciences University School of Medicine. She completed general psychiatry residency at Boston Medical Center and was awarded the Chairman's Award, the highest honor for a graduating resident in the BMC program. Dr. Arbelo-Cruz completed an addiction psychiatry fellowship at Yale. She is the past recipient of the APA Travel Scholarship for Minority Medical Students and the Externship in Addiction Psychiatry Award and the AAAP John Renner Award in 2021. She was accepted to the Yale REACH Scholar Program, a program aimed to adequately train physicians to work with minority patients with co-occurring mental health and substance use disorders. And last but not least, I know everyone has lots of accolades on this panel, but they're also really passionate and dedicated to their work. Some of them I call my friends as well. And I think any of us in this room would be honored to be treated by any one of them, and I think that is probably the best accolade that I think myself and other colleagues and friends would definitely want our family members to be treated by anyone on this panel. And I think that's the biggest accolade of all. So we're going to start with Ms. Bradley. It'll be followed by Dr. Arbelo-Cruz, and then Dr. Shorter, and we'll have some time at the end for questions and answers, and also any comments or thoughts you may have in the work that you're doing, where you're seeing folks to. So Ms. Bradley. Thank you so much for the wonderful introduction. Can you hear me? Yes. All right. So I'm excited to be here today, and I thank you all for being here with us and with me on this special day. Our organization is celebrating 18 years of being in business, and I tell you, it's been a lot of learning, a lot of hard work, but I'm at the end of the day when I have an opportunity to be before people and to see individuals in recovery really cross that bridge and get their lives on track. I wouldn't change it for anything in the world. So. All right. So we're going to be talking about, I'm going to talk about my business and the hard work that we're doing and how I think we're very creative. I feel that we deal with a brain disease that's really difficult to treat. It's out of the box, and we need very creative interventions. And so we've been able to do a lot of different work up in Cleveland, and so I'd like to share some of that with you. But before that, I have no conflicts of interest financially, personally, or professionally. All right. So by the time we finish today, you will learn that at the conclusion of the session, have a better understanding of some of the statistics that we're seeing across the country that relate to African-Americans and blacks as it pertains to substance abuse and mental health. We're going to be describing health inequities in the black community as it pertains to substance use treatment and how we can do a better job of trying to get individuals to access treatment and creative options for them to get their life back on track. We're also going to be describing ways to provide culturally responsive care for black people with substance use disorders. And sometimes when I say substance use, I'm talking mental health as well, because we also see a lot of individuals with co-occurring disorder. For the first maybe 14 years or so, our organization was very heavy on the substance abuse because that's what I knew. But over time, most recently, we have started to receive our certification to treat people with mental health disorders as well, because we want to do a better job of not necessarily having to send them somewhere else for care, but to be able to treat them under one umbrella so that the system is not as fragmented as it was when I originally started. So we know that some of us, that black people are 13% of the total population, but are overrepresented among drug users in the United States compared to the rest of the population. And so just looking at that data is scary. It's part of the reason that some of the interventions that we put in place in our community is to help curb that, particularly right now, we've seen a large increase in overdose among African American men in the community based on the things that they're putting in the drugs. They think that they're getting marijuana or possibly some pill or whatever from the streets, but a lot of fentanyl is being deployed into our community. And so the overdose rate has went up, it's skyrocketed. So we're putting some interventions in place to try to help curb that, particularly going out to the community. Most recently, I was able to ask our county board to help fund a Sprinter van. On that van, we're going to go out into the community, we're going to give out drug kits, test kits, Narcan, just try to befriend the community and get them to access treatment so that they know what they're dealing with. We're not going to go traditional hours, nine to five. I tell my staff all the time, we are a 24-7 company, and that people don't just use from nine to five or six to seven, it's a 24-7 illness, you know, and crisis can happen anytime. So we want to make sure that we're able to access, or they're able to access our services. And when we close at one in the morning, there's someone that takes that hotline so that they can get a live person at any time of the day. Black people often face barriers to treatment, more so than other populations, and so we're going to talk about the factors that tie into that stigma, biases, and socioeconomic status. So I did a little analysis around the target population of what we see. So substance use disorders among the general population is 7.4, but for African-Americans even being at 13% of the total population is 6.9. You know, and it's like, I know this stuff, but when I looked at that data, I was like, well, no wonder, you know, we're seeing, you know, we're seeing this rise, or, you know, there's a large rise in our population because of the different things that we'll talk about as we move forward. So having an illicit drug use disorder, the total population is 3%, where for African-Americans we're looking at 3.4%. So again, only 13% of the total population, and that's a pretty alarming piece of information. So over the past month, I think we put this, I put this together a couple months ago, less than 90 days, but cannabis use was at 10.1 for African-Americans. It was 12.2%, again, very alarming. And over the past month, illicit drug use for Caucasians was 12%, Latinos 9.7, and then for African-Americans was 13.7. And this was some data that was collected, and you'll have the, you know, where it came from at the very end of the presentation. So let's talk about health inequities and define it. So systemic differences that prevent people from accessing healthcare resources that would reduce morbidity and mortality in their population. One of the things that I really love about where our organization is located, we are in the heart of the community, you know, the African-American community. And while I always tell people, like, I'm not saying anything negative about, like, our clinic, you know, we have our renowned Cleveland Clinic. I actually go there. They're wonderful. However, there are individuals that are intimidated by accessing treatment in certain places because of, I think, even the way we treated the crack epidemic. And so then, at that time, you know, the crack epidemic, we think, was handled all wrong. We over-incarcerated African-American men. If a female was using cocaine or snorting cocaine, they would take the children away from the mom. They'd have to go through children's services, and they'd have to complete this care plan. And so when the opiate crisis came out, you know, individuals are just afraid to really go to certain places and let individuals know that I actually have a problem. But we are the places where they need to be going. And so he passed away this year. He was a good friend of mine. He funded the Alcohol and Drug Board of Cuyahoga County. He was the chief of police back in the 80s when the crack epidemic came out. And before we could even address the opiate crisis a couple of years ago, we had to—I brought him in, and we did a town hall meeting. And the town hall meeting was called Hindsight. And at that meeting, he got up in front of the community, and he apologized for not understanding the illness, being able to say we did what we knew how to do. However, like, let's move forward. Now that we understand—or we're understanding more that it's a real brain disease, let's really take this opportunity to move forward. And once he did that acknowledgment, especially to our religious community, it was like a healing. And I think the community was able to move forward. And from there, when we went to meetings to talk about, like, how we're going to address the opiate crisis, it wasn't so much tension. It was a lot better just by acknowledging that, you know, I did the best I could. And we all know that this illness is very difficult to treat, but we have success. The inequities include barriers that ethnic and racial groups face based on economic disadvantages. We all know financially, sometimes we can access care if we don't have insurances. We deal with barriers across the country where some states have their Medicaid, you're able to get Medicaid and be reimbursed. Other states are not. And so those communities that people can't access health care or get Medicaid if they lose their job, a lot of times they do because, of course, they're using, they can't access treatment or they have to go under this pool of dollars, which is very limited. And so, you know, you're on a waiting list. And I was telling my staff the other day, we have to be open 24-7 because when someone calls, if we're not there for them, and we say, well, there's a two-week waiting list, chances of them coming in in two weeks, we don't know, right? So we need to try to get people into treatment immediate access because I'm just, and I'm speaking from personal experience, when I was partying, you know, if you couldn't get me in on that day, a week from now, I don't know what I was going to be doing because I was going to go out and try to reinforce something to make myself feel better. So I have to, we have to understand those things. And that's what I'm, that's what I'm trying to do within the business. The LGBT community, LGBTQ community, people can face barriers based on homophobia, transphobia, as well as the impediment of provider bias. We have a company called B Riley, and he specializes in transgender, serving the LGBT community, has a bunch of recovery houses. And so we were partnering with this group. I had some professionals come in to train my staff so that when they come to our center, that we were, that we were culturally sensitive, and that we understood discrimination from within our subpopulations, and that we wanted to be a welcoming place. And so we partnered with this group, but everyone had to have a set of basic skills in order to work with the population. Because when I created, I call it Nora, when I created Nora, I said we want to work with diverse communities within recovery. And what that means for me is diverse community could be a youth, diverse community could be someone from the LGBT community, Jewish community, whatever it is. So we started to recruit people, not that just because you're, you ascribe to a certain population, you understand everybody. That's not we're saying, what we're saying. What I was saying is that I want to learn from you, because I don't know everything. And I need to be humble enough to do that. And so when we first started out, we trained 125 people in recovery. This was back in 2004. SAMHSA funded us for this RCSP grant. We trained 125 people each year over four years. And by the end of the four years, we had 500 people trained. We dispatched them into the jails, into children's services, homeless centers. And so we started to work with the staff to educate them about addiction and recognizing signs and symptoms. All right. So bridging healthcare inequities with substance use trends, historically adversity, which includes slavery, sharecropping, and race-based exclusion from health, education, social and economic resources, translates into social economic disparities experienced by black and African American people today. Social economic status, in turn, is linked to mental health. People who are impoverished, homeless, incarcerated, or have substance use problems are at a higher risk for poor mental health. And so while sometimes we hear that slavery was many, many years ago, but there's a thing called generational trauma. And the generational trauma really is passed on from generation to generation. And one of the things is I grew up and began to recognize some of those things that, I'll be honest, that was in our family. I was like, you know, I want to be healthy. I want a healthy life. Even though, you know, at some point, my own addiction kicked in when I was in college. But when I went out, came out on the other side at the age of 25, I really started to work on those things that I think some of my grandmother, my parents, like, they just didn't understand. And to be honest, they didn't always have the education or the ability to understand. My parents were very preoccupied with making a living. I tell people that all the time. They came from the south. They moved up north when the automotive industry was booming, General Motors, Chrysler, Ford. My dad landed a job in Ohio in Youngstown. You know, he made decent money, but they were preoccupied with trying to do that. Our other family moved up from the south. And so some of these things went unaddressed, whether it was in the family or just around me. And lo and behold, here I come, right? So I just feel like it's a blessing, but it was a curse at the time. But it's a good thing being able to look back and know that people can recover. And so that's why I applaud all the work that we all do, right? So also, African-Americans with substance use concerns may already be receiving less access to preventative care. Also this can be based on lack of transportation, gaps in insurance, and not having insurance. So back before the Affordable Care Act became present in Ohio, if you did not have a child in your home, you could not receive medical benefits. And with that being said, that made the waiting list for those pool of dollars smaller. So if you had a person that had went to jail for selling or using or something like that, and they came home and they wanted to access treatment, they couldn't access it. Well, they could, but it would take longer for them to access the treatment because of the barriers. Cuyahoga County, Cleveland, and a county called Lorain, Ohio borders each other. Lorain is partly rural, partly urban. And so there's right 40 miles down the road from me, there's communities that have lack of transportation. And so if there's lack of transportation, well, then when we started, it was very difficult to get to a treatment center, even for assessment or even to reach out. But now with telehealth, I think things are improving to some regard. So we were a little worried about telehealth in the beginning because of the inability to really build a relationship with people. So what we started doing was partly when COVID hit, partly telehealth and partly in-house. In addition to the broader body of work reveals that opportunities for rehabilitation or diversion may not be offered to black defendants. So this was in the news in Cleveland. There was a judge that they said was, her penalties for African-American males was much harsher than other populations. And so those types of disparities also affect what we're talking about here today. Because if you're incarcerated for the same crime and you come from a position of lack, then trying to get a diversionary program may not be what someone has given you. But whereas other people are given those opportunities, they can bounce back and get the resiliency skills in place that they need a lot quicker. So it makes my work, to me, it makes my work a little more challenging. And so that's why part of like trying to be creative and put things in place like the 24-hour hotline, providing transportation. Be real honest with you. I had a very serious conversation with our government about not incentives for getting to treatment, but incentives for being able to go out and talk to the community. After the first year of business in 2005, they have this data that we collect. And the data showed that the women, African-American women's behavior was very consistent to the way it was when they're using. They were at risk for HIV, at risk for a lot of different diseases. And so I asked for funding to be able to go out and talk to them about those behaviors. Because with recovery, we want them to recover in all areas. And so they were like, well, these women, they don't need incentives. And I'm like, well, it's hierarchies, what's his name, Maslow's hierarchy of need. They'll talk to us quicker if we can go in and make friends with them and maybe give them some milk for the child or pampers for the baby so that, you know, they don't have to worry about that while we're having this conversation about condom use or, you know, just different things that they needed. So I literally had to have several meetings to say, we really need you to pay for this because it's a part of the interventions. And I'll say this, it's later in the presentation, but, how do I, in motivational interviewing and contingency management, I'm not sure if you all are covering this, because I'm kind of like off the cuff talking, but I think it's a great thing. And especially when we're dealing with these different drugs that affect our brain, particularly like cocaine, we found that with the adolescents that we work with, just small tokens of appreciation, just like in school with the reward system, if we reward you for your clean urine after a month and give you something, you know, just some token of appreciation, it really just like celebrate, like your recovery, you trying to do something different. Our youth showed a 40% increase in coming to groups, coming to treatment, and having clean urines. So and some of this stuff has not always been documented. So what I like about what Health and Human Services is saying now that, you know, we talk about evidence-based practice, but now they have this saying, we say practice-based evidence, because in some communities, we, you know, people are practicing things that haven't been documented and replicated yet, but for that particular community, it may be something that really works. And we found that particularly like in the rural areas. So cannabis use is equally prevalent among black and white people, yet black people are 3.6 times as likely to be arrested for possession. 90% of African-Americans needing substance use disorder doesn't receive it. For me, even though that is for most populations that meet the criteria for alcoholism or addiction, it's relevant for African-Americans even more so. I tease a particular person that's close to me. I say, you know, you meet the criteria. She's like, oh, no, I don't meet the criteria. I said, you meet the criteria. Let me tell you what it is. So they're like, you're always diagnosing people. But the criteria is real simple. You know, there's like seven, eight major life areas. If you meet in three or four of them, you know, we need to take a look at that. But how many people have been impacted in those areas of their life? And because for whatever reason, they're able to move forward and not really understand that they're meeting the criteria. So of course, they're not going to access. Thank you. Systemic racism groups are historically and systemically excluded from access to treatment. It's imperative that we understand how economic and physical, social, political forces impact medical decisions. Research shows that black people have a harder time getting into treatment than white people do. And black people are less likely to be prescribed the gold standard medications for substance use as therapy. Sometimes just, you know, different hospitals just respond differently. So one of the things we do with outreach is go to the hospitals and put recovery coaches in the hospital so that if someone overdoses, that there's someone there to help them. Black people with substance use disorders are afraid. We talked about that earlier, of being caught up in a punitive system. I'm afraid to reach out for help to the very entities that need to help them because of the stigma and sometimes the punitive measures. COVID pandemic disrupted many recovery centers and harm reduction programs, and we're still trying to rebound from that. And when in treatment, black patients enter treatment, they're more likely to do so at a later time than white people and are less likely to compete treatment based on some of the economic factors that we see. And in addition to mistrust, the less favorable outcomes result from factors such as clinician bias, lack of racial and ethnic diversity, and among treatment providers. So I tell individuals the relationship between the clinician and the person is critical to success. There are different models that we use for substance use that reflects diversity in the population, and we can tweak those models to fit different cultures. And I support that, and hopefully people know that in terms of trying to follow the fidelity of models, sometimes you just need to get permission. So these are some particular ways that we can do it. Cognitive behavioral therapy can be adopted, adapted. Group therapy can easily be adapted based on the clinicians that are in the group. And acceptance and commitment that therapy can be used to clarify values of the group prior to starting. Just a couple highlights about the organization. I told you we celebrated 10, not 10 years, 18 years today. And so we're the first peer-driven organization in the Cleveland area. I've written for 27 federal awards, we're in 16 schools. So we have prevention programs in the school, teaching resiliency among the youth so that whatever they're dealing with, we can help them with those skills. We have a multitude of different services in our programs. We do medication-assisted treatment. It was a very different paradigm shift for us to bring in, like, medical staff to have to treat the opiate disorders, but we had to do it. We have peers that are a part of every program that we have, meaning you have to have two years of lived experience. And regardless of where the person is in treatment, they have someone with lived experience that can talk about, you know, help them through, navigate through the treatment process. Seven locations, I'm very proud of the social media impressions we have. We're all over social media. So we have two, actually kind of like two pages, because people are following and we send out positive media messages all day. Over the years, we've served about 65,000, conducted 900 HIV rapid tests, 2 million pounds of food were distributed. The Cleveland Browns partnered with us during COVID, and we gave out 40,000 pounds of food. And most recently, we fed 150 people with Chris Hubbard. Over Thanksgiving, he came in and we fed some of the families. My colleague mentioned some of the awards. I think the two biggest ones is probably the Obama administration for the work I did with the opiate use disorder. And then the hometown hero I received by the Cleveland Cavaliers in 1996. And it was so cool, because I remember being there like, they're going to win it this year. And they did. And I was so happy. That was before LeBron left. So LeBron left, everybody got mad when he went to Miami. But you know what I said? Hey, listen, he's a young man, let him do what he do, right? So thank you so much. I hope this was helpful. But you know, I just commend you all for being a part of this process. Our work is really tough, but we can do this together if we just learn and listen from each other. Do you want to do it? Hello, everyone. Thank you, Anita, for that great presentation. My name is Fabiola Arbelo-Cruz. And today, I will be presenting on the topic of substance use treatment in Latinx communities. First of all, it is an honor to be with these amazing people here, specifically, you, Michelle Durham, because you were my PD for four years and mentor. And it's truly an honor to be here with you. Equally, Fabiola. I have no disclosures. And for today, we have mainly four objectives. First, we're going to describe disparities in substance use treatment utilization for Latinx. We're going to discuss barrier to access and retention for substance use treatment in Latinx. Discuss how substance use treatment needs might vary among Latinx subgroups. And lastly, outline strategies for assessing diagnosis and treating Latinx. So before we start, I want to take some time to explain differences between the terms Hispanic and Latinx. Also, I want to extend an invitation for inclusive language. Hispanic and Latinx, both are pan-ethnic terms. They are used interchangeably, but they have different meanings. Hispanics refers to individuals that have a Spanish-speaking background and trace their heritage back to Spain. So does include people from Spain, does not include people from Brazil, for example. In the other hand, Latinx are individuals with heritage from Latin America, but not from Spain. So does not include people from Spain, does include people from Brazil. And you will see a variety of terms referring to people from Latin America. Mainly you heard Latina, Latino, but this term exclude people outside of the gender binary. So my invitation to you all is to use the term Latinx, that's the term that I'll be using mostly throughout the presentation, because it's gender inclusive. I also want you to be aware of the term Latine, ending with an E. It's also a gender inclusive term and is widely used and more accepted in Spanish-speaking countries. In the right, you will see a QR code. That's only if you're interested in looking about this information more in depth. It's pretty much an article about the Latina Latino Psychology Association, and pretty much it talks about the process of how they went about changing the name of their organization and their journal to the Latinx Psychology Association. So by the numbers, Hispanic have played a significant role in the U.S. growth in the past decade. From 2010 to 2020, the U.S. population grew by 22.7 million, and Latinx accounted by more than half of that amount. So why is this relevant for the AAAP? Because Latinx is the fastest growing minoritized group in the U.S. We are disproportionately affected by substance use, and we use treatment at low rates. This is data from the National Survey on Drug Use and Health, and pretty much speaks about million people identified as Latinx suffer struggle with a substance use disorder and a mental illness. To the left, in green, we see that 5.7 million people reported having a substance use disorder in 2020, and of those, 4.3 or three-quarters reported alcohol use disorder, 2.5 reported a drug use disorder. To the right, in blue, we see that 7.7 million people reported a mental illness, and of those, close to 2 million reported a severe mental illness. When taken together, close to 6% of people reported both SUD and mental illness, and we need to take into account who is missing in this data. The National Survey on Drug Use and Health was a household survey, so it's meeting data from people who are incarcerated, people who are in nursing homes, people who are homeless and on shelter, and possibly many immigrants, and because of fear of legal consequences, they're not included in this data. Looking at treatment gaps, this is data on Latinx folks that did not receive treatment for substance use disorders or any mental health issue. Pretty much, we can see that those who have a SUD, close to 94% did not receive any treatment, and this is quite similar to the data of the overall U.S. population. Of those with any mental illness, close to 65% did not receive any treatment, and this is a number higher than the overall U.S. population. I do want to point out that this data right here is for any treatment, including self-help groups. What about specialty treatment? I'm talking about specialty substance use treatment and mental health services, not talking about self-help groups. These barriers persist. Treatment gaps persist. The trend is similar. To the left, we see that a majority, close to 66%, did not receive any treatment, and close to 34% did receive treatment in a specialty facility. The majority of people received treatment at a mental health facility, not a substance use facility. So it makes me think about two things. What is going on with this treatment gap? Is it stigma? What barriers are we experiencing? And second, what can we do to tackle this? And something that I think about in the work that I do in the Institute of Psychiatry is that for a long time, and we still do this, we open our door and wait for people to come to the clinic. That's what we do. And I think we need to have a paradigm shift of going outside of the clinic and going to the community. It can be mobile vans. It can be teams like us working with allies, like community health workers, peer specialists. There's a lot of people in the community that know the people, and we need to get out. What about treatment completions? These data looks at estimates of disparities on treatment completion for alcohol and drug across all major racial and ethnic groups. And for all groups, completion rates were low, but specifically for black and Latinx Hispanic. When data was adjusted for socioeconomic status, that's their circle in red, that disparity narrowed down. And I know this data is a little bit dated, it's from 2007, but I think it's quite important. So again, when adjusting for socioeconomic status, disparities in completion rates in the Hispanic, Latinos, and black narrowed down. And what this tell us is that completion disparities for Latinx were largely explained by differences in socioeconomic status. It was not race, it was not ethnicity, it was socioeconomic status. So why do Latinx folks underutilize treatment? Research have hypothesized that Latinx face numerous barriers, more than white. But there is very little research examining this specifically, and results are inconclusive. I just put an overview of data using national studies, like the National Alcohol Survey and NISAR. And pretty much, overall, these studies found that Latinx reported more logistical barriers, meaning structural barriers, like lack of transportation, cost, insurance barriers. But these data had a lot of limitation. Like, for example, the first two studies, they only used bivariate analysis. And for the second study, for example, results were not statistically significant. On the same line, we're looking at data from a qualitative study done to better understand barriers in Latinx seeking treatment. And pretty much, it was using telephone interviews. They asked barriers to Latinx in three main domains, attitudes, like reasons why you did not seek treatment, and thoughts about treatment being effective, subjective norm, like how family and society reacted to it, and perceived controls, circumstances that will make it difficult to get treatment. And what they find is, first, in the attitude domain, there were many themes of cultural factors and perceived treatment efficacy barriers. For example, the provider was unfamiliar with the Latinx culture. Thus, the participant thought that the provider couldn't relate. And because of that, they thought that treatment was not going to be effective. There were also themes on recovery goals. The participant reported that remission was not their main goal. It was only decreasing substance use, and the provider did not agree with that goal. There was also barriers, sorry, themes on the perceived need for treatment. Many people thought that because they were functional with family and work, they did not receive, they did not need substance use treatment. And I see this a lot in my clinic. I have, I can think of the past two weeks having at least two people telling me, Doc, I don't have cravings, I don't use more, I don't have any issues with alcohol use, I'm good at work, I'm good with my family, I don't think I have any problems, so I need to get more creative on how I go about it. And usually, for Latinx folk, family is quite important, and we value extended family. So a third-degree cousin, second-degree cousin, that's part of the nuclear family, even a neighbor at times. So I go and ask them, so what does your cousin comment to you about your alcohol use? Or what does your son tell you about your alcohol use? And usually tell me, well, they're not happy. And why they're not happy? So I start listening more and getting more information that I can use to kind of like create more ambivalence and go more inside. In the area of subjective norm, teams that appear were stigma, for example, being negatively perceived, and lack of social support, like family not being in favor of treatment. Something that I always hear as well is, Doc, I don't want to go to medication because I don't want to substitute one drug over another. Buprenorphine is just like using another drug. And I need to sit down with them and talk about it. You know what? Yes, buprenorphine is a chemical. Buprenorphine is a drug. So can I share more information? And they will say yes. Buprenorphine, the way I prescribe it, is a specific dose. And the dose that I prescribe it is safe. And my plan is for you to not get euphoria. It's not the same when you use heroin or fentanyl that you just get euphoria. It will not be like that. Also if you use on top of your buprenorphine, it's less likely that you will get euphoria. So kind of explaining how medication is different just for the substance that you're using in the street helps a lot with patient. And I even do this with family members. Lastly, in the area of perceived control, themes that were brought up was logistical barriers or structural barriers like cost of treatment, insurance, lack of transportation, or wait times. We know that important predictor of treatment utilization is a perceived need for treatment. And this data also from the National Survey Drug Use and Health shows that Latinx folks with SUD, in this particular data, 5% only perceive a need for treatment. And of that 5%, the majority of them only look for treatment in a mental health facility. And I think what is important about this data is it's a call for better integration of treatment. We need to better integrate substance use disorder in mental health treatment. And I know that, I don't know if it was yesterday or two days ago, there was a workshop about the MIT Clinic of CMHC that I think was a great example of this integration of mental health treatment and substance use treatment. What about linguistical barriers? This is data from 2014 to 2019 on national trends in mental health treatment offered in Spanish. And they stratify it by share of Latinx population in all states. I know it's quite small, but states that are more in the left have lower share of Latinx population and the ones to the right have higher share of Latinx population. And pretty much what they found is that between 2014 to 2019, the proportion of facilities that offer services in Spanish decreased in 44 states. And this is important because in that same time, those five years, the U.S. Latinx population grew by more than 5 million people. What about health coverage? Community of colors have it worse. Specifically using this data, we can see that Hispanic and American Indian, Alaska Native, have lower percentages of being privately insured. We know that, for example, being privately insured, people that have private insurers are more likely to get prescribed buprenorphine, for example, compared to Medicaid or uninsured. Also, these two same groups have higher numbers for being uninsured. And that's something that I also encountered in my practice in street psychiatry and CMHC. I work with a lot of folks that do not have insurance. So the way I go around it is learning a lot about my community. I have learned to identify places that I can work and have my patients go there to get treatment. For example, in New Haven area, I have Coroner Scott Hill SCRC, and they have specific funding to manage people that are uninsured. It's a place that I go to for withdrawal management. But we need to do more. I need to advocate for more. What about specific needs by Latinx groups? And this is just data to show what is the composition of the Latinx population in U.S. The five largest groups in U.S. are, first, Mexican, second, Puerto Ricans, followed by people from Cuba, Salvador, and Dominican Republic. And Latinx community is not a monolithic group. We are diverse. We have a wide range of social, colonial, and political history. And many of us have different experiences while living in the U.S. So when we think about the heterogeneity within the Latinx groups, these are some features that we need to think about. What was the immigration experience? Was it because of political reasons? Was it because of homophobic violence? Was it because of natural disaster, economics? There are many. And you can have five or a hundred people with the same reason for immigration, but you have five or a hundred different experiences. We need to think about, is the person U.S. born or not U.S. born? How much time they have been in the U.S.? Are there a first-generation Latinx, second-generation, third-generation, gender role differences? For example, it could be that back home in their own country, only one household member was working. And now when they come to U.S., for example, all household members are working to survive. We also need to consider, of course, language fluency. Do they speak English? How well they speak English? Do they write in English? Do they read in English? And a little bit about acculturation, because it has been mentioned that it has a big impact on health outcomes and behavior. One of the main issues that I have is that in terms of research, there's a lot of heterogeneity on how this is measured. There are more than 15 scales, and many research also use a lot of proxies. They can measure acculturation based only on if the person speak English, the time they have been in the U.S., or they're U.S. born or they're not U.S. born. And pretty much when they evaluate the effect of acculturation and addiction, it have mixed results. Overall, there has been more data suggesting that acculturation seems to have a stronger and more consistent association with increased drinking and addressed drinking among Latinx women. And some of the hypothesis for that is how the gender role changes throughout time in the U.S. This slide here talks about the effect of nativity in the prevalence of substance use disorder. Pretty much this study was made because the authors wanted to evaluate the effect of the immigrant paradox in the prevalence of psychiatric condition, including SUD. And just for us who have common language, the concept of immigrant paradox claims that foreign nativity seems to be protective for psychiatric condition, even despite so of a lot of stress and poverty that come from immigration. So they did this study, and what they looked at is that when they disaggregated data by ethnic subgroup, a complicated picture came. And there was a limited application of the immigrant paradox to all psychiatric condition, and that included substance use disorder. Specifically here, the immigrant paradox did not hold true for Puerto Rican. There was not a protective effect of nativity for Puerto Rican. So in conclusion, this finding emphasized the importance of not overgeneralizing the effect of nativity to all Latinx. Almost in a similar line, this slide talks about U.S. overdose mortality rates within Latinx subgroups. Looking at data from 2015, 2019 from the National Centers of Health Statistic, and what they found is that Puerto Ricans had a higher rate of overdose mortality in the U.S. compared to all other ethnic subgroups, even so non-Hispanic black, for all years. And it surpasses non-Hispanic white from 2017 to 2019. So again, I think this take-home point for this is that when we look at overdose data, if we only take Hispanic as an overall group, we might be obscuring important data like differences, such as here. So what can we do? Besides keep on working. This slide is applicable to everyone, to all ethnics and racial groups. Key components for equitable addiction treatment, one, it needs to be readily accessible. We need to have minimal demands on the patient. Sometimes I see that there needs to be a number of appointment commitment for the patient to continue. I have seen clinics that for a patient to come and stay and have an intake, they cannot be on benzodiazepine, they cannot be on stimulant, for example. And we also need to incorporate a harm reduction approach. Not everyone wants just to stop using, they just want to reduce use. And for many folks, going down from three bottles of wine to one bottle of wine is hard, like really hard. And again, I mentioned this, going to the community. So instead of opening the door and waiting for people to come, going and meeting people where they are. Second, it must attend the multiple needs of the individual and not just the substance use. We need to target social determinants of health, talking about housing, food insecurity, job opportunities, education. Treatment should be of adequate duration. We should have strategies for engagement and we should be discussing with people how long treatment needs to be for. I ask them, they usually ask me, but if they don't ask me, I will ask, for how long do you think you need to be a muprenorphine, right? And my answer is most of the time, as long as you need to. Lastly, treatment must include effective medications with cultural and linguistically informed therapies and counseling. And it's important for me to discuss key differences between the Anglo-American culture and the Latinx culture and how that translates to the clinical encounter. I will not discuss everything in this table. I will discuss like two or three. To start with the first one, overall, because I cannot over-analyze, Anglo-Americans have a nuclear family orientation. And as I mentioned earlier, Latinx have an extended family orientation. It can be that third degree cousin is quite part of that nuclear household. And how that translates to clinical practice, that that person I use for collateral, that person might help us ensure compliance for anti-abuse treatment for alcohol use disorder, for example. Second, Anglo-Americans overall do not emphasize supernatural forces. For Latinx, spirituality is quite important. I did not learn this in medical school or psychiatry residency, but I see a lot that Mexican patients and patients from South America tell me that they use juramentos and promesas. I don't know if you guys have heard it. It translates to promises in English. And pretty much, that is a religious vow of abstinence or remission that they do to stop using. And they're pretty good and stick to it. And when you ask about it, they will tell you that their father also did promesas, that their grandfather also did promesas, and tells you a lot of information of that biological risk for substance use disorders. Thirdly, overall, Anglo-Americans have their way of communication. Latinx overall have a lot of use of indirect communication. We use a lot of proverbs. We use a lot of stories to share complicated concepts. For example, we use a lot of sayings in Spanish is dichos. And something that I want to also point out about this slide is that culture is not static. Culture is dynamic. So this might be applicable maybe more for a first generation Latino or Latinx or a second generation. But we need to know more of how this is applicable to a fourth generation or fifth generation if it is applicable. This is a story that I use a lot or an image to explain how addiction changes the brain. I tell people, imagine that you are in a green area and you walk every day from one tree to another for two months. What do you think will happen with the grass? And they will usually tell me, Doc, it will stop growing. I'm like, yes. How much time do you think you need for that grass to grow again if you stop walking? And they usually tell me, a lot, months, a lot of weeks. And I'm like, exactly. So similarly, if someone uses a substance every single day, the brain will change. And if you stop using the substance, it will take time for that brain to heal. And again, it's just an image that I use to kind of discuss a difficult concept. This is an example on application of a saying or dicho. I will just read the one in the left for time sake purposes. It's a case vignette for depression, but it's applicable for substance use. A 56-year-old Mexican-American female client was actively involved in her church, was seeking services for depression. Early in treatment, a clinician realized the importance of faith in client's life. The clinician appreciated the importance of family, and with the permission of the client, explore the client's belief and discuss the course of treatment with the family members. Several relatives complained that the client had a tendency to take passive stance in her life, in that whatever events occur, she talked about it being, quote, God's will. Much of treatment focused on the client's spirituality, how this was a source of great strength for her, and how her faith helped her cope with feelings of depression. Within this context, dichos, or saying in English, quien madruga, Dios lo ayuda, or in English, if you help yourself, God will help you, were used as a means of empowering the client to become more proactive with her life. The client, in turn, responded to the agree-upon intervention without feeling that her spirituality was being compromised. So again, this is an example of how a culturally-informed intervention, a saying or dichos, was used to acknowledge and incorporate spirituality and push in a proactive way the patient to focus and work on her mental health. We do not only need to diversify the workforce, but we also need to train people who are in the workforce. And I think these are two great examples of this. The one in the left is the REACH program, which I was part of, and I see Dr. Jenna Jordan here. It's a one-year experience for a trainee interested in pursuing an addiction fellowship, as well as for medical students, PA, APRN trainees, majority from URM backgrounds. And in that one year, not only do you get a lot of mentorship, but you get a lot of knowledge and skills on culturally-informed services, and a lot of information and knowledge about how systems of care perpetrate inequities in marginalized communities. I also want to give a shout-out to the Hispanic Clinic at the Connecticut Mental Health Center. It's a place where the majority of staff members are from Latinx backgrounds, even from the front desk staff, psychologists, social workers, MDs, and they speak Spanish. It's a place where trainees, like medical students, train. It's a place where psychiatry residents train, and it's also the home for the Hispanic Psychiatry Fellowship. And it's not only about the patients, because it's good that patients are getting culturally-informed services and treatment. It's also about the provider. Me, myself, I don't work in the Hispanic Clinic, but I work in the building. I go a lot. I eat lunch in that space, because it reminds me of home. That's how it is. So I think that having spaces like this not only helps patients, but also the providers that are from that ethnic background. So overall, we have a lot of information, and we can already be doing a lot. So a call for action. We need more studies examining how inequities in social determinants of health affect disparities in SUD treatment outcomes in Latinx. When feasible and possible, we need to desegregate data for Latinx subgroups. We need not only to diversity-wide the workforce, we need to train the workforce to meet the needs of the Latinx community, and we need to implement and study treatment strategies that are culturally and linguistically sensitive. And a great example of this is the Imani Breakthrough Project, a faith-based recovery intervention house in black churches in Latinx churches. So with this, thank you, and I'm looking forward for the Q&A. Good afternoon, everyone. While we're pulling up my slides, I wanted to say what an honor and a privilege it is to be on this panel in this symposium with such an illustrious group of colleagues. Oh, good. We're up. Great. So, I'm going to round out our conversation today in talking about substance use disorders among LGBTQ plus folks, and I may occasionally go back and forth between LGBTQ plus and queer as the language that I use. Here's my disclosure. So, today I'll spend some time talking about health disparities that impact queer folks specifically, and we'll also talk a little bit about risk factors as well as some of the protective factors for substance use as well as substance use disorders among folks that identify as queer. And then we'll spend a little bit of time at the very end of this conversation talking about a clinical approach to the management of SUDs as well as discussing maybe some off-label uses of medications that might be helpful specifically to this community. I don't know if everybody knows who this is. Lil Nas X. Call me by your name, Montero. Now, there's a reason why I opened with Lil Nas X. I imagine a young eight-year-old, Daryl, Dr. Shorter, listening to music and seeing somebody like him represented all over the place. Now, if you don't know who Lil Nas X is, and some of y'all are looking at me with a little bit of puzzlement, let me tell you a little bit about Lil Nas X. He sang a song or rapped a song called Old Town Road. And Old Town Road has been certified Diamond, which means it has sold over the equivalent of 10 million records, which is quite a feat for anybody. I mean, Beyonce can do it, obviously. But the Queen, y'all, it's Saturday. It's been a long week, okay. He also was named by Time as one of the 25 most influential people. He was named by Forbes Magazine to be one of the top 30 under 30. And he's rocking out, and he's all over the place. And I think what he really kind of symbolizes for us is that there has been an increasing social acceptance of queer folks. We, I think, can acknowledge that. But at the same time, oh, and at the same time, we have seen, as a result of this, that the average age of coming out has reduced, gone down significantly. So instead of coming out in your 20s, we have folks coming out in their teens and even earlier than that. But at the same time that we have this greater visibility and acceptance of queer folks, we are also seeing that there are persistent negative health and psychosocial outcomes for members of that community. And you know, this is kind of an interesting week to think about that, because we just saw the passage of the Respect for Marriage Act, which was a bipartisan, I mean, yes, thank you. Right, right. So this is like a big, big week. But we also, I mean, I was in the transgender medicine talk yesterday, which was really quite exquisitely delivered. But thinking about how I live in Houston, Texas, and in the state of Texas, if you were to try to access transgender medicine for your child, Child Protective Services could be called on you. And that was a mandate that was passed by our governor. So this is where we are. This is the circumstances under which we're living. And I think it really goes a long way to inform why it is that queer folks might actually still continue to experience some of these health disparities, which I'll talk about now. So we'll spend a little bit of time talking specifically about disparities that relate to gay men and lesbian women. But I also, for the purpose of this conversation, want to bring in folks that identify as bisexual. Because I think historically, we have had a tendency to erase bisexual folks from the conversation. There's a significant amount of biphobia that exists, a significant amount of bisexual invisibility that exists. And that actually goes a long way to really reducing their health outcomes as well. So anyway, gay men and lesbian women have a higher likelihood of experiencing psychological distress, moderate for lesbian women, severe for gay men. And that can also translate into heavier substance use, particularly smoking and drinking. And they are also at a higher risk or have a higher odds of not accessing care, specifically related to cost. And we've had some conversation and mention of how it is that people don't necessarily have access to insurance. I think, you know, when I was kind of growing up, there was this kind of image of gay men that was, you know, everybody was really well-dressed, ha. And sort of wealthy, right, and the club. But that's like not necessarily the story for everyone who identifies as a gay man. Y'all, it's Saturday. All right. Gay men, in one study, about 8% reported experiencing serious psychological distress in the past 30 days in comparison to 3% of cishet folks. And they were two times the odds of reporting trouble finding a provider. Among lesbian women, again, some of these same disparities. Increased likelihood of having poor or fair health, increased prevalence of overweight or obesity, increased risk of developing chronic conditions. And that may be related to the next bullet, because there are also decreased rates of screening for certain kinds of health care conditions, and that includes cancers. You know, I remember kind of early in my career being sort of surprised that people didn't think that someone who identified as lesbian needed a pap smear. I mean, this is where we, I mean, now, hopefully that's not a surprise to anybody in this room, but this is like 20 years ago, that was actually something that people discussed, whether or not a pap smear was needed by a lesbian woman. And again, higher rates of serious psychological distress reported. So to bring bisexual folks into this conversation in a very deliberate way, there's increased distress related to bisexual identity. We'll talk a little bit about some of the concepts of heteronormativity as well as homonormativity, this idea that there's kind of a right way to be gay or lesbian as well, and how bisexual folks don't necessarily neatly fit into this idea. Also greater distress reported, and that really seems to be the driving force behind why it is that they're seeking mental health treatment. There's also an increased odds of delaying or not receiving care for both cost reasons, so that's related to insurance, but also for non-cost related reasons as well. Bisexual women significantly more likely to have multiple chronic conditions, severe psychological distress, heavy drinking, moderate smoking, sexual violence, and even higher odds of delaying care in comparison to gay men and lesbian women. So the thing that you want to kind of, hopefully you all are doing this now in your mind as I'm talking, is you're like, all right, well, am I asking people specifically about who they are or are not having sex with? How do they identify? And are alarm bells going off for me when I'm working with a patient who identifies as bisexual? Because they are, of course, likely to experience pretty serious, severe psychological distress. So now I want to bring transgender and non-binary folks into this conversation as well. Higher rates of mental health conditions, that includes social anxiety, PTSD, major depressive disorder, and among those that have a history of major depressive disorder, higher rates of suicidal ideation and suicide attempt. Increased feelings of being self-conscious and a significant amount of mistrust of others, of healthcare systems, which we'll talk about in a second. And I think that this number is a little low, actually, only about 60% reporting that they've been exposed to some form of harassment or violence, but when we think about and sort of ask ourselves questions about the trans folks that we may be taking care of or encountering in our clinical systems, certainly the ones that are presented to treatment, it's like 100%. I mean, almost all of them are reporting some form of harassment and violence that they've had their experience, either in their home or outside in the community. Significantly decreased likelihood of actually having health insurance in comparison to heterosexual as well as other members of the queer community. And I think probably the most sobering statistic that I'll present today is that among trans people of color, a significantly lower life expectancy of about 30 to 35 years. When we think about LGBT youth, significantly more likely to be homeless, significantly more likely to attempt suicide, and also dealing with another host of other problems related to employment, poverty, healthcare costs, and inadequate social safety nets. And one of the things that we'll talk about when we get to sort of protective factors is kind of understanding how important it is for people to develop a sense of community. There's even kind of a sort of current parlance, this idea, this notion that all it takes is one person, having one relationship, one mentor, one teacher, one family member who is supportive of queer identity, that in and of itself might be enough to prevent someone from having a negative mental health outcome. I actually tried to find that in the literature, and I wasn't able to. So if somebody knows where that reference is during the Q&A portion, I really invite you to come up to the microphone, because I couldn't find it, and I'd love to include that in future discussions. When we think about LGBT youth and the kinds of conditions that they may present with, again, conduct disorder, major depression, and sort of astoundingly almost 10% with PTSD. LGBT youth also more likely to report feeling sad or hopeless. About half of LGB students seriously considered suicide. Again, quite sobering. About a third report being bullied at school. About one in four report non-medical use of prescription opioids. We talked a little bit yesterday about people numbing their pain, and when exactly that begins for them. It begins not once they're 20 or 30, it begins in their teens. Almost one in four using an illicit drug. And over 20% reporting that they've been forced to have sex. LGBT health and COVID, what we found is that there was a significant increase in the amount of depression, anxiety, and drinking among folks that identify as LGBT. But who's at the top of that list? The bisexual folks, right? So again, thinking through, like, how can I enhance the quality of my own assessment process, right? Am I going to where the greatest risk is for people? Now when we think about barriers to care, there are quite a few. But some of the ones that I'll focus on for today, lack of access. We talked a little bit about what queer identity means for people and their ability to attain employment, to certainly kind of reach the heights of their ability, and what that can mean for them in regard to insurance. One thing about this particular conference is I'm like sort of exquisitely aware of how I am in the South. And that my experience as an addiction psychiatrist in Texas is not the same as when I was in fellowship at NYU. It wasn't the same when I was a resident in Ohio. Thank you, Ms. Bradley. When you're sort of in the middle of the country, or certainly in the South, dealing with queer folks is not the same as it is in New York or San Francisco. And so one of the things I think we have to think about as an organization is how do we manage that part of it, right? Like we can't just think about addiction psychiatry for the East Coast and California anymore. And how that impacts people in the middle of the country has got to be a consideration, too. Soapbox done. There's a limited number of queer and culturally sensitive, responsive, humble providers that are available to folks. Now you can imagine somebody comes in to me, I'm colorful, and so somebody might feel comfortable with me. But not even necessarily all queer folks feel comfortable with me. I may be a little too out for them, and that's because of things like internalized homophobia and all kinds of stuff like that. So knowing the right balance to come in at, it's not always just about your outness, right? Or your lack thereof. I mean, it really does become you trying to in some ways match the person's level of comfort. So that means you've got to ask about it first. You have to get an understanding of their own experience of their queer identity. And make no assumptions. There's a pretty significant mistrust of providers and systems, and they're also unwelcoming systems as well. So one of the things that I often encourage people to think about is when you're in the waiting room, if your paperwork, when someone's filling it out to come see you, only has two boxes to check for gender, M and F, you've already lost your trans folks. They are already not seeing themselves represented in your system. I worked for many years in the VA system, and one thing I will say about the VA is they had tons of signage all over the place for LGBT veterans. This is a welcoming environment for you. You've got to do that, especially in Texas, right? You know, the VA is one of the leading, I think they are the number one provider of transgender health care in the country. And so really being open to that community and showing it on the walls, that's the part I'm talking about. You have to basically advertise it. That is how you begin to dismantle this notion that this system is unwelcome. So taking all this stuff together, really what we're dealing is what has historically been referred to as minority stress, and hopefully Dr. Jordan will give me the appropriate term for what this is called now. Now there are a number of things, again, we just celebrated the passage of this bill, and this is a couple days old, right? We are in a state that passed a don't say gay bill, and much of the language around that bill talked about how it's an anti-grooming bill, disgusting, like just the thought of it, right? Like this idea that people are being recruited just by being who they are and saying their identity. Now imagine if your identity is equated with being a sexual predator, and what that does for you from a psychological standpoint. The same thing happened to trans athletes with the Save Women's Sports Act in North Carolina. Now North Carolina ended up, as a result of the passage of this, they ended up losing a number of contracts and people pulled out of conferences and so forth, but the psychological impact that that has on North Carolinian, I think I got that, trans folks, and their families and their friends, pretty significant. And we just see that the number of, the amount of legislation that is being proposed nationally has just continued to go up, up, up, up, up, up. So even though people, I think, are experiencing the Lil Nas Xs of the world, they are watching the passage of these sorts of defensive marriage acts, right? That's the wrong one, it's the Respect for Marriage Act, excuse me. You also may be living in a state where you know that if you have a friend who's trans or non-binary and their parent is in support of it, that they could have Child Protective Services called on them. So this is the tension under which we're living. So this legislation prohibits trans youth from accessing gender affirming care, prohibits them from participating in sports. That's by far the most common one, almost 70 bills proposed for that specifically. We've got over 40 that assert religion as a justification for not providing services to LGBTQ folks, and then we're still dealing with bathroom bills in 2022. What's interesting, like, I mean, some of you all are shaking your heads like, oh, yeah. You almost forget, right, like in a year where an election's not necessarily taking place and this is being used as a divisive issue, which is almost all the time what it's about, you almost forget that bathroom bills are actually still being proposed. One final little bit about LGBTQ queer identity is that this gets even more complicated for folks that have multiple types of identities. And so queer folks of color might experience ostracism from within their racial or ethnic group or they might experience racism within the queer community more broadly. So it can create for folks a feeling of sort of being betwixt the between and that they're not, they don't really belong anywhere, which will further, you know, create psychological distress. So when it comes to other risk factors that might be present specifically for queer folks, I think that there are some other ones. There's a lack of institutionalized protections. We've been paying a great deal of attention to bullying and how that actually has an impact and creates feelings of further victimization. And also family rejection. And so one of the things that, you know, I think we can do as providers, especially when we're dealing with family members, is to try to help them to see that acceptance goes such a long way, not just for them themselves, but also for the people that they profess to love. Because family acceptance, it turns out, actually improves self-esteem, it helps people to feel supported and can actually improve their overall health, reducing their likelihood of going on to engage in substance use, develop substance use disorders, or have other types of depressed or suicidal behaviors. One other thing that can sometimes come up is like, well, you know, I don't want my kid to have sleepovers, I'm afraid that they may be, like, engaging in sex, or, like, stuff might be going on, like, I'm concerned about dating and what that can look like. It turns out that in some cases, for some kids, romantic relationships might actually be protective. Now, of course, you want to provide the appropriate structure around that. But this idea, this notion that people should wait, or that kids or adolescents should wait to figure out who they are before they date, actually, you may be removing a protective factor in those cases, particularly because it can reduce the likelihood of that feeling of rejection. We talked about one person, having one person to understand your experience and be accepting of you. And that might actually take place within the context of a romantic relationship. There are several community characteristics that can also be very helpful. So if there are more protections for LGBT couples, that can be helpful. Having a higher number of registered Democrats. The presence of GSAs, or Gay Straight Alliances, is another one. And then specific non-discrimination policies. So as I mentioned, I live in Houston, and years ago, there was a huge amount of attention around what was referred to as the Hero Ordinance, which was intended to be a non-discrimination policy. And unfortunately, it did not pass. And I can tell you that the sort of cultural impact, the social impact of that not passing on queer folks was quite tremendous, feeling like, all right, well, here I am in this big blue dot in this red state with, at the time, an openly lesbian mayor. And we couldn't even get Hero passed right now. Is there a space for me? One of the reasons why this becomes important is because it actually has been associated with decreasing suicide attempts among LGBT youth. So it's not just about whether or not a person has rights. It's also about the mental health of the community and of our youth. So LGBTQ folks, more likely to recreationally use alcohol and drugs, higher rates of substance use disorder, maybe less likely to abstain from use, and more likely to continue heavy drinking into later life. I don't want to spend as much time on the data part of it. Just to say, I will switch through just real quick. So I mentioned this concept of heteronormativity and homonormativity being a big part of the context under which LGBTQ identity is formed. So heteronormativity, this idea that there's sort of an appropriate way of being if you are straight. So if I say to you, like, you know, a man marries a woman, right, and they have, and first of all, marries is in part of that, right, like this assumption that people get married and that they marry someone of the opposite sex, okay, that's part. And then if they have how many kids? 2.2, and they live in the suburbs, and they have a what color picket fence? Okay, all of them, y'all are, y'all, it's a Saturday for you too. So essentially, we all kind of know, we get the script, and I don't even know when I got the script. I don't even know when I was told that this was the appropriate or the correct way to be, but we all got that message some kind of way. Well, that happens to queer kids too. And so then how do you, do you see yourself fitting in, especially if like, you have two moms or two dads, you live in the state of Florida, and you go to school and you're not allowed to say gay. So there's also homophobia. There's blatant transphobia, and we still have bathroom bills, still have bathroom bills. There's the concept of toxic masculinity, so there's a right way to be masculine or to be male. I will argue that toxic femininity exists. Thank you to the Kardashians. Oh my gosh, if you keep up with the Kardashians, you're part of the problem. I'm teasing. I'm actually not teasing, but I am teasing a little bit. But if you keep up with the Kardashians, talk to me after. And homonormativity. Again, I think that this idea that there's a kind of a right way to be queer really contributes significantly to the experience of our bisexual folks, brothers and sisters. So for a little bit, final bit, and then we'll, okay, and I've got five minutes, I just want to talk a little bit about a treatment approach, and then I'll briefly mention a couple meds, and then we'll take questions from the audience. So as has been mentioned multiple times, the idea or the notion, and I feel a little bit like I'm preaching to the choir, but the idea or the notion that someone has to come in and they have to establish abstinence is something that we really have to challenge. And it's great to be in a room with addiction psychiatrists, because I think most of us, many of us, the vast majority of us get that as a concept. I've shouted out my state multiple times, and I tend to work with people who approach with a very abstinence-oriented perspective, and that not everyone who is providing addictions treatment believes that. So you might be working with counselors or in treatment programs, or with peers who got sober through blank organization, and they feel very strongly that abstinence is the only way. And so some of the work that I feel like I've been doing in the community is really trying to counteract that narrative and to provide people with options and multiple pathways to recovery. So it begins with this. So medically, of course, you want to make sure that you screen, and I know people aren't talking about monkeypox quite as much, but there was a period of time where we were talking about monkeypox a lot. COVID vaccination is another aspect of this as well, screening for chronic medical conditions, because you may be the first or the only person that's willing to address chronic medical conditions because everybody else has been focused on the substance use disorder or the mental health condition. So is there a way in your evaluation process when you're coming up with a treatment plan for someone to fold in that aspect of it too, so that the person feels wholly cared for? When it comes to substance use, again, you're going to try to figure out what their goals are. I want to go from, what did you say, three bottles of wine a day to one bottle of wine a day, and maybe even acknowledge that, like, oh, that's not really what I want for you. Okay. Oh, I really would love for you to just not drink three bottles of wine at all. Okay. But let's work with where you are. And of course, use pharmacotherapy. From a mental health standpoint, of course, it's assessing for safety. This is a population that has higher risk for suicide, again, providing pharmacotherapy. And then, as Ms. Bradley mentioned, you know, this is a Maslow's hierarchy of needs situation as well. You might have to talk to someone about where they're living, talk about whether or not they have access to food, and what their community, what their safety looks like, especially if you're talking about dealing with patients that are trans and non-binary, like, where does that person live? Like, how can we maybe provide protections for them if their employment is sex work? And working with them, not necessarily to pull them out of that, but to support them through it and help them to be safe. I will just say a quick word about methamphetamine pharmacotherapy, and then we'll kind of take it out from here. If many of you all may live in large cities, and Houston is no different, where we have seen a massive increase in the amount of methamphetamine use, as well as methamphetamine related overdose globally, and particularly among queer folks. Our proximity to the Texas-Mexico border really has allowed a flooding of our markets with cheap, highly potent methamphetamine. Now, you know, normally when I have a full hour to give this talk, Dr. Durham, I get to go into all of the reasons why it is that people- You have four minutes, but no, you have two. I get to go, it's Saturday. I get to go into all of the reasons why it is that methamphetamine, in particular for MSM, is really like a kind of a go-to substance, because it sort of eradicates all of the societal noise around the shame and guilt that someone would experience from having a type of sex that is typically found, or thought of to be immoral, or unnatural, or dirty, or any of the words that are oftentimes associated with queer sex, right? And if you've been getting those messages and hearing that noise from the time that you were this big, having that noise removed is extraordinarily seductive. So we need to back up a little bit and think about why it is that someone might use meth, and it's not just about their exposure to it, it's about sort of this history of garbage that they've been hearing, and how all of a sudden it's gone. In a conversation yesterday, we were talking about how the difficulty of establishing sobriety recovery from meth use disorder, and how redefining one's relationship to sex is a part of that recovery for so many people. But we got to go back even further to acknowledge the ways that heteronormativity, that this idea of dirty, impure, unnatural sex has played into why it is that someone would even use that substance in the first place. Okay, so let's go, I'm just going to skip through, okay, I'll go through. So stigma, discrimination, obviously are huge factors in why it is that queer folks are perhaps more vulnerable to the use of substances, as well as the development of substance use disorder, and what can we as an organization do? I think we lobby not only about substance use, but we also lobby about queer rights. Our position has to be not just about addiction, but also about the factors that contribute to the development of addiction. Triple A-P. All right, and your role in providing safe and affirming healthcare, for being a place where people feel accepted, and beginning to evaluate the systems in the clinics in which you work, I would encourage everybody to go home from this conference and take a look at the paperwork that your clients fill out when they come to see you. That's an easy place to start, right? One of the other things that sometimes people will do is they have badges that say their pronouns on them. That's an easy one, right? I mean, these are low-cost interventions to help people feel safe. Using pharmacotherapy when we can, I'm sorry we didn't have as much time to talk about that as I might have liked. There's a pretty substantial lack of research, excuse me, on lesbian women, bisexual women, and trans men, so those are areas of focus that we can and should think about in terms of including in our own future research. One final thing, I was fortunate enough to have as an attending when I was in residency, a guy by the name of Dr. Pepper, I know, it's too good. And he said, you know, you never know which time could be the time, so you treat every time like it could be the time, and I think that that has really kind of informed why I do this work, how I continue to do this work, because I never know which time could be the time. So thanks for letting me all chat it to you for 30 minutes, I appreciate it. Thank you. Thank you all for fantastic presentations. I know we have time for people to ask questions. I see someone at the mic already who I know. I do want to say one thing before Dr. Ayanna Jordan starts talking for the 25 remaining minutes, which is that, you know, what I always think about when we have these talks about inequities is at the heart of it is a lot about racism, discrimination, bias, stigma. And we know that there are historic, systematic things that have happened in this country, but at the end of the day, it's each one of us in the room that are people within systems that make policies, that make laws, that design where people are coming in for treatment. And so I just want to, we have to, as individuals, do this better. And so that means doing your own work so that the kid that comes into clinic feels whole, feels supported. That means meeting people where they are, right, going out into the community. But we have to do the work at an individual level, and we are all a part of a community. We are all a part of a family, of a network of people that we can have these conversations and figure out where our blind spots are. Because at the end of the day, people are dying because of the fact that we are super biased and decide who and who not to give treatment to, and that our systems are built upon systemic inequalities. And so I just have to say that because every time we do these sort of talks, I end with thinking, well, it's the people, each one of us, that are perpetuating a lot of this. Our kids should feel safe, right? Our adults that may look differently that the provider in front of them should feel very comfortable coming into a room to talk about, you know, deep, dark secrets with each one of us, right? And things that are impacting their lives because we want them to be successful in whatever family, in whatever relationship they choose, and in their communities. So with that, I'll let Dr. Jordan ask a question or make a comment. No, I don't, okay. I really will be quick. I just wanted to say, it's a comment, not a question at all. There's an African proverb that says that if you want to go fast, go alone. If you want to go far, go together. And I just want to say that this panel was exceptional, starting from Ms. Bradley to Dr. Fabiola Cruz to Dr. Shorter, and also to have you, Dr. Durham. A couple of things. I think AAAP is continuing to evolve, and I'm glad for it. A few years ago, before the assassination of George Floyd, before I think this country really grappled with what it was to be black in America, what it was to be minoritized in America. We couldn't even get a workshop accepted about intergenerational trauma and blackness and substance use disorder. So to have this be a symposium, I think just shows what happens with representation. I also think when we're talking about these professional organizations, we have to understand that representation matters. I learned so much from each of you. Fabiola, you took me to task in understanding the points of breaking down subgroups and what I need to ask, what I don't need to ask. Same thing with Dr. Shorter, and I was like, oh, I didn't think about my bisexual brothers and sisters that come and see me, and so these things. And so we have to push for more representation. It's not okay for me that we're in, I don't know, Naples, Florida. Because my thing is, only do I understand what it means to be a black person. I want to go to the beach, but everybody's white. And so we have to understand that our lived experiences matter to our patients. And so we have to have more of us in the room. And as an organization, what does that mean? Does it take using more of your money to have trainees? Does it mean that you're going to have people who don't look like you in your labs? Does that mean that you're going to do whatever it takes so you don't have the majority? It's most important. And we have to call our organizations to task in terms of, if we want to eliminate disparities in substance use disorder, we have to advocate for systems that talk about, like Ms. Bradley said, the social determinants of health. So we can't talk about treatment if we're not talking about universal basic income. Having to have mandated housing, what does that really mean? And medicine is political, Dr. Shorter, like you told me, because I can't talk about something if it is not legal in my country. And so as an organization, are we pushing that our presence and our leaders are involved in the political system? So thank you, guys, for this amazing symposia and allowing us to have the conversation. Thank you. Thank you, Dr. Jordan. I see someone over here. Hi. I'm Colleen Ryan. I'm from Kentucky. We're a very- Can you put the mic a little bit closer? Thank you. Is that better? Yes. Okay. Colleen Ryan. I'm from Kentucky, which is pretty conservative, but thank God we have a Democratic governor. It's our saving grace. I think my question is actually somewhat similar. I mean, I was just sitting here thinking about, we have all these organizations, AAAP, AMA, APA, ASAM, and they all have policy statements, but policy statements only go so far. Do you feel like our organizations are doing enough at the top to push this agenda? What would happen if ASAM and APA and AMA got together and flooded Texas with education? Does that make a difference, or are these ears just deaf? I honestly- It's not a- No, you're good. Yeah. Okay. Thanks. Yeah. I honestly can't imagine that it wouldn't be helpful. Texas is tough, right? I use it as an example because of its difficulty and really trying to wrestle with, well, how do we... I'll use, again, the trans youth example because it's one of the most recent ones, but there are innumerable ones. What would it look like for not just the Texas Medical Association, but the AMA and the Pediatrics Association and APA and AAAP, for all of us to get together and say, like, Governor Abbott, this is wrong, and it impacts the health of not just these kids, but their parents and their community, but we don't know because we haven't had that conversation. I do think it does become the responsibility of the members of these organizations, especially because I think in situations like this, we are all very interested in equity and in social justice to push and say, like, what does it look like when you all get in the room together? I think your point is really well made, and it's something that I think we as members should really push our organizations to do. And I'll just add to what Dr. Shorter mentioned in thinking I am more involved in the APA. I also know that there are a lot of members, like we're all here today for AAAP, but at the highest levels, like in many organizations, it's not as diverse, to Dr. Jordan's point. And so for that particular board, I'm thinking of the APA to push the boundaries. We actually need to get more folks that are actually believing a lot of what we're all saying here. And that's not necessarily true at the APA, for an example. In today's APA, the board is very homogeneous. It does not look like the rest of society and a lot of the folks that we're treating. And so I do think we not only have to push as members, but also push within these organizations to have a more diverse board that speaks for the people we're seeing and for us, you know, as an organization. Oh, so he's next? Okay. Sorry. Hi, everyone. My name is Kalen Pettis. I'm originally from Memphis, Tennessee. And my question is, how does spirituality, what role does spirituality play within each of these communities? Being from Memphis, Tennessee, where you have a church at every corner, understanding, like, the history of churches and how they were very impactful in the Civil Rights Movement, how they were educated and resources for black communities. However, in the same way, they have been detrimental to different communities, such as the LGBT community and everything like that. So how do we use these infrastructures that are already in these communities? And how can we use these, use people's beliefs that kind of help motivate them to navigate substance use disorders? Did you say Kalen? Yes. Oh, good to see you in person. Yes, ma'am. Ms. Bradley, I think we'll take that. Can you hear? I'm trying. There it is. There we go. Excellent question. So, the way we work around it is we allow consumers that want to be involved in spiritual programs or religious programs the opportunities when they're in our program. You know, there's the separation of state and church, how you receive federal funds, you can't do this. But there's nothing that we can do to take away a person's right to go to church to pray on their own. Actually, we encourage it. And one of my colleagues was talking about asking the right questions. So when you come to a program, that should be a part of the questions that we ask, like when you were a kid, did you go to church or what do you believe? So for myself, in addition to being in treatment and going to church on Sunday, it all came together. But I really think we need to find ways to open and make those options available, critical to the African-American community. Oh, you know I did. This is a very simple answer, but just to build on that. Please keep your comments to a minute. Okay. I will be brief. I will be brief. I will not be brief. So, queer folks have a very complicated relationship to religious organizations and spirituality. One of the things that I think we have to acknowledge is the amount of religious and spiritual abuse that queer folks have experienced, how many times they are told that they don't belong in a particular church or temple or synagogue or what have you. And how people are really wrestling with that, because sometimes that religious affiliation has informed the beliefs of their family, the beliefs of their community. And so, it's not just like I don't belong in this particular religious system, it's also like now I don't belong in this family because of their affiliation with this religious system. Okay. At the same time with substance use disorder treatment, we recognize that people oftentimes will maybe attend a certain type of AA group or NA group within a church. And so, people are sometimes receiving at least some form of mutual help or support within the various systems and structures that they have found complete lack of acceptance. And so, one approach that I've tried to use, not necessarily successfully, is to say, well, what would it look like for you to reclaim spirituality as an act of protest? Like to say, I belong here. I'm actually going to believe because you told me I couldn't. Now, see, something like that would work for me. Oh, it's Saturday. Sorry. Yeah, yeah. Sorry. Okay. I'm sorry. So, I think that, but engaging people in that conversation about like, all right, well, what would it look like for you to actually reclaim this? And is there a space for that? And if they say, no, it's way too toxic, then you just circumnavigate it and find something else for them that will work. Thank you for that question. Try again. It should be on. It was a very powerful depiction of many of the issues that we are raising, and I think, you know, I'm glad that it got the Oscar, you know, it did a lot to educate people and also reduce stigma. So the thing is, you know, like, we really, I think, need to work with the media as, you know, the media is very powerful, and it has a wide outreach, and much of the discrimination has to do with people's ignorance and familiarity, and education, I think, will overcome that. So thank you. Thank you for that comment. Any comments about working with the media? I think that all of us. Is it working? Yeah. Good, thank you. I learned that I have the privilege of being a doctor, and learning a lot, and we have a duty to be able to share that with the public. The articles that I describe, perhaps, if I show it like that just to the public, they might not understand. So I think one role of all of us is being able to digest all this information and putting it in baby food and attracting information to the general public. Because the articles are in PubMed and all that. Who reads it? It's not the general public. So each of us have the power to, the things that we know, be able to put it like in baby food for the public. It could be in a movie, it could be in an op-ed, but we all have a role in that. Thank you. Hi, Deborah Barnett from Tampa, Florida. Yes, Florida. I did just say, mm. It's amazing how many times Florida's come up in the meeting this few days. But at any rate, one of the previous questions had to do with how national organizations perhaps can help at state levels on some of these issues. Actually, I'm also with the Florida Psychiatric Society, now legislative chair. Great time to take that spot, right? It's a dicey situation when you try to get national organizations to come in and help. Are they trainable? Some of the governors, I would say some are probably not. It's not to say that the national organizations shouldn't come in and help. They do. In fact, we use a lot of the resources from national organizations to do what we can do, but it can be a dicey political situation at best. Let's face it, even Disney couldn't convince the legislators not to go that way. Anyway, just comment on that. Back to the issue of faith-based and spiritual organizations, especially for LGBTQ. I think about a lot of our patients that we refer out to other levels of care, outpatient services, sober living, and a lot of that is faith-based, which brings up a couple of issues. Of course, there's the whole medication issue, right? A lot of those are like, oh, no, medications. Really, for the LGBTQ, that could be also a dicey proposition. Yes, hard agree. One of the things that I think we have to do as a treatment community is to know what our local landscape looks like and to utilize our networks to have a better understanding of places that are and are not safe. Unfortunately, that requires some trial and effort, and the patient is the one who suffers. Anytime I hear that there's an organization or a clinic or a program or a sober living facility that is not accepting, it goes on a mental list and say, do not refer anyone else there because we don't want to do harm to the individual. Follow-up. If I could, I guess the other thought that occurred to me is that any thoughts on how we could better try to bring some of these folks into the fold, so to speak, and educate? Yes. I spend a lot of time running my mouth in the community, actually. I get to talk at places like AAAP, but I also spend a lot of time engaging with faith communities and with black and brown folks and with queer folks. I think it's important for us to sometimes take our message out of the ivory tower and really challenge people. We have the benefit of being able to speak to not only our experience as treatment providers and to provide data for them about how outcomes are actually better if you are maintained on Suboxone, so that when you get to a program where they want to take you off of, it's like, no, no, no, don't do that. Here's the reason why, but saying it to them in a way and in a language that they can understand. Challenging them and then remind them, like Dr. Durham just said, that folks are dying. What would you rather have them on, a medication and alive or living up to some ridiculous idea or principle of sobriety and abstinence that is archaic but dead? What do you want here? Just real quick, I was thinking about just as practitioners, us holding ourselves accountable for challenging institutions, whether they're religious or whatever. When we send our consumers to programs, our programs, that if they experience biases or whatever because of whatever, their ethnicity or their sexual preference, that we challenge that. To me, there's nothing worse than coming to seek help and being damaged in an institution that's supposed to be there to help you. That's right. We have like two to three minutes, so try to get all the questions that we have left. Is this working? Okay. Thank you so much. This was an amazing panel, and congratulations on 18 years of your program. I'm Jen Creeden. I'm child and adolescent addiction psychiatry in New Orleans at LSU, so a neighbor to Dr. Shorter. I get the privilege of working in our tiny but mighty gender clinic at our children's hospital. We are a very blue dot in a very red state, and we've been protected up until probably next year, the year after, by a Democratic governor. We haven't had some of the insane anti-trans laws passed that have it to our neighbors, but we're already preparing that that's going to happen. I guess a couple of questions for all of you, but particularly for Dr. Shorter, since you're living this. For the kiddos who are being forced off their medications and gender-affirming hormones, what are you seeing? Then any tips for, I know this has been touched on, but for advocating as the minority in a state for our kids? Absolutely. You and I should exchange information before you go. A couple things that we saw. One, we saw lots of folks go out of state, it turns out, which is just another barrier and makes me sick to even have to talk about it, but we did see that happen a bit. Initially, things were on hold, but then many of the hospitals and clinics just came back online and just did so under the radar. It can be a little dicey, and then just trying to provide people with support, from a mental health standpoint, because we knew that people were just going to fall apart, but we should for sure continue to talk about this afterwards. I think this will have to be our last question to the left, my left. Real quick, thank you so much. It was really nice to have this talk at the AAAP. I'll keep it short. I work as a medical director, chief medical officer for a group of clinics in the Philadelphia area. A lot of the, I feel like some of the more black and brown issues have been, people are more sensitive to, but a lot of the issues regarding sexuality, bisexuality, gender issues, I think people, while they may have the best intentions, they lack the language, the sensitivity, and how to address issues. With clients, just because, to some extent, they may not have had any interaction with these folks at all. To the media point, there's no exposure, less exposure in the media than to black and brown issues. My question is, how would you enhance the public or even provider sensitivity to these groups of people so they can respond in a very like-minded way, to your point, so they feel more receptive to the providers? Providers certainly mean well, but they just lack the language to convey that. Yeah, I think one of the things that I have seen is certain organizations really adhere much more tightly and rigidly to these notions about religion and spirituality, especially in addictions treatment. You have folks that are maybe coming in with their own experience, and not to necessarily take away from that, but they come in with their own experience, and that really can color the lens through which they even view someone with sexual orientation or gender identity. That's sort of that part of it. I also want to acknowledge that some people are able to, they learn about sexual orientation and gender identity through social media, and that is like a whole other way that information is provided to people, but there's no real consistency around it. So training, training, training, bringing outside trainers, people that really specialize in this sort of thing where they speak to and kind of challenge the ideas and the notions that people are coming to the table with, and really can help people to wrestle with the ways in which queer identity is presented through the media so that folks can tease out what is and is not quote-unquote true or accurate for folks. I mean, I sort of came of age when HIV-AIDS epidemic, and that was the only image of gay men that I saw when I was growing up, right? And there are still vestiges of that that persist to this day. And so it's a generational conversation. It's a race and ethnicity conversation. It's what you've been exposed to. It's cities versus rural. It's a south versus north. It's an east coast or coast versus the middle of the country. There's a lot of complexity around the messages that people receive about queer identity, and so I think beginning to deconstruct some of those locally and then bringing in people who can help to understand it is probably how I would go about it. Thank you all for your attention and staying with us this afternoon. Thank you.

substance use disorder

marginalized communities

Black population

Latinx population

LGBTQ+ population

treatment access

addiction treatment

stigma

discrimination

logistical barriers

cultural barriers

social determinants of health

housing

job opportunities

culturally informed interventions

spirituality in treatment