Substantial Racial Inequalities Exist in Opioid Use Disorder Treatment, Study Finds

White patients were significantly more likely to receive and fill prescriptions for medications to treat opioid use disorder (OUD) compared with Black or Hispanic patients in the months following a high-risk OUD event such as an overdose or infection, a study published in the New England Journal of Medicine found.¹ Patients across racial groups made a similar number of visits to providers, however, suggesting these disparities are not rooted in not seeking care.

The study, led by researchers at the Harvard T.H. Chan School of Public Health, aimed to address evidence gaps on racial disparities in overdose and OUD treatment.

“Opioid overdoses are rising faster in the Black population than in any other racial group: In 2021, they surpassed overdose rates in the White population for the first time in decades. And rates of overdose in the Hispanic population have recently risen by 40%,” said lead study author Michael L. Barnett, MD, associate professor of health policy and management, in a statement. “We need to understand barriers to obtaining life-saving addiction treatment for minority populations to address this huge demographic shift and public health crisis.”²

Previous research has shown racial disparities in addiction treatment, but few studies have examined the full range of OUD medications—buprenorphine, naloxone, naltrexone, and methadone—or the receipt of opioid analgesics or benzodiazepines, which are associated with overdose and mortality risk among individuals with OUD. Past research has also been limited to data from federal surveys on outpatient settings or substance abuse treatment centers, which only include patients receiving treatment for substance abuse, or have used geographic proxies for race.

The new study explored disparities among 23,370 Medicare beneficiaries with disability and active OUD symptoms who experienced a high-risk OUD event such as an overdose or infection. Of these patients, 3524 were Black, 1858 were Hispanic, and 17,988 were White. Overall, there were 25,904 OUD-related index events: 3937 (15.2%) among Black patients, 2105 (8.1%) among Hispanic patients, and 19,862 (76.7%) among White patients.

Black patients were less likely to receive buprenorphine in the 180 days following an index event: A prescription for buprenorphine was received and filled after 12.7% of index events among Black patients, 18.7% of Hispanic patients, and 23.3% of White patients. Black patients also received prescriptions for a significantly lower days’ supply of buprenorphine compared with White patients on average. Naloxone, which can reverse overdoses and was recently approved by the FDA for over-the-counter sales, was prescribed and filled after 14.4% of OUD events in Black patients, 20.7% of Hispanic patients, and 22.9% of White patients.

A follow-up analysis including data from 2020 to 2021 found that differing access to methadone between racial and ethnic groups did not explain the differences in postevent prescriptions seen in the study. Black, Hispanic, and White patients received and filled methadone after 8.3%, 11.2%, and 8.6% of OUD events, respectively. Methadone receipt could not be observed in the main study time frame from 2016 to 2019 because the claims data precede 2020, when Medicare coverage expanded to include methadone.

Regardless of race, prescriptions for opioid analgesics and benzodiazepines, which are known high-risk medications, were frequent after OUD events. Opioid analgesic prescriptions were received and filled approximately 23% of the time after OUD events across racial and ethnic subgroups, and benzodiazepines prescriptions were received and filled 23.4%, 29.6%, and 37.1% of the time among Black, Hispanic, and White patients, respectively.

Health care utilization was also similar between groups, with Black, Hispanic, and White patients’ index events followed by a mean of 6.6, 6.7, and 7.6 ambulatory visits in the following 180 days, respectively. The slightly higher number among White patients is a small difference relative to the substantial disparities in the receipt of OUD medications. Black patients had more emergency department visits and hospitalizations than White patients, but the overall rate of overdose was similar between racial and ethnic groups.

“In this national study of Medicare beneficiaries with disability and active OUD symptoms, we observed substantial racial and ethnic disparities in the receipt of medications for OUD, particularly among Black beneficiaries,” the study authors wrote. “The disparities were not explained by state of residence or observable differences in beneficiary age, sex, or burden of chronic conditions across groups.”

Although the study was limited to Medicare fee-for-service beneficiaries with disability and may not be generalizable to other groups, the authors noted that patients in this population should be a priority population for better addiction treatment because they represent a disproportionate number of opioid-related overdoses. The study also could not factor in methadone receipt for OUD in the main study period, which is a confounder for buprenorphine prescription.

The authors concluded that substantial racial and ethnic disparities in the receipt of OUD medications exist, especially between White and Black patients, despite similar health care utilization across racial and ethnic groups.

“Skyrocketing rates of overdoses in minority groups are unlikely to shift without a major overhaul in the addiction treatment system,” said Barnett. “Addressing the overdose crisis and racial disparities in addiction will likely require community-specific interventions that engage with minority populations and the clinicians who serve them to reduce stigma and bolster trust.”

References

1. Barnett ML, Meara E, Lewinson T, et al. Racial inequality in receipt of medications for opioid use disorder. N Enlg J Med. 2023;388(19):1779-1789. doi:10.1056/NEJMsa2212412

2. Substantial racial inequalities despite frequent health care contact found in treatment for opioid use disorder. News release. Harvard T.H. Chan School of Public Health. May 10, 2023. Accessed May 12, 2023. https://www.hsph.harvard.edu/news/press-releases/substantial-racial-inequalities-despite-frequent-health-care-contact-found-in-treatment-for-opioid-use-disorder/