Cultural Competency a Key Component of Substance Use Treatment Services

Substance use treatment providers increasingly understand the importance of offering personalized, culturally sensitive care that respects patients’ beliefs, preferred languages, and communication needs. In a roundtable conversation, four officials from the Massachusetts Department of Public Health—Nicole Schmitt, assistant director of planning and development, Bureau of Substance Addiction Services (BSAS); Oanh Bui, culturally and linguistically appropriate services (CLAS) program coordinator, Office of Health Equity; Jen Miller, state opioid response program manager, BSAS; and Jen Parks, assistant director for provider support, BSAS—discuss how culturally and linguistically effective care is a guiding principle in their work to prevent, assess, and treat opioid use disorder (OUD).

This interview has been edited for length and clarity, and the respondents' answers do not necessarily reflect the views of their employers or their agency.

Q: Why is culturally and linguistically effective care so important in your work?

Nicole Schmitt: Because we continue to see disparities in overdoses and access to treatment. Our data shows that people of color don’t access our system services and treatment at the same rate as White people, in part, I believe, because of their perception that the system isn’t responsive to their unique needs. That’s forcing us to rethink how we can better meet the needs of these communities.

Oanh Bui: We’ve been using the national CLAS standards—principles developed by the U.S. Department of Health and Human Services that are intended to help eliminate health care disparities—as a performance management and quality improvement (PMQI) framework for designing our services to be equitable and respectful of the diverse beliefs and needs of our communities. We look at diversity really broadly, to include Black, Indigenous, people of color (BIPOC) and/or Latinx individuals; individuals with disabilities; individuals experiencing homelessness; individuals with mental illness; people who identify as LGBTQIA+; individuals who speak languages other than English; and others.

Jen Parks: And we can’t provide culturally and linguistically effective services if our workforce is not (a) representative of the folks we want to be serving, (b) well-trained to serve diverse communities, and (c) well-supported in being able to get the ongoing training, supervision, and resources needed to provide culturally and linguistically appropriate services.

Q: How do you build that kind of workforce?

Jen Parks: The BACE (Black Addiction Counselor Education) and LACE (Latino Addiction Counselor Education) programs are the most concrete effort that we’ve made at the bureau. LACE started over 20 years ago to address the need for a more diverse substance use counselor workforce by providing flexible and affordable education required for licensure for people who identify as Latinx. BACE is designed to be very similar, with its own curriculum focused specifically on unique cultural values and perspectives for Black and African individuals doing this work and getting services.

Besides those programs, we provide ongoing equity, inclusion, and diversity trainings for our workforce. It makes all the difference when not just providers but BSAS staff also participate.

Jen Miller: We also offer a specific training, through the Institute for New England Native American Studies, for our workforce, community members, and providers on cultural humility while working with Native American communities. Through federal State Opioid Response Grant dollars, we were able to put together a training on the “Two-Eyed Seeing Approach” for medication for OUD, which integrates Western medicine with tribal and Native American medicine, and on engaging tribal elders.

Oanh Bui: We encourage our contracted programs to provide certified interpreters who are trained and well-versed, especially in the context of substance use disorders. We look at budgets, too—if treatment programs spend too much money on interpreters, for example, we can discuss whether with the same budget they can instead recruit bilingual, bicultural staff who can better engage the communities they’re serving.

Jen Parks: We’ve also trained a number of people who are deaf and in recovery as both trainers and recovery coaches.

Q: What’s the impact of these initiatives on patients?

Nicole Schmitt: Ideally, people are more likely to access and stay engaged in services and maintain long-term recovery if we can provide services that reflect their unique cultural and linguistic needs.

Jen Parks: The biggest impact we’ve seen is how recovery coaching has supported folks. The coaches are still primarily White, but we’re making more of an effort to connect with Black churches and Islamic centers, and training people to be recovery coaches in those communities. We need to do a much better job of engaging and connecting people with coaches who look like them and have similar experiences to them.

Q: What can states do to encourage services that are more culturally and linguistically effective?

Nicole Schmitt: States should set the standards. When state agencies like ours contract with treatment service vendors, we ask in the procurement process how they will incorporate CLAS standards into their services, and ultimately we include in the contracts a condition for providing culturally and linguistically appropriate services, so it’s communicated as an expectation and a priority. We then provide the tools and resources, as well as assess and monitor progress during site visits.

Additionally, our regulations for the licensure of substance use treatment programs include language requiring programs—at a minimum—to provide annual training related to cultural competence, including CLAS.

Jen Parks: We have to be able to walk our talk as well in our own agency, so we’re doing this work internally (staff training, policy and practice reviews, etc.). We want to show the providers that we’re doing the work ourselves.

Q: One barrier to implementing these initiatives is identifying patients’ cultural needs in the first place. How do you determine that? Do you use data?

Oanh Bui: We’re trying to understand what’s behind the numbers and the stories behind them. If we can disaggregate the data to break it down by race, ethnicity, and language to see the inequities in treatment for different groups/communities, then we would better understand patient needs and allocate the resources accordingly.

Q: What are some of the challenges to getting more detailed, accurate data?

Oanh Bui: For one, it’s a lot of self-reporting. Race data may fall into an “other” category, so it’s challenging for us to see the inequities in treatment among diverse communities.

Nicole Schmitt: Additionally, the data we get only reflects those who currently access our treatment system. That’s something we’ve struggled with a lot: How do we get data on the folks that we’re not serving? And how do we find out more about them and why they’re not accessing services?

Q: What efforts have you made to answer those questions?

Nicole Schmitt: The Public Health Data Warehouse, a research tool to access multiyear data, has helped to link data sets from the Department of Health with those from other state agencies to analyze trends in fatal and nonfatal opioid overdoses. A key finding from a peer-reviewed 2019 study was that 50% of people who died from an overdose in Massachusetts touched the state system within the past 12 months—and we could see where people were coming out of incarceration or had a previous nonfatal overdose, and we could target our services in response. But again, we also knew that meant that 50% of people aren’t touching our system at all. How do we find them? We’re becoming more savvy and sophisticated with data but still have work to do.