6.1 Alcohol & Drug Abuse
Substance abuse is a significant issue affecting communities all across the United States, regardless of individual backgrounds or financial status. The cost of substance abuse to the nation is staggering, estimated at $700 billion annually, with substantial impacts on healthcare, crime rates, and workforce productivity (CDC 2015; NDIC 2011; USHHS 2014). With the increasing cultural diversity in the United States, it’s becoming increasingly crucial to understand how substance abuse affects immigrant populations (Szaflarski et al. 2011).
The American Psychological Association (APA) describes substance abuse disorders as recurring patterns of alcohol or drug use that lead to significant impairment in various aspects of life. People with substance abuse disorders typically experience difficulties in controlling their substance use, face social problems, engage in risky behaviors, and may meet specific pharmacological criteria (APA 2013). Substance abuse disorders are diagnosed separately for each substance, including alcohol, tobacco, cannabis, stimulants, hallucinogens, and opioids. These diagnoses fall into five main categories: substance use disorder, intoxication, withdrawal, other substance-induced disorders, and substance-related disorders.
Substance abuse is a widespread issue that affects people from all backgrounds, including immigrants and refugees living in the United States. However, the process of resettlement adds layers of complexity to how substance abuse impacts these communities. Immigrants bring with them customs and habits related to substance use from their home countries, and they must navigate these practices alongside American customs. Moreover, limited employment and housing options can trap immigrants in neighborhoods where substance abuse is prevalent. Immigrants often face various stressors such as scarce job opportunities, financial responsibilities to their families, past traumatic experiences, and separation from loved ones, which may lead some individuals to turn to substance abuse as a way of coping. However, immigrants also benefit from protective factors like cultural norms and support from their families.
When immigrants first arrive in the United States, they generally have a lower risk of alcohol abuse compared to native-born citizens, even among those from the same ethnic background. However, studies have shown that the longer immigrants stay in the United States, the more their risk of alcohol abuse increases. This could be due to factors that immigrants share or because culturally appropriate assessments for substance use may be lacking in immigrant communities. Understanding substance abuse among immigrant and refugee populations in the United States is challenging due to the wide range of substances that can be abused, including alcohol, tobacco, illicit drugs, and non-prescribed prescription drugs, as well as the diverse backgrounds and cultures within these populations.
Substance use often serves as a coping mechanism for individuals dealing with past or ongoing trauma, stress, isolation, and uncertainty (Ezard 2012; United Nations Office on Drugs and Crime 2014; Weaver and Roberts 2010). These factors can increase the risk of substance abuse and related disorders within immigrant communities, especially considering the impact of cultural norms and acculturation stressors in the United States.
Many immigrants, particularly refugees, have experienced violence and trauma in their home countries and during resettlement, which can lead to mental health issues like PTSD, anxiety, depression, and others (Porter and Haslam 2005). Research indicates that exposure to trauma increases the likelihood of mental health disorders, which, in turn, can heighten the risk of substance abuse (Ezard 2012; Weaver and Roberts 2010). However, despite exposure to trauma, many immigrants and refugees abstain from substance use. For instance, a study of Cambodian refugees found low rates of alcohol use disorder despite high rates of PTSD and major depression disorder in the community (Marshall et al. 2005).
Immigrants also face stressors related to the resettlement process, such as finding employment and adapting to a new life, which can contribute to increased substance use (Organista 2007). Discrimination and unfair treatment in employment further exacerbate these stressors and are linked to alcohol and drug disorders (Gee, Delva, and Takeuchi 2007). Additionally, legal consequences related to substance use pose significant challenges, particularly for racial minority immigrants, leading to criminal charges and increased involvement with social services (Iguchi et al. 2005; Roberts and Nuru-Jeter 2012).
Cultural norms from the country of origin also influence immigrants’ substance use behaviors, along with acculturation to American customs. For example, drinking patterns and prevalence in the home country are associated with alcohol abuse symptoms in immigrant populations (Cook et al. 2013). Moreover, acculturation to American lifestyles can further heighten the risk of substance abuse, particularly among adolescents (Pumariega et al. 2007). These factors underscore the complex interplay between culture, migration, and substance use among immigrant communities.
Despite facing various risk factors, immigrants often report lower rates of drug use compared to United States-born individuals (Hussey et al. 2007). This unexpected trend, known as the immigration paradox, challenges the assumption that difficult transitions to a new country increase the likelihood of substance abuse. For instance, research has shown that adolescents living in neighborhoods with a high concentration of immigrants tend to have lower rates of alcohol, cigarette, and marijuana use, compared to those in neighborhoods with fewer immigrants (Kulis et al. 2007). This suggests that the presence of immigrants in a community may serve as a protective factor against substance use among adolescents, despite higher levels of crime, poverty, and residential instability in such neighborhoods.
Although the immigration paradox doesn’t apply uniformly across all immigrant groups (Hernandez et al. 2012), researchers are intrigued by these findings. Recent studies suggest that family support may play a significant role in explaining why immigrants generally exhibit lower rates of drug use compared to their United States-born counterparts.
Family involvement and cohesion play crucial roles in protecting immigrants from substance abuse (Bacio et al. 2012; Kam 2011; Prado et al. 2009; Pumariega et al. 2007). For instance, researchers investigating neighborhood influences on substance use hypothesized that strong family bonds were the primary protective factor against substance abuse. According to general family and ecological systems theories, family members influence each other through regular interactions, which may be especially significant for newly arrived immigrant families who rely on each other for support.
Parenting style is another important protective factor. Studies on Latinx adolescents have shown that parenting style patterns are linked to adolescent alcohol use. Permissive parenting, characterized by lenient rules and low discipline, was associated with increased alcohol use among adolescents, while authoritative parenting, which combines high expectations with warmth and support, was not linked to increased risk of alcohol use (Driscoll et al. 2008).
Moreover, the overall family environment can influence substance use. Family functioning has been found to impact identity formation, with adolescents in immigrant families experiencing higher levels of identity confusion being more likely to initiate cigarette and alcohol use (Schwartz et al. 2008). This suggests that positive family functioning acts as a protective factor against initiating drug and alcohol behavior. Notably, pre-immigration family cohesion has also been associated with lower drug use among young adults (Dillon et al. 2012).
The parent-child relationship is particularly significant in the transmission and prevention of substance abuse. When mother-adolescent distress is high, the risk of drug use among adolescents increases (Farrell and White 1998). In immigrant Latinx families, conflicts between parents and children predict lifetime alcohol use and binge drinking behaviors (Marsiglia et al. 2009). It’s important to consider that not all families immigrate together, and separation experiences can also impact substance use. For instance, when there is separation between mother and child, adolescents face an increased risk of drug and alcohol use (Mena et al. 2008). Another type of separation, related to ambiguous loss, occurs when parents are unable to care for their children due to financial, health, or substance abuse issues (Mena et al. 2008).
In addition to facing numerous challenges related to displacement, immigrants coming to the United States may encounter additional legal hurdles if their substance use comes to the attention of immigration authorities. Substance use can have serious consequences, potentially leading to denial of entry into the United States or deportation. Immigration laws categorize substance use into three main types: abusers, addicts, and individuals convicted of drug-related offenses (Mautino 2002). Determining whether someone falls into these categories can be challenging, but for immigrants, convictions related to drug offenses often result in deportation. Furthermore, individuals classified as “abusers” or “addicts” may be deemed “inadmissible,” meaning they are ineligible to immigrate to the United States or obtain a temporary visa (Mautino 2002). Importantly, even without a drug-related conviction, immigrants can be deported if the Immigration and Naturalization Service (INS) determines them to be an “abuser” or “addict,” typically based on admitting to using illegal substances at least once in the past three years (Mautino 2002). Drug convictions, whether inside or outside the United States, related to possession, transportation, or trafficking of illegal substances, can lead to deportation or being labeled as inadmissible (Mautino 2002).
Substance abuse prevention and intervention programs are widely available in the United States for both teenagers and adults. However, very few of these programs are tailored to specific ethnic groups, and none address the unique challenges faced by refugees due to conflict-related displacement. In this section, we explore the obstacles to substance abuse treatment among immigrants and refugees, offer suggestions for professionals providing such treatment, and highlight programs that have attempted to overcome these barriers.
Various barriers hinder immigrant and refugee populations from accessing substance abuse treatment. There is a pervasive stigma surrounding substance abuse, especially considering the potential legal repercussions for immigrants identified as drug abusers. Even when individuals seek treatment, they often encounter a shortage of culturally relevant evidence-based treatments and trained providers from diverse immigrant and refugee backgrounds. Additionally, services available in the immigrant’s language may be limited, further deterring them from seeking help. For instance, a study by Arfken, Berry, and Owens (2009) revealed that Arab Americans faced stigma and language barriers, preventing them from accessing appropriate treatment. In underserved communities lacking adequate healthcare resources, immigrants may also opt out of treatment due to a lack of information and concerns about how laws and policies affect them (Moya and Shedlin 2008).
Furthermore, there is a dearth of culturally appropriate assessments for substance use. Most assessments for alcohol abuse, for instance, inquire about the frequency of alcohol consumption. However, individuals from different countries often consume beverages of varying potencies and sizes. Effective measures need to adapt to these differences, considering the type of beverage consumed, portion sizes, and cultural drinking habits. For instance, assessments that inquire about alcohol consumption over the past seven days may not be culturally appropriate for individuals from rural Mexico, where heavy drinking primarily occurs during seasonal celebrations (WHO 2000).
