Black Americans account for approximately one-quarter of all drug arrests in the United States (Federal Bureau of Investigation, 2018) and one-third of individuals sentenced to prison for drug possession (Carson, 2018, Donnelly et al., 2020), despite making up less than 14% of persons who use illicit drugs (Substance Abuse and Mental Health Services Administration, SAMHSA, 2017). Structural racism augments racial disparities related to substance use disorder (SUD) morbidity and mortality (SAMHSA, 2020, Bailey et al., 2017) and occur regardless of involvement in the criminal legal system (CLS). Black Americans progress to SUD more quickly relative to Whites (Alvanzo et al., 2011), while experiencing longer duration of use (Caetano and Kaskutas, 1995) and more substance-related consequences over the life course (Witbrodt et al., 2014, Gadgeel and Kalemkerian, 2003). Black women with SUD face additional barriers to treatment and recovery supports due to discriminatory practices within social service, employment, healthcare, and CLS (Pinedo et al., 2020, Verissimo and Grella, 2017, Bailey et al., 2017).

Limited research has focused on examining SUD treatment needs or the underuse of mutual support groups such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) among Black American women involved in the CLS (Hai et al., 2022) and Black women with no CLS involvement (Smith et al., 1993, Durant, 2005). While some studies suggest Black Americans and women may perceive mutual support groups comprised of mostly White men (Hillhouse and Fiorentine, 2001, Timko, 2008); research also indicates that Black Americans have positive comparable outcomes as White Americans from involvement in mutual support groups (Hillhouse and Fiorentine, 2001, Humphreys et al., 1994). Mutual support groups offer a free option without attendance requirements that are broadly accessible to women and people involved in the CLS (Schonbrun et al., 2019). One approach to addressing racial inequities related to SUD outcomes is to gain a better understanding of within-group differences in SUD treatment and mutual recovery support needs among Black women to culturally inform treatment and recovery approaches (Parlier-Ahmad et al., 2022). Thus, the purpose of this study is to identify Black women’s substance-related need classes and examine the effect of substance-related need classes and culturally relevant factors on Black women’s use of both SUD treatment and mutual support recovery groups. Substance-related needs are operationalized as substance use, mental health, and social network indicators of instances when SUD treatment or mutual support group services may be beneficial. The analyses focus on Black women across three levels of involvement in the CLS (i.e., Black women recruited from prison nearing re-entry, while on probation, and while in the community not currently involved in the CLS) and examine cultural factors selected based on existing recovery literature (i.e., religiosity, active coping, trust in physicians, and gendered racism).

Studying within-group differences can help reduce overgeneralization and may reduce stereotyping (Sodowsky and Plake, 1992, Sue and Zane, 1987). Without confirmation by empirical investigation, some researchers assume “race/ethnic similarity” (Hunt, 1996, Hunt et al., 2000), or that social processes operate uniformly throughout a racial/ethnic group. The within-group study approach is particularly useful for avoiding this assumption while studying the mechanisms that propel racial differences in health behaviors, including substance use, and outcomes. This paper focuses on within-group differences among three groups of Black women with varying levels of CLS involvement (i.e., prison, probation), as well as women with no CLS involvement.

Determining classes of need for treatment or recovery supports is particularly useful for SUD studies, and many studies have demonstrated the utility of latent class analysis for this purpose (Agrawal et al., 2006; Bunting et al., 2020; Bunting et al., 2021; Harrell et al., 2012; Patra et al., 2009; Roth et al., 2015; Schwartz et al., 2010; Trenz et al., 2013). Identifying subpopulations, or classes, is beneficial for determining the risk levels and factors influencing risk for individuals across groups. These classes may be used to examine patterns of use and provide insights for targeted interventions to reduce SUD burden. Latent modeling techniques may be particularly helpful for populations where homogeneity is assumed - such as the case for studies focused on Black women. In populations that are relatively homogenous based on demographic characteristics such as gender, latent modeling techniques can identify heterogeneity and differential risk. For example, in a population of white, rural women, latent modeling techniques identified variations in criminogenic risk factors (Staton et al., 2021), and pinpointed drug use severity as an important differential factor among the women’s criminal trajectories.

Cultural factors may play a role in Black women’s use of both SUD treatment and mutual support groups, including active coping, religiosity, trust in physicians, and gendered racism. John Henryism active coping (James, 1996) refers to the beliefs among some Black adults with lower socioeconomic positions that hard work and self-determination are vital for coping with and overcoming adversities. Prior research with a sample of Black women who use drugs on probation and in the community (but not on probation) found John Henryism was negatively correlated with participation in SUD treatment (Stevens-Watkins et al., 2016), even when controlling for probation status. Given the lack of resources among this group, SUD treatment may not be a viable option for many Black women. Prior studies have not explored how active coping, which is contradictory to the AA/NA premise of being powerless, is related to Black women’s participation in mutual support groups. Moreover, women, especially Black women, may not connect with the powerlessness aspect of AA/NA based on their imposed gendered and racialized subservient history (Hillhouse and Fiorentine, 2001; Timko, 2008). This method of active coping involves relying on oneself to manage challenges related to substance use instead of depending on treatment programs or help from others within mutual support groups.

Among persons involved in the CLS and community-based samples of Black women, spirituality is positively associated with less drug use and positive SUD treatment outcomes (Bakken et al., 2014; Staton-Tindall et al., 2013; Stevens-Watkins et al., 2012). The perceived spiritual or religious components of AA/NA may be a draw for some Black women but are generally cited as a major obstacle to participation in general (Hillhouse and Fiorentine, 2001). Overall, there is limited research on Black women’s use of mutual support groups (Hang Hai et al., 2019). In addition, women’s trust in healthcare providers may be impeded partially because of prior experiences with diagnosis, treatment, and outcomes, along with stigma (Cockroft et al., 2019). Decades of research consistently demonstrate levels of trust in physicians are significantly lower among Black populations due to the heightened awareness of the legacy of racism in the healthcare system (Boulware et al., 2003), which includes SUD treatment. Thus, addressing racial inequities in SUD treatment requires gaining a better understanding of the cultural factors that are relevant to treatment and recovery among Black women, especially among women with varying levels of CLS involvement. Mandated participation in SUD treatment and/or mutual support groups by the CLS is commonplace (Werb et al., 2016) and may be viewed as a form of governmental systemic control by Black women. Furthermore, Black women’s experiences of gendered racism, or discrimination due to the distinct status as both a gender and racial minority, is a stressor associated with adverse health outcomes (Perry et al., 2012). Gendered racism is negative correlate of Black women’s psychological distress (Stevens-Watkins et al., 2014), but is a positively associated with the use outpatient health services among Black women who are (Pullen et al., 2014) and are not involved in the CLS (Oser et al., 2016).

Studies have largely ignored the investigation of substance use patterns, and especially the use of recovery support groups, among Black women with varying levels of CLS involvement (i.e., prison, probation, and no CLS involvement). This work will provide insights for targeting interventions for women who experience life at the intersection of multiple marginalized statuses and are exposed to unique negative stressors. The study aims are to: (1) determine the classes of substance-related needs among Black CLS-involved women, and (2) examine treatment use and mutual support group participation by substance-related need classes and cultural factors.