The ASAM Principles of Addiction Medicine 5th Edition

37. Cultural Issues in Addiction Medicine

Joseph J. Westermeyer, MD, MPH, PhD and Marion Warwick, MD, MPH

CHAPTER OUTLINE

■  DEFINITIONS RELATED TO SUBSTANCE USE AND ABUSE

■  CULTURE AND PATTERNS OF SUBSTANCE USE AND ABUSE

■  CULTURAL ASPECTS OF CLINICAL ASSESSMENT

■  SUBSTANCE-SPECIFIC HISTORY

■  ADDICTION AND PATIENTS’ CULTURAL FUNCTION

■  CULTURE, TREATMENT, AND RECOVERY

■  CONCLUSIONS

Addictive disorders can vary widely across nations and cultures. For example, high rates of alcohol abuse and dependence occur in several countries of Eastern Europe, especially Hungary, Poland, and Rumania (1), the aboriginal people of Australia (2), and the Northern Plains Indian tribes of North America (3). Likewise, ethnic groups in Southeast Asia that raise poppy as a cash crop (e.g., Hmong, Iu Mien) have high rates of opium dependence (4). Social disruption and armed conflict can lead to widespread addiction (5). At times, sociocultural subgroups can manifest high rates. For example, 40% to 50% of college students in the United States report an episode of binge drinking (5 drinks or more for men, 4 drinks or more for women) in the last 2 weeks (6), with Euroamerican men and women having the highest rates of heavy drinking and alcohol-related problems (7). Some nations have demonstrated the ability to notably reduce the prevalence of addiction, such as the decline of opium use in China during the latter half of the 20th century (8).

As a means of enhancing their effectiveness, clinicians need to appreciate the interactions between culture and addiction. Basic to assessing cultural factors is the ability to take a culture–ethnicity history (9).

DEFINITIONS RELATED TO SUBSTANCE USE AND ABUSE

Several concepts are helpful in guiding the addiction specialist in understanding the role of culture in contributing to, as well as alleviating, addictive disorders (see Table 37-1 for a list of these terms). Culturestypically have laws or traditions regarding substance production, distribution, and consumption. Most nations encompass numerous ethnic groups. Within a culture, ethnic groups can differ greatly in their use of alcohol and other psychoactive substances. Their attitudes, values, or practices may resemble or differ from those of the culture at large (10).

TABLE 37-1 DEFINITION OF CULTURE-RELATED TERMS WITH UTILITY IN UNDERSTANDING, ASSESSING, AND TREATING SUBSTANCE USE DISORDERS

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Groups of people with substance use disorder can comprise subcultures, such as a drug or drinking subculture tied to a particular using context (e.g., neighborhood tavern, crack house, or college party house) (11). Any one person may belong to more than one subculture or ethnic group, which can enrich the human experience as well as create norm conflicts. From your patient’s standpoint, affiliation with a recovery-oriented subcultures that shares norms and values can reduce stress (and relapse risk) during recovery.

An ideal norm might prescribe use of a substance under certain circumstances, such as drinking wine during Jewish Passover or consuming peyote in the Native American Church. Or, an ideal norm may demand abstinence, such as abstention from alcohol by many Moslem sects or abstention from tobacco by Seventh Day Adventists. Behavioral norms consist of what people actually do (12). A norm gap or conflict occurs if the ideal norm and behavioral norm conflict. In cultures with norm conflicts regarding substance use, substance disorders predictably ensue (13). Bringing norm conflicts to the patient’s awareness can be useful in the journey to a culturally syntonic recovery.

Exploring the individual’s identity can lead to valuable insights that can guide interventions as part of motivational interviewing. For example, asked about his identity, one patient replied, “I’m what you might call a common drunk, doc, but I’m not an alcoholic.” This response led to a useful conversation regarding the patient’s criteria for these categories and why he was willing, even anxious, to accept one identity while vehemently rejecting the other. Entrenched negative identities (e.g., “common drunk,” “pot head”) can serve as a justification for continued addiction and avoidance of recovery (14).

CULTURE AND PATTERNS OF SUBSTANCE USE AND ABUSE

Among groups in which ideal norms and behavioral norms regarding substance use are identical, substance abuse rarely exists. On the other hand, groups that prohibit use of a substance in theory and yet allow it in practice invite individuals to decide use on their own. This circumstance results in some people using the substance excessively. Current examples of norm conflicts fostering increased substance abuse in the United States include legalized medical marijuana in certain states (15), opioid prescribing for “chronic pain,” (16) and college binge drinking (6). Table 37-2 shows the concomitants of substance use in association with norm conflicts (17).

TABLE 37-2 CONSEQUENCES OF SUBSTANCE USE DEPENDING ON PRESENCE VERSUS ABSENCE OF NORM CONFLICT

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Appreciating ethnic patterns of substance use and abuse in the United States can provide a useful primer for the beginner (18), but relying on general trends can be misleading for the following reasons:

■  Within any large population, considerable differences exist among subgroups. For example, Korean Americans tend to have higher rates of substance disorder than other Asian American groups (19).

■  Rates of substance disorder may change with the generations since immigration. For example, Mexican American women have extremely low rates of substance disorder in the first generation after immigration, but rates comparable to other American women in the second and subsequent generations (20).

■  Sociocultural changes within ethnic groups can affect the pattern of substance use and disorder over time. For example, many Hispanic Americans have abandoned Roman Catholicism for abstinence-oriented Protestantism in an effort to resolve alcohol disorder (21). An Asian American immigrant group, the Hmong, formerly had no norm gap with regard to alcohol use and virtually no alcohol disorder. However, widespread conversation to abstinence-oriented Protestantism resulted in a norm conflict regarding drinking and the appearance of alcohol disorder (22).

Clinicians must conduct individual assessments for each new patient while avoiding stereotyping. Failure to do so results in both missed diagnosis (in patients from groups with low rates of substance disorder) and erroneous overdiagnosis (in patients from groups with high rates of substance disorder).

CULTURAL ASPECTS OF CLINICAL ASSESSMENT

Taking a Cultural History

The first step in conducting a cultural history consists of asking the patient about the ethnic origins of his or her parents and grandparents. Their place of birth, national origin, language learned at home, migrations, roles and affiliations in the ethnic community and in the community-at-large, educational experiences, or marital history may be relevant, depending on the case. The second step consists of assessing the family’s overall enculturation of the patient into his or her ethnic groups of origin (23). Was one or more of the parenting adults actively abusing substances during the patient’s childhood? Parental substance disorder can disrupt a health identity formation and undermine cultural competence (24). Inability to work, to play, and to have meaningful relationships increases the risk to addiction (25).

Adapting to life in an unfamiliar culture can involve stressors that may precipitate excessive substance use (26). Adoption or foster home placement can also affect ethnic affiliation and identity, especially if the new parents differ in their ethnic origins from the biologic parents (27). The developing child’s enculturation, which may involve integrating distinctly different cultural norms and values, can affect the use of psychoactive substances. During late adolescence or early adulthood, the patient may have chosen to relocate away from the family/community of origin and into a more mainstream community, such as college, the military, or a cross-ethnic marriage (28).

SUBSTANCE-SPECIFIC HISTORY

Cultural groups ensocialize young people in psychoactive substance using specific methods. Inquiry into these methods can help both the patient and the clinician in understanding the patient’s earlier decisions regarding substance use, as follows:

■  Observations of role models: What substances did the parenting adults use in the home or outside of the home? Was the use excessive, associated with problems, or disruptive to the family?

■  Socialization into psychoactive substance use: Who first taught or guided the patient’s use of psychoactive substances? Did this occur in the home and family or outside with peer groups? Who were these mentors and what substances or instruction did they provide? How old was the patient at the time?

■  Early experience with substance use: Who determined the substances, occasions for use, dose, and patterns of use? Was it the patient, family, or peers? Were these teachers substance abusers themselves? How did early use assist coping in the family, in school, at work, or while dating?

■  Linkage with other developmental tasks: Was the patient learning other developmental tasks at the same time? These other developmental tasks might include recreation, courting, acquisition of social skills, early sexual experiences, or coping with illness or anxiety.

ADDICTION AND PATIENTS’ CULTURAL FUNCTION

The relationship between psychoactive substances and social performance is a complex one. Psychoactive substance use may foster social coping, at least initially. For example, use of stimulants may contribute to studying, athletics, working, or coping with lack of sleep. Over time, if addiction ensues, it generally undermines performance.

Young people may use psychoactive substances as aids in acquiring social competence. An example in the 19th century was the use of the herbal anticholinergic drug belladonna or “beautiful lady” to produce rosy cheeks and project an image of health and vigor. Alcohol, cannabis, opiate, sedative, or tobacco use can relieve social anxiety or alleviate performance anxiety. Symptom-relieving use may escalate if anxiety persists, as in the following case:

CASE EXAMPLE

A college freshman found that one drink before attending a party alleviated her severe anxiety about socializing with new people. By her 3rd year, she required several drinks to achieve the same effect as formerly achieved with one or two drinks. Consequently, she was showing up intoxicated at social events. This led to an intervention by her peers, who had become alarmed at her drunken behavior. She sought professional opinion, complied with treatment recommendations, and was successfully treated for social phobia. Abstinence was recommended in view of her propensity to anxiety disorders, her family history of substance disorder, and her own escalation to heavy drinking. She joined an abstinence-oriented recovery group composed of college students.

Loss of social coping during the course of substance use disorder is a common feature of addiction in all cultures (17). Indeed, the achievement of a certain social stature in a community followed by gradual loss of status is a common presenting feature in addictive disorders. Examples of status loss include the following:

■  Marital status: divorce, repeated failed marriages, and liaisons of ever-shorter duration

■  Employment status: jobs of brief duration at a status below one’s level of training or education, longer periods of unemployment, inability to obtain a job, and losing jobs because of positive alcohol or drug screening tests

■  Housing: living with friends who abuse substances, living in institutional settings (e.g., halfway houses, shelters), and homelessness

■  Community participation: alienation and isolation from non–substance-related groups, events, and activities

■  Friends: most friends use substances heavily

■  Legal: breaking laws related to driving under the influence of alcohol or drugs, drug possession or sale, property law offenses, and assault

■  Financial: inability to pay bills, selling property to buy alcohol or drugs, and bankruptcy

The addiction subculture may comprise a welcome identity group to a person estranged from family and other groups. Drinking and drug subcultures do not impose hurdles of the kind that distinguish career advancement, achievement on the sports field, or time or effort invested in family and community activities. The norms and values of the drug subgroup are congenial to the addicted person, unlike norms and values of community organizations. Thus, young people who have failed social advancement may drift toward the identity proffered by a drug subculture.

CULTURE, TREATMENT, AND RECOVERY

Addiction and the Normal Social Plexus

The normal social plexus consists of 20 to 30 people organized into four or five groups (29) (Table 37-3). Typical plexus groups include the face-to-face living group, relatives, friends, coworkers, and perhaps another group or two (e.g., neighbors, association members, church or recreational group members). The chance that any one person knows another in the proband’s (the identified individual) social plexus (the plexus “connectedness”) is about 80%. The group tends to be stable: Even if a proband and another member become alienated for a time, the group overrides antipathy and foster rapprochement. In this way, the social plexus promotes the settling of inevitable interpersonal problems, thereby enhancing maturation and interpersonal intimacy over time. Plexus associations are reciprocal: that is, the proband exchanges work, time, or resources with other members of his/her plexus—a major factor in the limitation of the plexus to around 20 to 30 people (and rarely into the 40s or more). Favazza observed that middle-class, middle-aged, married, employed alcohol-dependent patients coming to treatment had “normal” social plexus by the numerical criteria enumerated here (30). However, they lost about half of their social plexus members (mostly other heavy drinkers) during early recovery.

TABLE 37-3 CHARACTERISTICS OF THE INTIMATE SOCIAL PLEXUS IN RELATION TO CLINICAL CHARACTERISTICS

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aLikelihood that any one person in the plexus knows anyone else in the plexus.

With progressive addiction and dysfunction, the social plexus dwindles to around 10 to 19 people, with two or three groups (e.g., family and relatives) plus some one-to-one relationships. The “connectedness” of the plexus tends to be less, about 60%, and the one-to-one relationships are recent rather than long lasting. Although the element of reciprocity persists, the proband is often a client of other people in the plexus. The latter consist of drug dealers, bar tenders, hair stylists, clergy, social workers, and health and mental health professionals. These patients sometimes report plexus members not ordinarily reported in “normal” groups. Examples include not only caregivers but also deceased persons, pet animals, or people who were friends years ago but rarely seen in recent years (31).

With disability, the social plexus declines further to 1 to 10 people who know one another. Their common link involves nonreciprocal relationships with the proband, who cannot return time, resources, or instrumental support. For example, a parent, a social worker, a homeless shelter manager, and a law enforcement officer may all know one another through their common efforts to help the proband. Eventually, the alienated proband may become isolated to the point of not having anyone to call upon (32).

Social plexus reconstruction comprises a potent means of intervening in the addiction process and then providing support during recovery (33). A key element involves elimination of active substance abusers from the plexus, with retention of those committed to the patient’s ultimate recovery (34). This approach has proven useful even in cases possessing limited family or economic resources (35). Therapeutic communities as well as recovery houses and shelters depend on this powerful strategy. Recent failures in the “housing first” movement (in which housing becomes superordinate over recovery) have accrued when active substance abusers displace plexus members committed to their sobriety. These programs have produced increased mortality and health costs (36), plus loss of housing and programmatic support (37). Safety through exclusion of those apt to undermine the addicted person’s fragile early recovery is not the only means of social plexus reconstruction. With sobriety and sufficient time, those who are employed, living within a family, and supported by peers can usually rebuild a social plexus without living in a therapeutic community or recovery house, as in the following case:

CASE EXAMPLE

A surgeon referred a Native American veteran who reported that the preoperative sedative provided him with the first full night of sleep that he had experienced in years. The patient, in for surgical repairs related to shrapnel injuries, had been seriously wounded in combat, with polytrauma and probable traumatic brain injury from a nearby blast. Despite these injuries, he completed postcollege professional training. After his return from combat, he would go to his basement once or twice a month to drink a quart of whiskey alone and think about his experiences and deceased comrades-in-arms. Aside from his spouse and two children, he had minimal social contacts or commitments outside of his professional work. Raised on a reservation by his grandparents and exposed to English and the majority society only when he began grade school, he had achieved notable success in the military, in his educational pursuits, and in his professional role. Evaluation revealed chronic posttraumatic stress disorder in addition to episodic alcohol abuse. After the patient had a 3-month period of sobriety and good relief from his posttraumatic stress disorder and insomnia, social plexus reconstruction began. He chose first to expand his affiliations with his former combat unit, providing him with opportunities to obtain support from those with similar experiences and, eventually, to provide support to others (similar to the role of sponsors in Alcoholics Anonymous). A few years later, he became active with the alumni group where he received his professional training, providing him with opportunities to “pay back” that institution as well as provide a role model (and support) for Native American students at that school. Ultimately, he undertook efforts to help others in his extended family, as well as the people on his reservation. These efforts all began humbly, by attending social events, accepting support and acceptance from others, and then gradually becoming a resource to others. Thus, gradual process required almost a decade.

This case demonstrates several principles of social plexus reconstruction. First, the patient had a period of sobriety and psychological recovery from his alcohol disorder and posttraumatic stress disorder before initiating a process that could be stressful and produce rejection or loss. Second, he chose to join a sequence of groups that he discerned would accept him without excessive demands. Whereas the clinician might have chosen the extended family or reservation first, he chose his veteran comrades first. He recognized (and rightly, as it turned out) that his veteran group would accept him whatever his circumstances, given their shared combat experience and injuries. Third, he began by merely attending social gatherings, whether these were veterans’ meetings, extended family events (weddings, funerals), or reservation ceremonies (powwows, historical remembrances). Fourth, as opportunities to help others or assume leadership positions occurred, he weighed their impact on his family, his work, and his available time and energy.

Cultural Recovery in Addictive Disorders

Reconstruction of the social plexus poses a serious challenge. Most people have a full complement of people with whom they have stable reciprocal relationships. Thus, they do not readily take on another person. Nonetheless, a number of strategies have proven useful in social plexus reconstruction during recovery, as follows:

■  Joining a recovery group whose members are also looking for new associates (e.g., Alcoholics Anonymous) (38)

■  Joining a group that shares similar interests, such as a community action group, church or parish, a sports club, an avocational group, a professional work group or guild, or a political party (39)

■  Joining a charitable organization or a social group with a charitable purpose (40)

■  Volunteering at a health care facility, a school, a nursing home, or similar facility (41)

■  Returning to a group or organization from the past, such as an ethnic association or church group (42)

■  Going to school or taking a job (part time or full time), which leads to new contacts (43)

These strategies lead to affiliations with new people and groups, affording the recovering person new opportunities for success. They replace the groups associated with psychoactive substance use in the person’s previous life (44).

A more difficult task may lie in building bridges back to relatives and family members. These people have probably been hurt or alienated by the addiction-related behaviors of the past. They have come to distrust the recovering person. Consequently, the recovering person should not expect to be immediately welcomed back and lauded for the Herculean efforts required in early recovery. On the contrary, the recovering person should expect a long period of rebuilding trust. This takes a year or more. Relatives will want to know if the recovering person can follow through on appointments and commitments, engage in reciprocal acts of mutual support, and adopt a predictable lifestyle. For all of these reasons, it may be wise to delay rebuilding these family relationships until a modicum of sobriety has been established, say 6 months or a year or two. If the recovering person undergoes a series of slips or recurrences—common in the early months or recovery—this can reaffirm the family’s worst fears. Awash with renewed negative expectations, after an initial spurt of hope and optimism, family members may become ever more entrenched in their wariness (45). Fortunately for those involved in 12-step work, several of the earlier steps prepare the recovering person for making amends to family members and to former friends who have suffered at his hands.

Resuming affiliations can give rise to emotionally warm and spiritually uplifting experiences. Such a social or cultural “rebirth” can feel like a second chance, a turning back the clock, a visit back to familiar places and habits. This experience can elicit feelings of acceptance, belonging, and positive identify. By the same token, these journeys back can be suffused with pain, regret, shame, and guilt. Fortunately, most patients have more positive rather than negative encounters. A few patients do undergo such rejection that they may seek other social groups. New affiliations may include a new religion, a new ethnic affiliation, or marriage to someone from an outside ethnic group.

Computer-based social plexuses comprise an increasingly popular means for recovering people to join with like-minded people, play competitive games, acquire new cognitive skills, facilitate their own self-help, obtain jobs, and begin dating relationships. Overuse, risky use, or too trusting use of computers can lead to problems that precipitate relapse (46). A lonely person might buy into the illusion of real relationships, which turn out to be Internet fictions (avatars). Or having 400 “friends” on Facebook cannot mimic the commitment, continuity, and reciprocity existing within a functioning network plexus.

Culture-Specific Treatment

Therapies specific to particular cultures, ethnic groups, nationalities, and religions can contribute to recovery from substance use disorders. Participation aids the recovering person in several ways: provision of a stable and sober environment, engagement in meaningful and productive work, availability of emotional support from other members, and establishing a new social identity as a “recovering person.”

Some of these interventions are ceremonial in nature, such as a healing ceremony, powwow, or religious ritual (47). Entering a sober environment may occur in religious or ethnic residential facilities, halfway houses, and working farms or ranches with a rehabilitation emphasis (48). Supervised use of peyote as a sacramental substance within the Native American Church has helped to sustain sobriety in some American Indian people (49).

Referral to treatment that undermines the patient’s cultural or ethnic values or that introduces unacceptable risks can be counterproductive. For example, some people may dislike the concept of a “higher power” emphasis in Alcoholics Anonymous. In such cases, clinicians might refer the patient to Rational Recovery. Many Native Americans, Asians, and Northern Europeans find group sweats relaxing and supportive, but they can pose a risk if the patient is still in withdrawal or has cardiovascular problems.

CONCLUSIONS

Substance use is much too important in most cultures to be left to individual judgments and decisions. Across history, cultural groups have fostered specific norms with regard to substance use. Disparity between ideal and behavioral norms, or norm conflict, results in substance disorder that is costly to many individuals as well as the society at large. In addition, cultural groups with high rates of addiction have developed approaches for intervening.

Clinicians can increase their effectiveness by inquiring about the cultural elements that the patient brings with him or her. This task begins with understanding the patient’s enculturation from childhood to young adulthood and continues to a study of present-day affiliations. Current and past cultural affiliations can be helpful in devising a successful recovery plan. Assessing the patient’s social plexus is a critical first step in this plan. As cultural factors have contributed to the onset of substance disorder, likewise cultural resources and traditions can aid clinicians and patients in the challenging process of recovery.

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