Despite the continuing rise in opioid overdose deaths, one of the most effective treatments for opioid addiction is still drastically underprescribed in the United States, especially for Black patients, according to a large new study.
From 2016 through 2019, scarcely more than 20 percent of patients diagnosed with opioid use disorder filled prescriptions for buprenorphine, the medication considered the gold standard in opioid addiction treatment, despite repeated visits to health care providers, according to the study, which was published Wednesday in the New England Journal of Medicine. Within six months following a high-risk event like an overdose, white patients filled buprenorphine prescriptions up to 80 percent more often than Black patients, and up to 25 percent more often than Latino patients, the study found. Rates of use for methadone, another effective treatment, were generally even lower.
“It was disheartening to see that buprenorphine or methadone treatments were so low, even among patients who just left the hospital with an overdose or other addiction-related issue,” said Dr. Michael L. Barnett, the lead author, who teaches health policy and management at Harvard. “And not only that, but people of color received lifesaving treatment at a fraction of the rate that white patients did.”
Access to medical care, a reason often used to explain racial disparities in treatment, was not necessarily at work here, said Dr. Barnett, an associate professor at the Harvard T.H. Chan School of Public Health. Noting that all the patients regardless of race encountered doctors roughly once a month, he said, “There are two mechanisms left that could explain disparities this large. One is where people of color get their health care, which we know is highly segregated, and another is racial differences in patient trust and demand for buprenorphine.“
Buprenorphine, often marketed under the brand name Suboxone, is a synthetic opioid that satisfies a patient’s cravings for other opioids and prevents withdrawal, without providing a high. It was approved for addiction treatment by the Food and Drug Administration more than two decades ago, but still faces some resistance and stigma because it, too, is an opioid.
In the study, researchers from public health programs at Harvard and Dartmouth examined claims filed through Medicare’s disability program for prescriptions of buprenorphine and other addiction treatment drugs. The claims, for 23,370 patients nationwide, were filed during the six months following an episode during which a health care provider had determined they had opioid use disorder.
These patients represented a vulnerable population. They qualified for Medicare either because of a mental health disability or a physical one, typically arthritis or back pain. Most were also poor enough to be eligible for Medicaid.
Researchers did not examine the number of prescriptions actually written and compare them to those that were filled. But the findings suggested that far fewer prescriptions were being written than were needed across all racial groups: In the study, only 12.7 percent of Black patients received any buprenorphine in the six months after the precipitating event, compared with 18.7 percent of Latino patients and 23.3 percent of white patients.
Those Black patients also received supplies for fewer days at a time, and maintained the buprenorphine regimen for shorter durations, than Latino and white patients.
Dr. Ayana Jordan, an addiction psychiatrist who teaches at the N.Y.U. Grossman School of Medicine and was not involved in the new research, said the study showed the result of many intertwined problems in addressing addiction, especially for Black patients.
She theorized that often physicians made automatic, unconscious assumptions about such patients: “ ‘They’re not going to participate fully in taking care of themselves, so why go through the motions or take the time, compared to a white patient, to go over everything?’ ”
Doctors often don’t emphasize the importance of the medication nor fully explain how to use it, Dr. Jordan continued. Even though most Black patients in this study were covered by Medicare and Medicaid, these medications can require a modest co-payment, she said. For patients struggling to afford food, transportation and shelter, even a small cash outlay for medicine can be a low priority. And, she added, studies show that such medications are not often readily available at pharmacies in poorer communities of color.
“I don’t want to blame doctors,” Dr. Jordan said. “I want to blame the system, because it’s one that promotes limited engagement with patients overall, one that’s even more limited when you’re dealing with Black people.”
In another finding causing concern, patients in the study filled prescriptions at higher rates for medications known to be life-threatening for people addicted to opioids than they filled prescriptions for the lifesaving medicines. Those problematic medications included painkillers and anti-anxiety drugs which, particularly in conjunction with street opioids, can slow breathing and blood pressure to dangerous levels.
Nearly a quarter of the patients filled prescriptions for opioid painkillers, a troubling finding because during encounters with doctors they had already indicated a dependence on opioids. Rates of filled prescriptions for benzodiazepines, like Xanax, Valium and Ativan, differed by race: 23.4 percent among Black patients, 29.6 percent among Latinos and 37.1 percent of white patients — all of which far exceeded rates of the patients’ acquisition of buprenorphine.
“A lot of these patients have chronic pain, for which they are receiving opioids, and they might have mental health comorbidities like anxiety that they might be getting benzos for, ” Dr. Barnett said. “Very often these patients will end up with more than one controlled substance, sometimes to counteract side effects from another. It’s a complex mix. But we know for sure that these meds are a very bad combination together.” The researchers also looked at a separate database of prescriptions filled for methadone, an older treatment medication. From 2020 through 2021, those numbers were also very low across all races, ranging from 8 to 11 percent.
The new study greatly expands upon earlier research about racial disparities in prematurely terminated addiction treatments. It also complements studies last month that underscored the lag in buprenorphine prescriptions, despite not only a clear need but considerable efforts , especially since the onset of the pandemic, to ease the regulation of providers who prescribe the medication.
Dr. Giselle Corbie, an expert on health equity research at the University of North Carolina School of Medicine who was not involved in the current study, described the results as a worrisome reflection of failures throughout the American health system.
“At multiple points along this cascade of treatment we are doing a poor job,” she said. “We need to be doing a better job of understanding the kinds of supports that need to be put around patients and around the clinicians that are caring for them, to ensure that these preventable death are averted. And so this study, to me, really is the canary in the coal mine.”