Addiction treatment is vastly under-prescribed, particularly by race, study finds (2023)

Despite the steady increase in opioidsoverdose 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 major new study.

From 2016 to 2019, barely more than 20 percent of patients diagnosed with opioid use disorder received prescriptions for buprenorphine, the drug considered the gold standard for treating opioid addiction, despite repeated visits to health care providers, according tostudy, which was published Wednesday in the New England Journal of Medicine. Within six months of a high-risk event such as an overdose, white patients took prescription buprenorphine up to 80 percent more often than black patients and up to 25 percent more often than Hispanic 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 treatment rates were so low, even among patients who had just left the hospital for an overdose or other addiction-related problem," he said.dr. Michael L. Barnett, lead author, who teaches health policy and management at Harvard. "Not only that, but people of color received life-saving treatment at a fraction of the rate of white patients."

Access to medical care, a reason often used to explain racial disparities in treatment, was not necessarily at play here, said Dr. Barnett, an associate professor at the Harvard T.H. Chan School of Public Health. Noting that all patients, regardless of race, went to the doctor about once a month, he said: “There are two mechanisms left that could explain such large differences. It's one place where people of color get health care, and we know it ishighly segregated, and the second is racial differences intrust and request of patientsfor buprenorphine."

Buprenorphine, often sold under the brand name Suboxone, is a synthetic opioid that satisfies a patient's craving for other opioids and prevents withdrawal without causing a high. It was approved by the Food and Drug Administration to treat addiction more than two decades ago, but it still faces some resistance and stigma because it, too, is an opioid.

In the study, researchers from the public health programs at Harvard and Dartmouth examined claims submitted through the Medicare disability program for prescriptions of buprenorphine and other addiction treatment medications. Claims for 23,370 patients nationwide were made during the six months following an episode during which a healthcare professional determined they had opioid addiction disorder.

These patients represented a vulnerable population. They qualified for Medicare because of a mental or physical disability, usually arthritis or back pain. Most were also poor enough to qualify for Medicaid.

The researchers did not examine the number of prescriptions actually written and compare them to those that were filled. But the results showed far fewer prescriptions than needed across all racial groups: In the study, only 12.7 percent of black patients received buprenorphine in the six months after the precipitating 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 maintained their buprenorphine regimen for a shorter period of time than Hispanic and white patients.

Dr. Ayana Jordan, an addiction psychiatrist who teaches at N.Y.U. Grossman School of Medicine, who was not involved in the new research, said the study showed the result of many intertwined problems in dealing with addiction, particularly for black patients.

She theorized that doctors often make automatic, unconscious assumptions about such patients: "They're not going to fully participate in self-care, so why would they 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 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 modest co-payments, she said. For patients struggling to afford food, transportation and shelter, even a small cash outlay for medication can be a low priority. And, she added, studies show that such drugs are not often readily available at pharmacies in poorer communities of color.

"I don't want to blame the doctors," Dr. Jordan said. "I want to blame the system, because it promotes a limited engagement with patients in general, one that's even more limited when you're dealing with black people."

Another troubling finding was that patients in the study were more likely to prescribe drugs known to be life-threatening to people addicted to opioids than they were to prescribe life-saving drugs. Those problematic drugs included painkillers and anti-anxiety drugs that, especially when combined with street opioids, can slow breathing and blood pressure to dangerous levels.

Nearly a quarter of the patients received prescriptions for opioid painkillers, a troubling finding because they had already indicated opioid addiction during meetings with their doctors. Rates of prescriptions filled for benzodiazepines, such as Xanax, Valium and Ativan, differed by race: 23.4 percent among black patients, 29.6 percent among Latino patients and 37.1 percent among white patients — all of which far exceeded the rates of patients who were taking buprenorphine.

"Many of these patients have chronic pain that puts them on opioids, and they might have mental health comorbidities like anxiety that might put them on benzos," Dr. Barnett said. “Very often these patients will end up on more than one controlled substance, sometimes to prevent the side effects of another. It's a complex mix. But we know for sure that these drugs together are a very bad combination.” The researchers also looked at a separate database of prescriptions for methadone, an older treatment drug. From 2020 to 2021, those numbers were also very low across all races, ranging from 8 to 11 percent.

The new study expands greatlyearlier researchon racial disparities in early withdrawal from addiction treatment. It is also replenishedstudy last monthit highlighted the lag in prescribing buprenorphine, despite not only a clear need, butconsiderable efforts, especially since the start of the pandemic, to facilitate the regulation of prescribers.

dr. Giselle Corbie, an expert in health equity research at the University of North Carolina School of Medicine who was not involved in this study, described the results as a troubling reflection of failures throughout the American health care system.

"We're not doing badly at multiple points along this treatment cascade," she said. “We need to better understand the types of support that need to be provided to patients and the clinicians who care for them, to ensure that these preventable deaths are avoided. And so this study is really the canary in the coal mine for me."