Ethnic, Cultural, and Religious Issues in Drug Use and Treatment

In national statistics for the United States, including many national surveys on drug use, Americans are divided into four racial groups: (1) white, (2) black, (3) Asian or Pacific Islander, (4) American Indian or Alaska native. The races are often subdivided into ethnic groups. For example, people with recent or distant family origins in such countries as Spain, Portugal, Mexico, and Cuba belong to an ethnic group called Iberian, Hispanic, or Latino. People also belong to cultural groups, which share similar customs, ideas, and behaviors. Racial, ethnic, cultural, and religious backgrounds often overlap.

The use of drugs and alcohol differs from one ethnic, cultural, or religious group to another. Drug abuse, as well as the way in which people respond to treatment, also varies within groups. It is helpful for public health officials to be familiar with these differences, so that they know which segments of the population have a greater need for alcohol and drug treatment and prevention services. However, the evidence of racial and ethnic differences in alcohol and drug use does not mean that these differences are due to heritable , genetic factors. Conditions such as poverty and neighborhoods with high rates of crime must be taken into account to explain different rates of drug abuse among ethnic groups.

This article discusses issues of drug and alcohol abuse among some major ethnic groups and treatments specifically geared toward these groups.

African Americans

In the United States, many health-care workers believe that fellowships such as Alcoholics Anonymous (AA), Narcotics Anonymous, and Cocaine Anonymous offer the best programs to help people recover from their addictions. Others believe that these programs mostly benefit white, Christian males from European backgrounds but may be less well-suited to people from other cultural backgrounds. Successful programs that use AA's Twelve Steps do not require members to belong to a particular religion, but they do require them to believe in a power outside themselves that can guide them through recovery, even if that power is the meeting group itself.

The concept of surrender to a higher power is difficult for some cultural groups to embrace. African Americans, for example, may feel that they have suffered from a lack of power either as individuals or as a race for many generations, and they have no desire to surrender to anything else. The African-American Extended Family Program (AAEFP) is a good example of how the twelve-step recovery can be adapted to the needs of a specific community. The AAEFP pays attention to African-American cultural values and traditions and makes them central to recovery. Culturally, African Americans strongly value the sense of community. An individual's identity is closely tied to the identity of the group. Many treatment programs targeted to African- American populations relate drug use and addiction to slavery. For example, many African Americans see methadone , a common treatment for addiction to heroin, as a type of chemical slavery.

See Organizations of Interest at the back of Volume 2 for address, telephone, and URL.

In African-American neighborhoods, the church is often the center of community life as well as spiritual life. Churches in various cities have developed recovery programs that specifically meet the needs of African-American culture. Such programs try to overcome the resistance of people of color to participating in the twelve- step process.

Asian Americans

The large category of Asian Americans includes smaller distinct groups, such as Japanese Americans, Filipino Americans, Vietnamese Americans, and Chinese Americans. Each of these groups has its distinct cultural background and its own attitudes toward substance abuse. However, in general, most Asian Americans seem to share a fear of addiction and of injecting drugs. The Asian-American community strongly disapproves of drug users.

Biological factors sometimes play a role in determining a person's preference for alcohol or particular drugs. Asian Americans, as a group, consume less alcohol than any of the other racial or ethnic groups. Their lower drinking rates may be due in part to an enzyme in their bodies. This enzyme's action causes unpleasant side effects after drinking alcohol.

Some researchers have argued that low alcohol consumption levels among Asians are related to cultural values, and that ancient Confucian and Taoist philosophies have an influence on Chinese and Japanese drinking styles. The emphasis on conformity and harmony in those philosophies is believed to promote moderate drinking. The emphasis on responsibility to others in traditional Chinese culture also helps reinforce moderate drinking and sanctions against drunkenness. Similarly, traditional Japanese culture focuses on interdependence, restraint, and group achievement, and may thereby contribute to controlled drinking. Finally, drinking in most Asian cultures takes place in prescribed social situations, which may limit the likelihood of alcohol abuse.

Native Americans

Native American society is organized around the tribe. Traditional tribal beliefs place great emphasis on the spiritual element of human life. For many Native Americans, treating drug and alcohol problems involves an attempt to heal the spirit. Healing may involve coming to terms with the difficult history of Native Americans since the establishment of the United States. Some in the Native American community view addiction as a crisis of the spirit caused by the suffering of their people. Researchers also suspect that high levels of stress in this population have led to an unexpectedly high use of alcohol.

Studies conducted on alcohol and other drug use by Native Americans show a considerable variation in alcohol and other drug experiences from tribe to tribe, from one part of the country to another, and even from one type of residential location to another (for example, boarding school students versus other young people). Summarizing the alcohol and drug experiences of Native Americans is, therefore, difficult. For many Native American young people and adults living in urban environments, and sometimes on reservation lands as well, the use of alcoholic beverages and also inhalants has resulted in social and health problems. Public health workers and government officials have developed many programs to encourage Native Americans with alcohol abuse problems to begin treatment. Like African Americans, Native Americans have trouble with the aspect of twelve-step recovery that calls for surrender to a higher power. This requirement conflicts with tribal beliefs in the importance of self-reliance.

Hispanic Americans

Studies show that drug use by Hispanic Americans becomes more likely the longer the person lives in the United States. There is more crack cocaine smoking among Hispanic Americans who have adopted main- stream customs (such as speaking English rather than Spanish) than among Hispanic Americans who maintain the customs of their original country (such as continuing to speak Spanish). This relationship is more pronounced among Hispanic Americans from Mexico than among those from Cuba, however, and indicates the diversity present within the large and growing Hispanic segment of the U.S. population.

A survey of American high-school students found that Hispanics' rates of use for all drugs tend to fall between that of whites and African Americans in the 12th grade, but in the 8th grade they tend to be the highest for all drugs, including alcohol. Rates of alcohol use before age 13 are higher for Hispanic youth than for African-American youth and white youth.

Rates of alcohol use by adult males also tend to be higher among Hispanics than among African Americans or whites. One traditional explanation for heavy drinking patterns among Hispanic men, particularly Mexican Americans, is the concept of exaggerated machismo. This concept implies that Hispanic men strive to appear strong and masculine, and that the ability to drink large amounts of alcohol helps prove their masculinity. However, one study (using a complex measure of machismo) found that machismo was related to alcohol use among men regardless of ethnicity and could not explain the high drinking levels among Mexican Americans.

Christians

In addition to racial and ethnic groups, people identify with other members of their religion. Within a particular religious group, people share certain attitudes and behaviors having to do with alcohol and drugs.

According to some studies, the heaviest, most frequent, and most problematic drinking in college campuses occurs among Catholics and Protestants. However, direct involvement in religious activities seems to be associated with lower use of alcohol and other drugs. For example, a survey of close to 3,000 North Carolina residents found that recent and lifetime alcohol disorders were less common among weekly churchgoers and those who considered themselves born again. Members of conservative or fundamentalist religious groups had lower recent and lifetime rates of alcohol abuse and dependence than members of other denominations. Lifetime, but not recent, alcohol disorders were more prevalent among members of Pentecostal denominations. Some other studies have suggested that Protestants consume less alcohol but perceive greater problems with the substance. In contrast, Roman Catholics consume more alcohol but do not perceive its consumption as problematic.

Jews

The Hebrew Bible (which Christians call the Old Testament) mentions several alcohol-related problems, such as the drunkenness of Noah. Proverbs 23:29–35 describes several of the ill effects of intoxication. Yet Jews of Biblical times were known for their moderate drinking habits as compared to other groups of the era. Unlike their neighbors, Jews drank wine as part of their religious rituals rather than to achieve its pleasurable effects. The modern Jewish community has a low rate of alcoholism as compared to other groups. One theory says that the traditional use of wine in religious ritual continues to discourage Jews from abusing alcohol. Yet studies of alcoholism among Jews show that many cases often go unrecognized.

Among Jewish adults, rates of abuse of drugs other than alcohol do not appear to differ significantly from the rates for members of other religions or people who have no religious preference. Nevertheless, as with alcoholism, denial of drug problems in many Jewish households and communities is an ongoing problem. Interest in helping Jewish alcoholics has grown, both in the United States and in Israel. The Jewish Alcoholics, Chemically Dependent Persons and Significant Others Foundation, Inc. (JACS) sponsored an extensive study of chemically dependent Jews and their families. JACS encourages prevention, treatment, and the opening of synagogues and Jewish community centers to twelve-step programs such as Alcoholics Anonymous, Narcotics Anonymous, and Gamblers Anonymous.

See Organizations of Interest at the back of Volume 2 for address, telephone, and URL.

Muslims, Hindus, and Sikhs

Islam, the religious faith of Muslims, forbids the consumption of alcohol or any other mind-altering substances, and observant Muslims abstain completely from taking drugs or drinking alcohol. However, some Muslims, particularly men, do drink, and there are some who abuse drugs.

Among Hindus, alcohol is forbidden for members of upper-caste groups, but Indian men living in the West have a higher than expected prevalence of alcohol-related disorders. In one study, a random sample of 200 each of Sikh, Hindu, and Muslim men, as well as 200 white men, were asked about their drinking patterns. Sikhs were most likely to be regular drinkers, followed by whites and Hindus. The very few Muslim men who drank consumed the most alcohol on average.

The frequently reported pattern of an inverse relationship between drinking and age (younger people drinking more, older people drinking less) was found for white men but not among Sikhs and Hindus. In both of these groups, older men reported consuming more alcohol than did young men. Among regular drinkers, Sikhs had higher average scores on the Alcohol Problem Scale than did white men or Hindus. The highest average scores were recorded for the few Muslim regular drinkers, who also consumed the most alcohol. A clear association with religious observance was found for all three Asian groups and for the white men. Religious Muslims tended not to drink alcohol at all, and a relatively small proportion of the other groups who were regular church/temple attenders drank regularly.

Treatment Issues

Successful treatment requires more than prescribing medication and offering basic counseling. Counseling must be based on an understanding of the specific qualities of addiction in various groups. Counselors must also be able to speak the language of the person they are treating and understand the unique family structures and pressures of that person's culture. The challenge is to adapt the process of treatment and recovery to all cultures and races.

The experience of counselors shows that when a patient and counselor share the same ethnic background, the patient is more likely to benefit from treatment programs for drug and alcohol abuse. A counselor who shares the cultural background of the patient understands the values of that group and can tailor the treatment program based on that understanding.

The counselor must consider several issues:

• At what point is the use of alcohol or other drugs considered a problem in this culture?
• At what point does the culture agree that the user needs treatment?
• Who takes responsibility for the problem—the individual, the family, or the community?
• Do members of the cultural group disapprove of the person's drug problem? If so, how strongly do they disapprove?
• Is disapproval stronger for certain individuals, such as women?

The answers to these questions will help determine the best approach to treatment.

see also Adolescents, Drug and Alcohol Use; Drugs Used in Rituals; Gender and Substance Abuse; Treatment: History of, in the United States; Treatment Types: An Overview.