The opioid epidemic continues to be a growing public health concern in the United States, with Black mothers who have young children being a particularly vulnerable population. In this review, the authors first summarize the mental and physical health disparities faced by this population from the perspective of minority stress theory, considering the role of racial discrimination, gender stigma, trauma, parenting and other life stressors. We then report how chronic stress exposure results in increased susceptibility to poor physical and mental health outcomes, and subsequent development of Opioid Use Disorder (OUD). Opioid addiction itself creates additional disparities, further perpetuating this population’s stress reactivity, emotional dysregulation and OUD. Next, we identify the overlapping neuroadaptations implicated in both chronic stress and OUD, notably the reward pathway. We propose the use of a brief Mindfulness-Based Stress Reduction (MBSR) as a supplement to gold standard treatments for OUD today, highlighting its efficacy in improving emotional regulation, stress, physical and mental health, and substance abuse outcomes for Black mothers with OUD who have small children. If MBSR is found to be efficacious for this vulnerable population, this intervention can be added to existing treatment protocols with modifications to better support opioid-addicted Black American mothers with small children. We propose that future studies adapt existing treatments for OUD to include a brief MBSR, and address potential barriers in implementing this intervention within community addiction treatment settings (e.g., education level, need for childcare) to improve accessibility, compliance, and treatment outcomes for Black American mothers with OUD.
Black mothers; Mindfulness; Minority; Neuroadaptations; Opioid Use Disorder; Racial disparities; Stress
The opioid epidemic continues to be a growing public health concern in the United States with its trend of increasing morbidity and mortality. According to the CDC , drug overdose deaths have quadrupled between 1999-2019 with 70% of drug overdose-related deaths in 2019 involving an opioid. In an effort to combat the opioid crisis, stricter prescribing practices, increased availability of pharmacologic and non-pharmacologic treatment alternatives, prescription monitoring programs and abuse-deterrent strategies among other interventions have been put into place . Despite these efforts, rates of Opioid Use Disorder (OUD) continue to rise, especially within marginalized populations .
The majority of OUD research today is focused on the biological, social, and political effects of opioids on White middle-class American men; however, the impact of the opioid epidemic on the Black community has largely been neglected despite their rising rates in opioid-related deaths . Similarly, women have been understudied despite evidence suggesting that women progress more rapidly from intended, appropriate opioid use to OUD and suffer from greater emotional and physical consequences of drug use, when compared to men .
Research by Sinha  highlights the important role that stress plays in the development and perpetuation of drug abuse and relapse. Black women are a population at risk for chronic stress due to their minority and gender status . For those who suffer with substance addiction within marginalized communities, drug use is often stigmatized, which contributes to chronic stress due to fear of being judged . In addition, mothers experience chronic stress related to difficulties raising children [9,10]. Based on this existing research, we propose that Black women with small children experience heightened levels of chronic stress, which puts them at an increased risk of OUD. To the best of our knowledge, there is no existing literature studying OUD in Black American mothers with young children.
This review aims to summarize the role of life-long disparities faced by Black American mothers of small children in their development and perpetuation of OUD, implicate neurological alterations due to chronic stress and opioid addiction, and propose the use of additional interventions with current OUD treatment to target these mechanisms and improve treatment outcomes.
A web-based literature search using various databases such as Google Scholar, PubMed and PsycInfo electronic databases was carried out. The keywords “mindfulness,” “mindfulness-based stress reduction,” “MBSR,” “opioid use disorder,” “OUD,” “opioid addiction,” “minority,” “racial discrimination,” “African American,” “Black American,” “Black mothers,” “Black women,” “racial disparities,” “chronic stress” and “neuroadaptations” were used to search the databases. The search encompassed articles published from March 1989 to February 2022, and the search was limited to articles published in the English language. After examining titles, abstracts, and full articles, 66 articles were included in this review.
Health disparities of Black women and chronic stress
Black American women face lifelong challenges linked to their minority status, including racial and gender discrimination [11,12], low socioeconomic status (SES; ) and trauma . These daily experiences of multiple discriminations contribute to heightened levels of chronic stress in Black women [12,14]. As a result, Black women report high rates of psychiatric comorbidity (e.g., depression, anxiety) and poor life satisfaction , as well as employment issues . In addition, physical health-related outcomes as a result of chronic stress in this population include increased risk of cardiovascular disease, hypertension, obesity and high blood pressure [15,17]. These stressors increase the likelihood of Black Americans turning to drug use to cope with negative affect , thus, may have greater risk of developing and perpetuating OUD.
Although Black American women are at high risk for OUD due to their chronic stress, they are frequently hindered from seeking and receiving appropriate care, which contributes to this population’s poor health outcome. This group experiences further disparities in healthcare access and utilization at a disproportionate rate to White and Black men and White women [3,18,19]. Black American opioid users also experience high rates of incarceration as a result of racial discrimination within the American justice system , further hindering them from seeking treatment.
Chronic stress in Black mothers with small children
Black American mothers experience additional difficulties raising children , which we propose amplifies the chronic stress Black women already experience due to their minority status and predisposes these individuals to developing and perpetuating OUD. Existing literature states that women experience greater chronic stress if they are Black, have a Black toddler, are single-parenting long-term and are working (compared to non-Black coparenting and unemployed women [21,22]). According to McCallum and colleagues , low-income African-American mothers revealed that they experienced child-related stressors associated with financial difficulties (e.g., losing child support, providing adequate housing and transportation), racism in the school system, lack of control with disciplining their children and their children’s health and safety.
Additionally, Black American mothers suffering with OUD are discriminated against because of the stigma that people of color, especially mothers, with addictions should be punished rather than treated , which we suggest serves as another contributor to chronic stress. Many drug-addicted Black American mothers are unable to care for their children adequately; thus, these children are often raised by their grandparents and great-grandparents . In 1992, 1.2 million African-American children lived with their grandparents, which is three times the rate for these children’s White counterparts . Since Black American mothers with young children experience multiple daily stressors related to their race, gender, and parental status among others, we propose that Black American mothers with young children are a vulnerable population with an increased risk for the development and perpetuation of OUD. More research is needed on this population to better understand how these multiple disparities work together to increase levels of chronic stress.
Chronic stress, functional brain networks, and Opioid Use Disorder
Exposure to chronic and repeated stressors results in changes to the neuroendocrine [Hypothalamic-Pituitary-Adrenal (HPA) axis], sympathetic/parasympathetic autonomic and immune systems . These systems, collectively known as the stress response, work together to maintain homeostasis and adapt when an individual is in the presence of aversive or dangerous stimuli [16,27]. Dysregulation of the stress response system results in neuroadaptation and impairment to functional brain networks such as prefrontal cortex, hippocampus, amygdala, anterior cingulate cortex, and salience network, responsible for emotion and stress regulation [7,28]. These changes result in the development of allostatic overload and ultimately to poor physical and mental health outcomes [16,29].
Chronic activation of the stress response system is associated with an increased tendency towards practicing unhealthy behaviors, including drug use, which may temporarily act as a defense from the psychological effects of stress by reducing anxiety . However, long-term use of these maladaptive coping strategies increases risk for developing and perpetuating addiction , including opioid addiction. Opioids, while beneficial for the treatment of moderate, severe, and persistent pain , also results in HPA axis dysregulation leading to allostatic overload and subsequent adverse physical health consequences . Alterations to the HPA axis also causes neuroadaptation and impairment in the brain’s functional network, such as the mesocorticolimbic striatal reward pathway (including the prefrontal cortex, anterior cingulate cortex and salience networks; ), which we expect to find in opioid-addicted Black mothers with small children who are undergoing chronic stress. As a result of these neuroadaptations, we propose that Black mothers with small children are hypervigilant to discrimination-related (e.g., race, gender, stigma associated with being an addicted mother) and opioid-related cues which result in increased susceptibility to stress, opioid craving and relapse and subsequent negative mental and physical health consequences. More research should be conducted to understand the brain mechanisms implicated in chronic stress and OUD in Black American mothers with small children.
Current OUD treatment and its limitations in Black American community
Gold-standard pharmacotherapy for detoxification and maintenance in OUD individuals is Opioid Agonist Treatment (OAT), primarily methadone and buprenorphine replacement therapy, which work by relieving narcotic craving, suppressing withdrawal symptoms and blocking the euphoric effects of concurrent illicit opioid use [33,34]. However, individuals with OUD, even after years of abstinence  or while on methadone-maintenance therapy , have heightened response to drug cues, increased craving, reduced response to natural rewards, and persistent physiological changes and thus, have high risk for relapse. Likewise, buprenorphine replacement therapy has shown to be effective in reducing withdrawal and craving in early abstinence; however, probability of relapse after detoxification remains high .
Despite the effectiveness of OAT, research suggests it would be more beneficial to treat OUD with a more integrated biopsychosocial approach, implementing therapies such as Cognitive Behavioral Therapy (CBT; ) and structured family therapy  in addition to medication-assisted treatment. According to opioid literature, patients tend to be more compliant and stay in treatment longer when using OAT (methadone > buprenorphine; ), which allows for incorporation of psychosocial interventions into treatment regimens . OAT with psychosocial support together have shown to increase compliance to treatment, decrease illicit opioid use, reduce risky drug-seeking behavior, improve mental health and decrease overall mortality .
Unfortunately, Black Americans have limited access to viable OUD treatment options, which contributes to further development and perpetuation of OUD within these low-income marginalized communities . Methadone is often the sole treatment option provided by federally-regulated opioid treatment centers in low-income areas and patients have difficulty participating in these demanding programs due to increased burden to find childcare, transportation and time off from work . Furthermore, the use of methadone replacement therapy is often underutilized in these communities due to the stigma that OAT simply replaces “one drug [with] another drug” . We propose that Black American mothers with young children face additional challenges due to their parental status, which further limits their accessibility to OUD treatment. To our knowledge, very limited research has been done to examine Black American mothers with small children on OUD. Additional treatment options are needed to increase accessibility and utilization while reducing relapse rates in this vulnerable population.
Mindfulness-Based Stress Reduction (MBSR) is a mind-body complementary health approach developed by John Kabat-Zinn  that uses mindfulness, defined as “the awareness that emerges through paying attention on purpose, in the present moment and nonjudgmentally.” Mindfulness allows for better emotion regulation in response to stress caused by negative life events and experiences, reducing physical symptoms and psychological distress and thus, improving overall quality of life [42,43]. MBSR targets the stress response system and has historically been used for stress reduction in daily life and pain management for chronic illnesses . However, the practice of mindfulness outlined in MBSR now serves as a conceptual framework for other branches of Mindfulness-Based Interventions (MBIs), which have made modifications to support different populations within various contexts . For example, MBSR has applications for targeting stress during addiction treatment to prevent relapse by breaking the cycle of drug cravings and use , which has been useful in the treatment of OUD .
While addictive behaviors are perpetuated by escape and avoidance of negative affect , mindfulness alternatively teaches acceptance of emotions and thoughts, fostering more flexible responses to cravings and stress than reactive drug use . Garland and Howard  found evidence for the efficacy of MBIs for restoring alterations in prefrontal cognitive control function and improving reward processing, resulting in decreased drug cravings and relapse. There is also growing evidence on the benefits of mindfulness on neurological functioning related to stress-induced HPA axis  and autonomic activation . Furthermore, MBIs, when used in conjunction with standard OUD treatment (i.e., OAT), may also be linked to greater patient retention and satisfaction levels compared to standard OUD treatment alone .
Although minority groups are often underrepresented in existing mindfulness research , some headway has been made in addiction studies involving minorities. Literature suggests that MBIs are especially beneficial within substance-addicted racial/ethnic minority populations, including African American and Latina women with history of trauma  and racially and ethnically-diverse low-income women . Among racial/ethnic minorities, MBIs may be even more effective than current relapse prevention treatment in reducing drug use and addiction severity  as well as reducing relapse rates . One reason may be that mindfulness can serve as a buffer for racial oppression [51,57], which we argue is a major contributor to chronic stress, the development and continuation of OUD, and relapse.
Similarly, few studies have researched the use of MBIs for treatment of mothers experiencing chronic stress. More specifically, in existing research with Chilean mothers of preschool children, there was a significant negative correlation between MBIs and the mothers’ stress (general and parent-specific), depression and anxiety . In drug treatment-seeking mothers (predominantly Caucasian) with young children, mindfulness was associated with significant reduction of general and parenting stress, with women exhibiting the greatest baseline general stress levels benefiting most in terms of total stress reduction . However, there is no existing literature which is examining applications of MBIs as an adjunct to OUD treatment in Black American mothers with young children. We propose that this population could benefit from MBSR targeting discrimination-related chronic stress to improve their OUD outcome. If MBSR is found to be efficacious in Black American mothers with young children, this intervention can serve as an adjunct to existing OUD treatment protocols to improve outcomes.
Necessary adaptations to current OUD treatment in Black mothers with small children
Adapting MBSR to align with the goals and needs of Black American mothers with OUD will require the use of flexible treatment protocols to increase accessibility and compliance in community settings. Nicholls and colleagues  suggest the use of outpatient OAT (methadone and naltrexone) with psychosocial treatment in a medical office setting as an alternative to placement in inpatient methadone facilities. Spears  also highlights the importance of cultural competency in the delivery of addiction treatments, which includes adjusting existing language and providing relevant definitions/examples, allowing for modifications to accommodate clients discomfort with triggering practices (e.g., closing the eyes), working collaboratively to identify barriers to treatment, and developing more feasible, informal practices. The culturally-sensitive practice of mindful acceptance of discrimination could also be used as a tool to target discrimination-related stress triggers . Adaptations to current treatment practices also require a holistic approach to increase public awareness and community engagement, foster social support groups and increase diversity within existing programs . Existing feasibility studies involving the use of MBIs within low-income racially/ethnically-diverse community settings support the use of such adaptations [45,54,62].
For mothers with young children, programs that address childcare and family support may aid in improving OUD treatment outcomes  while mindfulness-based parenting may aid in quality of parenting behavior . We propose that similar programs can be applied to opioid-addicted Black mothers with small children to improve treatment outcomes. Another promising avenue to explore is the use of mobile health technology in adapting more feasible MBIs. Existing studies support the efficacy of mobile technologies for the delivery of psychotherapy and other behavioral interventions , and have had some success with low-income minority mothers suffering from depression . We propose mobile technologies can be used for the delivery of mindfulness interventions for OUD treatment in Black mothers with small children. We propose that if adaptations can be made to the delivery of existing OUD treatment to ensure that it is culturally sensitive and more accessible, while also increasing public awareness and community engagement to decrease the stigma associated with seeking treatment, then there will be substantial improvement in OUD outcomes for Black mothers with young children.
The opioid epidemic continues to be a growing public health concern in the United States. Black mothers with OUD who have young children are a particularly vulnerable population because their drug addiction is perpetuated by the prolonged stress they experience due to lifelong struggles with racial discrimination, gender, social stigmas, psychiatric comorbidities, trauma and parenting. The role these disparities play in drug addiction is largely understudied, which contributes to the decreased accessibility of treatments, and low utilization and retention rates of services associated with this population. Current treatment regimens for OUD include OAT and limited psychosocial treatments, though increasing relapse rates persist . We propose that the use of a brief MBSR , modified to address barriers in OUD treatment for Black mothers with small children, may be particularly useful as an adjunct to OAT, as existing research suggests MBSR can target specific neurological mechanisms implicated in chronic stress and addiction, essentially interrupting the stress-drug use cycle [45,46]. The challenge lies in increasing accessibility, effectiveness, and integration of these interventions into lower-income neighborhoods, specifically in their use with Black mothers with young children. The adaptations suggested previously, including the use of mobile health technology, may help to limit the barriers associated with seeking and sustaining treatment in this vulnerable population.
This research was supported by a Healthcare Foundation of New Jersey grant (Award# 3888) to Dr. Suchismita Ray.
The authors report no conflict of interest.
Citation: Suarez AB, De Jesus M, Ray S (2022) Addressing Chronic Stress and Opioid Use Disorder in Black Mothers with Small Children using Mindfulness-Based Stress Reduction: A Review. J Addict Addictv Disord 9: 106.
Copyright: © 2022 Alexis Budhi Suarez, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.