Addressing the Opioid Crisis in Communities of Color

OMB Control Number 0990-0421

Expires October 12, 2020

Attachment B: Small Group Discussion Guide

ADDRESSING THE OPIOID CRISIS IN COMMUNITIES OF COLOR

Small Group Discussion Guide

Instructions for interviewer

The following semi-structured discussion guide is designed to gather the professional perspective and knowledge of respondents. Each of the bolded discussion questions will be asked of the respondents, and possible probes for each will be used as needed to obtain additional information or clarification. Due to time constraints, researchers may prioritize and skip some questions.

In a few sites, where there are several stakeholders whom we would like to include in our study, we may conduct small group interviews instead of individual interviews. In those cases, we will use this discussion guide for the small group interviews.

Before beginning, interviewers will attain verbal consent, providing information about the study and asking explicit consent for participation in the study and for audio-recording.

1. Work History/Experience

1. Can you please tell us about your position and role or responsibility with [employer name]?

Possible probes:

1. How long have you worked in this position?

2. What is your role in [effective or promising model]?

3. What experience do you have working with individuals of color who misuse substances?

4. What experience do you have providing substance use services (including mental or physical health services) and/or human/social services to individuals of color?

______________________________________________________________________________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0421. The time required to complete this information collection is estimated to average 1.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

2. Communities of Color Targeted by Model

To provide us with some context, our first questions are about the populations served/affected by the [effective or promising model].

2. Which racial/ethnic populations are served by the [effective or promising model] and what is the distribution of racial/ethnic groups across the program’s clientele?

Possible probes:

1. What is the distribution of racial/ethnic groups across program leadership and staff?

3. How would you characterize unhealthy substance use among your clients, families, communities?

Possible probes:

1. What are the most common types of substance use, e.g. opioid use, illicit or not, methamphetamine, alcohol, and/or poly-substance use, among each of these populations?

2. How has substance use affected communities of color served by your organization?

3. How have overdoses and overdose deaths affected the people you serve in your organization?

4. What subgroups have been particularly affected by substance use (such as adolescents, pregnant women, parents, runaway and homeless youth, etc.)?

5. How has substance use changed over the last ten years or so for the clients you serve?

4. How have the sequelae/consequences of substance use been affected by federal, state and local policies related to racial/ethnic minority populations? [Note: Treatment and access is addressed separately below.]

Possible probes:

1. How has

   1. poverty;

   2. racial/ethnic inequities related to law enforcement and criminal justice;

   3. racial/ethnic inequities related to child welfare system;

   4. other societal, political and economic inequities;

affected the sequelae/consequences of substance use for these populations?

2. How have the sequelae/consequences of substance use changed over the last ten years or so for these populations?

4. How has substance use among minority populations shaped your organization?

Possible probes:

1. Has substance use affected the clientele that you serve and their needs?

2. Have you changed your services, policies and procedures to meet the needs of your clients that are part of minority populations?

3. Have you made changes to your service capacity? If yes, how are you financing the infrastructure development and ongoing service expansion?

5. How is unhealthy substance use including opioid misuse in these minority populations typically identified?

Possible probes:

1. Through standardized screening tools or other means

2. Is this screening universal or based on certain criteria (please specify)?

3. Is the screening voluntary? Do you obtain consent?

4. In what setting (school, health care, jail, prison or other justice setting, child welfare system) does identification occur?

5. Does the identification process differ by racial/ethnic group?

6. Does the identification process include an assessment of the level/type of follow-up care, if needed?

7. Is some kind of brief intervention available immediately if a person is using drugs but not yet addicted? Is there immediate access to treatment if the person has a substance use disorder?

8. How are referrals to care handled, if needed? Do you have providers to whom you can refer? Do patients like these places? Do they provide culturally and linguistically appropriate services?

9. Does this process include assessment of mental health conditions and/or physical health conditions?

6. To what extent are services to address substance use available and accessible to the racial/ethnic minority populations in your community?

Possible probes:

1. What types of treatment services are available, e.g., outpatient, intensive outpatient, residential, opioid treatment providers (also known as OTPs or methadone clinics), abstinence programs, halfway houses, etc.

   1. Are there wait lists to get into treatment? If yes, for which programs? How long is a typical wait? Do the providers offer evidence informed services?

   2. Are there treatment programs or other services specifically designed for minority populations?

   3. How do people in your community learn about substance use service, including treatment options?

   4. Is there any public assistance available to help people navigate treatment options (such as for care managers)?

   5. How/by whom is appropriate level of treatment determined?

   6. Are certified peer counselors available? If so, what is their scope of work?

   7. What types of recovery services are available, e.g., peer supports, recovery residences?

   8. What types of harm reduction services are available, e.g. syringe exchange, naloxone distribution?

   9. Are there/what type of social services are attached to any of the above or does your organization provide wrap around services?

   1. What are general public attitudes toward people with substance use disorder (SUD)¹, particularly people of color with SUD, harm reduction and treatment for SUD? How does it compare to other communities (or the state overall)?

7. How has access to and take up of substance use services, including treatment, been for the minority populations your organization serves?

Possible probes:

1. In your estimation, what share of minority populations with SUD is receiving treatment at any given time? How does it compare to the general population with SUD?

2. What are the major barriers to minority populations accessing substance use services, including treatment?

1. Is stigma for receiving substance use services, including treatment a particular barrier among the racial/ethnic minority populations you serve? What types of stigma?

2. Is health insurance coverage (both lack of coverage and/or comprehensiveness of coverage) for services, including treatment, a barrier?

3. Is fear of child welfare or criminal justice consequences a barrier?

4. Is fear of losing employment a barrier?

5. Is lack of services, including treatment capacity, a barrier?

6. Is lack of culturally and linguistically responsive services, including treatment a barrier?

7. Is lack of transportation a barrier?

3. Are the barriers just described specific to these populations?

4. Are there other barriers we have not mentioned?

9. 8. What types of human service needs among your racial/ethnic minority populations are typically identified:

1. TANF, SNAP and other financial support;

2. Housing and homelessness services,

3. Diversion and reentry programs

4. Job training and placement;

5. Legal and health advocacy (both including advocacy related to child support);

6. Child care (including Child Care and Development Fund (CCDF) subsidies and Head Start)

7. Need for child welfare system and foster care

8. Linkages to advanced education opportunities

9. Other human service needs (specify)?

9. How are human service needs among your populations typically identified, and is this the same for racial and ethnic minority clients?

Possible probes:

1. Through standardized screening (specific types and modality)?

2. Is this screening universal or based on certain criteria (please specify)?

3. Is the screening voluntary?

4. In what setting (school, health care, jail, prison or other parts of the justice system, child welfare system) does identification occur?

5. Does the identification process differ by racial/ethnic group? Does it differ by any other demographic or grant funded status?

10. What are the human services needs of your clients and how/to what extent are they being met?

Possible probes:

1. What are the major barriers to your clients accessing human services?

   1. Is stigma for receiving human services a particular barrier among the racial/ethnic minority populations you serve?

   2. Are application requirements a barrier, e.g., administrative hurdles, income limits, reporting requirements?

   3. Are work requirements or other conditions of eligibility a barrier?

   4. Is immigration status a barrier?

   5. Are there language or cultural barriers?

   6. Are there other barriers, e.g., lack of awareness, perceived discrimination, and fear of government intrusion?

   7. Is substance use itself a barrier?

2. Are the barriers just described specific to these populations? Are there barriers we missed?

3. Where do people who are unable to access government-sponsored human services typically go for assistance?

11. How have the sequelae/consequences of substance use been affected by federal, state and local policies related to racial/ethnic minority populations? [Note: Treatment and access is addressed separately below.]

Possible probes:

3. How has

   2. racial/ethnic inequities related to law enforcement and criminal justice;

   3. racial/ethnic inequities related to child welfare system;

   4. other societal, political and economic inequities;

affected the sequelae/consequences of substance use for these populations?

4. How have the sequelae/consequences of substance use changed over the last ten years or so for these populations?

3. Effective or Promising Models and Strategies

12. Please tell us about [effective or promising model] and how it serves the communities of color we have just discussed.

Possible probes:

1. What are the key components of the [effective or promising model]?

2. Who leads the program and who are key partners?

3. What substance use services and treatments are provided as part of this program?

4. Does your program provide treatment medications, e.g. for opioid use disorder, nicotine, alcohol? If so, what types?

5. Is harm reduction a part of this program? If so, what types?

6. Are other physical health services or mental health services a part of this program?

7. What is the capacity of your program?

8. Is capacity sufficient to meet the need? Are there wait lists for any of the services? How many clients are on the wait list?

13. In what ways does your program provide culturally effective care (including culture, language, etc.)?

Possible probes:

1. Do you think it is important for program leadership and staff to know about different cultures? If yes, how does this knowledge contribute to the program’s effectiveness?

2. Do you think it is important for the program to hire leadership and staff from different cultural backgrounds? If yes, how does this hiring approach contribute to the program’s effectiveness?

3. Do you think that clients prefer to see program leadership staff from their own cultural background? Why or why not?

4. Do program leadership staff receive training in providing culturally effective care? If yes, what type of training?

14. How are human services integrated with substance use treatment?

Possible probes:

1. Does your program actively work with other agencies and service providers who are working with the same individuals?

1. Health care providers (physical and mental)

2. Public health

3. Substance use recovery providers

4. Harm Reduction Providers

5. TANF, SNAP, and other financial support

6. Child welfare system and foster care

7. Housing and homelessness services

8. Diversion and reentry programs

9. Job training and placement

10. Legal and health advocacy (both including advocacy related to child support)

11. Child care (including Child Care and Development Fund (CCDF) subsidies and Head Start)

12. Educational systems

2. When there are multiple agencies working with a client, does someone coordinate the work? Who? How is this person financed?

3. How do you work with partners to get clients the services they need?

4. How are referrals made to partner organizations? Are these organizations providing culturally relevant services? i.e. do you clients like the agencies to which you refer? Do you know?

5. How do partner organizations make referrals to you?

6. Are there formal agreements in place to guide collaboration among different systems? What types of information do you share as part of these agreements?

7. Are there work requirements for receiving human services and if yes, does substance use treatment count?

8. Do you interact with the criminal justice system or child welfare and if so, how?

1. Do you share data with the criminal justice or child welfare workers? How about with any other systems?

   1. For instance, data regarding urine drops, meeting attendance?

   2. What sort of consents are in place?

2. If so, how does that occur?

3. If not, why not?

9. Is family preservation a part of the program and if yes, how do you promote keeping families together?
   
   
   

15. What are the barriers to integrating substance use services and treatment with human services?

Possible probes:

1. Do you have access to an up-to-date directory of human service providers?

2. Is availability of culturally and linguistically appropriate providers a barrier?

3. Is availability of culturally and linguistically appropriate resources for your program to make referrals and coordinate services a barrier?

4. Is payment for human services a barrier?

5. Do human services providers offer culturally effective care? In what way?

6. Are there policy or administrative barriers?

7. Do human service providers provide your clients with high quality services?

8. What barriers are there to working with partners?

16. What facilitates integration of substance use and human services?

Possible probes:

1. High-level leadership or champion

2. Previous history of cross-sector collaboration

3. Supportive political and/or funding environment

4. Mission alignment/shared vision across agencies at the state, local levels

5. Sense of urgency due to the opioid or other epidemics?

6. Strong community support

17. How is your [effective or promising model] funded?

Possible probes:

1. Do you receive federal funding and if yes, through what programs?

2. To what extent does Medicaid reimburse your services?

3. Is the program funded through state financing?

4. Do you receive local or county funding?

5. Private or foundation funds?

6. Do any of these funds specifically support the provision of culturally effective services?

7. Have there been challenges with stitching together different funding sources, such as the requirements that come with each source? If yes, what types of challenges?

8. Is funding a barrier to integrating substance use and human services (e.g. screening, provision, referral, and follow-up)?

18. How do individuals of color with unhealthy substance use typically enter your program?

Possible probes:

1. Do people voluntarily seek treatment? Are people referred for services? Do other agencies or the courts mandate treatment?

2. Is this approach the same as or different from how others in the general population get connected to treatment?

3. Is there often a mandate from child welfare agencies or other legal authorities for treatment? If so, how does that influence treatment access, outcomes, and the likelihood of relapse?

4. Is the entry point to services through your model typically through substance use treatment or through human services? Is there a “no wrong door” approach?

5. Do you conduct any outreach to communities of color? Does your outreach differ by racial/ethnic group and compared to the general population?

19. Among those who engage in treatment for substance use, how would you characterize the typical treatment (for different types of substance use, e.g. alcohol use disorder, opioid use disorder, methamphetamine use disorder, etc.)?

Possible probes:

1. Approximately how long are clients engaged in treatment? Do clients remain in treatment for the recommended time period?

2. Are there effective transitions from one level of treatment to another (i.e. residential to intensive outpatient to outpatient etc.)? Does this differ by race or ethnicity?

3. Are there any conditions related to continuing in treatment (e.g. urine screen, etc.)?

4. Approximately what portion remain in your programming for the clinically recommended period of time? Is there pressure to have people leave treatment or “graduate?” If so, why? What happens when they leave?

5. Does this differ by racial/ethnic group, and compared to non-minorities?

6. What factors affect treatment retention for communities of color?

7. elated to ny conditions on continuing in treatment (e.g. urine screen, etc)?elow..What types of culturally effective care strategies do you use to improve treatment engagement and retention for racial/ethnic populations?

20. What strategies or aspects of [effective or promising model] do you see as most successful in addressing the needs of individuals of color who use substances in a harmful way?

Possible probes:

a. Why? What contributes to this success? How is success defined?

b. What strategies have you found ineffective? Or harmful?

c. What could be done to help you succeed?

21. In your opinion, what are the primary challenges to, or missing pieces in, your work with communities of color?

Possible probes:

1. What gets in the way (a barrier or challenge) of improving wellbeing for your clients of color that you most wish you could address?

2. What would be most helpful to address these challenges?

3. Do these barriers/challenges differ because of opioid use compared to other substance use?

1. How have these barriers/challenges changed over time?

2. How common are these barriers/challenges?

3. Are these barriers/challenges unique to serving communities of color?

22. What would be most helpful to you in working with communities of color?

Possible probes:

1. Are there certain services that need more capacity?

2. If you had a magic wand, aside from additional financial resources, what would you do to help meet their substance use and human services needs?

4. Lessons for the Field

23. Is [effective or promising model] being evaluated? If yes, by who and how?

Possible probes

1. What outcomes are being tracked? Are they tracked across race and ethnicity?

2. Is cost being measured? How about the benefits or cost-savings?

3. What data are being used? What data do you wish you could use?

24. Have you been able to find relevant educational tools, research or other resources to help you in your role related to this model?

Possible Probes:

1. If yes, what have you used?

2. If no, what is missing?

3. What would be useful information for people who do work that is similar to yours?

4. Have you had to learn the information on your own time or is education embedded into your organization’s structure?

25. What lessons have you learned that would be useful to others who want to serve similar populations as you do?

26. What policies (federal, state, and local) have most affected your program’s impact on racial/ethnic minority clients, either positively or negatively?

Possible Probes:

1. Are there any policies you wish would change?

2. Which policies do you think are effective?

27. Is there anything we haven’t discussed today about your experience providing substance use or human services to communities of color that you think we should know?

Possible Probe:

1. Is there anyone use you think we should talk to who could answer the types of questions we asked you?

1 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

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