Despite the continued rise of opioids overdose deaths, one of the most effective treatments for opioid addiction is still being heavily prescribed in the united states, especially for black patients, according to a large new study.
From 2016 to 2019, just over 20 percent of patients diagnosed with opioid use disorder obtained prescriptions for buprenorphine, the drug considered the gold standard in the treatment of opioid addiction, 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 after a high-risk event such as an overdose, white patients filled up to 80 percent more prescriptions for buprenorphine than black patients, and up to 25 percent more than Latino patients, the study found. Rates of use of 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 had just been released from the hospital with an overdose or other addiction-related problem,” he 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 life-saving treatment at a fraction of the rate white patients received.”
Access to health care, a reason often used to explain racial disparities in treatment, was not necessarily at stake here, said Dr. Barnett, an associate professor at the Harvard TH Chan School of Public Health. Noting that all patients, regardless of race, saw their doctors about once a month, he said: “There remain two mechanisms that could explain such large disparities. One is where people of color get their health care, which we know is highly segregatedand another is the 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 it still faces some resistance and stigma because it’s also an opioid.
In the study, researchers from the Harvard and Dartmouth public health programs examined claims filed through the Medicare disability program for prescriptions for buprenorphine and other addiction treatment drugs. The claims, for 23,370 patients nationwide, were filed within six months of an episode during which a health care provider determined they had opioid use disorder.
These patients represented a vulnerable population. They qualified for Medicare because of a physical or mental health disability, usually arthritis or back pain. Most were also poor enough to be eligible for Medicaid.
The researchers did not examine the number of prescriptions actually written and compared them to those that were filled. But the findings suggested far fewer prescriptions were being written than needed across all racial groups: In the study, only 12.7 percent of black patients received buprenorphine within six months of the triggering event, compared with 18.7 percent of Latino patients and 23.3 percent. percent of white patients.
Those black patients also received supplies for fewer days at a time and stayed on the buprenorphine regimen for shorter periods of time than Latino and white patients.
Dr Ayana JordanAn addiction psychiatrist who teaches at NYU Grossman School of Medicine and who was not involved in the new research, said the study showed the result of many intertwined issues in dealing with addiction, especially for black patients.
She theorized that doctors often made automatic, unconscious assumptions about these patients: “’They’re not going to fully participate in caring for themselves, so why go through the motions or take the time, compared to a white patient, to review? all?’ ”
Doctors often don’t emphasize the importance of the drug or fully explain how to use it, Dr. Jordan continued. Although most of the black patients in this study were covered by Medicare and Medicaid, these drugs may require a modest copay, he said. For patients struggling to pay for food, transportation, and housing, even a small out-of-pocket for medication can be a low priority. And, he added, studies show that these drugs are often not available at pharmacies in the poorest communities of color.
“I don’t want to blame the doctors,” Dr. Jordan said. “I want to blame the system, because it promotes limited engagement with patients in general, one that is even more limited when it comes to black people.”
In another troubling finding, patients in the study filled prescriptions at higher rates for drugs known to endanger the lives of people addicted to opioids than they did for lifesaving drugs. Those problem drugs included pain relievers and anti-anxiety medications, 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 pain relievers, a worrisome finding because they had already indicated opioid dependence during encounters with doctors. Fill rates for benzodiazepines, such as Xanax, Valium, and Ativan, differed by race: 23.4% among black patients, 29.6% among Latinos, and 37.1% among white patients, all of whom exceeded greatly increased the acquisition rates of buprenorphine by patients.
“Many of these patients are in chronic pain, for which they are receiving opioids, and could have mental health co-morbidities such as anxiety that they could be receiving benzodiazepines for,” Dr. Barnett said. “Very often, these patients will end up on more than one controlled substance, sometimes to counteract the side effects of another. It is a complex mix. But we know for sure that these drugs are a very bad combination together.” The researchers also looked at a separate database of prescriptions for methadone, an older treatment drug. From 2020 through 2021, those numbers were also very low across all races, ranging from 8 to 11 percent.
The new study greatly expands previous investigations on racial disparities in prematurely terminated addiction treatment. also complements studies last month which highlighted the delay in buprenorphine prescriptions, despite not only a clear need but also considerable efforts especially since the beginning of the pandemic, to facilitate the regulation of providers who prescribe the medication.
Dr Giselle CorbieA health equity research expert at the University of North Carolina School of Medicine who was not involved in the current study described the results as a troubling reflection of failings throughout the American health care system.
“At multiple points along this treatment cascade, we are doing a poor job,” he said. “We need to do a better job of understanding the types of support that should be provided to patients and the doctors who care for them, to ensure these preventable deaths are prevented. So this study, to me, is really the canary in the coal mine.”
