It's been four days since Kevin Hargrove last took the drug that calmed his dangerous cravings. He woke up with a sick stomach and sore muscles, then threw up on the pavement as he set off from his camp under a bridge in Washington this month.
Hargrove recently switched insurance companies funded by Medicare and was unable to get his prescription for buprenorphine, the medication he has taken for years to treat his opioid addiction. The withdrawals proved too much. The 66-year-old found a dealer on the street, paid $6 for two pills he believed to be codeine painkillers and washed them down with a can of Olde English 800 malt liquor.
Less than an hour later, Hargrove passed out at his sister's apartment in Columbia Heights, having overdosed on what was suspected to be fentanyl. "Don't tell me!" cried his sister. "You were so good!"
Hargrove's story illustrates the challenges that those struggling with opioid addiction — especially people of color — often face when receiving buprenorphine, a drug that public health experts believe should play a key role in curbing the fentanyl-fueled addiction and overdose crisis. His overdose occurred this month as a recently published national study by the Harvard T.H. Chan School of Public Health showed that white patients are up to 80 percent more likely to receive buprenorphine than black patients, and that black patients receive a more limited supply.
"There are many completely counterproductive insurance restrictions on this drug, especially for populations where the need is greatest," said the study's lead author, Michael L. Barnett, an associate professor of health policy and management at the Harvard School of Public Health.
StudyPublishedin the New England Journal of Medicine reviewed the medical records of more than 23,300 Medicare beneficiaries with disabilities whose opioid encounters led to nonfatal overdoses, injection-related infections, or inpatient or rehabilitation treatment between 2016 and 2019. In the six months following the event that led to treatment, more than 23 percent of white patients received prescriptions for buprenorphine, compared with less than 13 percent of black patients. Nearly 19 percent of Hispanics received medication. The study did not measure whether prescriptions were written and left unfilled.
This comprehensive study adds to a growing body of research reflecting racial disparities in medication-assisted treatment of opioid addiction. Last fall, ananalyze15 years of prescription data published in JAMA Psychiatry found that black and Hispanic patients received shorter periods of buprenorphine treatment than white patients.
More than 100,000 Americans die each year from drug overdoses — mostly from opioids — and that includesspikein the death rate among African Americans.
"The system has the capacity to aggressively treat chronic health problems. They just don't when it comes to substance use disorder, especially for African Americans,” said Ricky Bluthenthal, a professor of population sciences and public health at the University of Southern California Keck School of Medicine who was not involved in the recently published study.
In the Harvard study, researchers looked at a random sample of Medicare beneficiaries diagnosed with disability, a group heavily affected by opioid addiction. The study also found that black and Hispanic patients were less likely to receive prescriptions for naloxone, a drug used to reverse opioid overdoses.
Another alarming finding: Patients in all three racial or ethnic groups were prescribed opioid painkillers or benzodiazepines, commonly used to treat anxiety, at a higher rate than they received buprenorphine. These pain relievers and benzodiazepines can greatly increase the risk of overdose for someone who is already addicted to opioids.
Experts say there are many reasons for disparities in access to buprenorphine, including a lack of providers willing to prescribe the drug, prescribing bias, mistrust of the medical establishment and racism long entrenched in the U.S. health care system.
Expanding drug-assisted opioid addiction treatment is a plan of the Biden administrationstrategyto combat the overdose crisis. First approved for the treatment of opioid addiction in 2002.buprenorphineit helps fight cravings and withdrawal from heroin and, increasingly, the illicit fentanyl. Last year, the federal governmentmade it easierfor more doctors to prescribe the drug, and the Drug Enforcement Administration extended a pandemic-era rule allowing doctors to prescribe buprenorphine via telemedicine.
However, doctors inexperienced with buprenorphine are sometimes reluctant to prescribe it. Oluwole Jegede, a professor of psychiatry at Yale University, said stereotypes and implicit racial bias can also prevent doctors from prescribing buprenorphine to black and Hispanic patients, especially if those doctors fear the patients might abuse or sell the drug, or fail treatment. . Instead, patients of color may be referred to methadone, a more powerful but highly restricted addiction treatment drug that for five decades has only been allowed to be dispensed in specialty clinics, he said.
Jegede called it a "two-class system" supported by false notions. "We know from the data that the fear of patients selling their buprenorphine is unwarranted," he said.
This claim was emphasized by the Inspector General of the Ministry of Health and Social Servicesreportthis month which concluded that the risk of patients selling or giving away their buprenorphine is extremely low.
As drug-related deaths rise, experts call for expanded access to methadone
Mario, a 26-year-old Mexican-American and former US Army soldier, had never heard of buprenorphine. His addiction began with painkillers prescribed for a shoulder injury after a tank accident, then progressed to fentanyl after he couldn't get pills after his discharge.
He sought help at the Veterans Affairs Hospital in Orange County, California. No one mentioned buprenorphine, Mario recalled, even though he was offered care at a methadone clinic. But he worried that the methadone was too strong. In addition, he would have to wait in line every day at a clinic in a tough part of his hometown of Santa Ana.
"I didn't want to do it," said Mario, who spoke on the condition that his full name not be used for fear of stigma. "What if someone I know sees me there?"
He learned about buprenorphine later from other users. When he called two clinics for a prescription, Mario said, he was turned away without explanation, despite having insurance subsidized by the VA and the state of California. Mario said he was confused when his White friend, also a veteran but with a job and stable housing, got a prescription through one of the same clinics.
"Back then I was living out of my car," said Mario, who is disabled and suffers from post-traumatic stress syndrome.
Mario ended up securing a prescription for buprenorphine through a telehealth provider. The drug helped him flush out the fentanyl. After months of use, he also stopped taking buprenorphine in the meantime, fearing he was still using an addictive drug.
His perceptions are not unusual. Patients' negative opinions of buprenorphine may also play a role in the differences, addiction experts say.
A Harvard study found that patients of all racial groups had a similar number of visits to health care providers, meaning that the differences are not always explained by fewer contacts with the medical system. Last year, researchers in a separatestudydetailed interviews with 41 buprenorphine-naïve patients in Boston, and found that black and Hispanic patients "expressed greater distrust" of drug treatment, with some preferring to drop the drug and join group or residential programs.
Jawad Husain, associate professor of addiction psychiatry at Mass General Brigham in Boston and lead author of the study, said the researchers found that black and Hispanic patients looked to methadone or buprenorphine as a substitute for illicit opioids.
"That's not the case," he said. "When they take these drugs, they don't get high. They have a tolerance built up where they just feel normal again.”
Husain, like other addiction experts, believes that educating a wider range of physicians, community groups and patients about medication-assisted treatment is key to breaking down barriers.
Even with doctors and patients like Hargrove accepting buprenorphine, the insurance system can impose barriers.
An affable former martial arts instructor, Hargrove suffers from mental illness and has lived on the streets of DC for the better part of the past two decades. He said he became addicted to codeine painkillers decades ago to cope with injuries.
A decade ago, he turned to Edwin Chapman, 77, a doctor who specializes in addiction medicine and treats mostly black patients on the outskirts of Capitol Hill. He is known as a fierce advocate for his patients, sending frequent emails to public officials to warn them of the dangers of the toxic drug supply in D.C., while advocating for expanded access to buprenorphine.
"He's the reason I'm alive today," Hargrove said.
Chapman said Hargrove's case illustrates an ongoing problem for addiction treatment doctors: that an insurer's "prior authorization" policy gets in the way of treatment. Hargrove receives disability benefits, D.C. Medicaid andMedicare Advantage, in which the insurance company contracts with Medicare. Hargrove's previous insurance covered a monthly supply of four daily eight-milligram doses of buprenorphine, and he visited Chapman's office monthly for prescription renewals.
Hargrove recently switched to UnitedHealthcare. In March, Chapman and Hargrove said, the company would agree to just three doses a day, meaning he had to extend his supply for an entire month. "That first month was hell," Hargrove said.
UnitedHealthcare said in a statement that Hargrove's prescription was "filled in accordance with his benefit plan," which complies with Food and Drug Administration guidelines for the drug. "We had no documentation or other support from his provider to support the higher dose required," the company said.
Chapman said United's pharmacy rejected his prescription recommendation. "How is it that a pharmacist can outvote a doctor?" Chapman said.
Hargrove overdosed on pills suspected to be fentanyl on May 11, before he was authorized to pick up his new three-a-day prescription. At his sister's apartment, he threw himself on a chair in her bedroom and passed out. The whites of his eyes turned gray. His sister, Claudette Inge, called 911, frantically poured a glass of cold water over his face and began chest compressions.
Paramedics used Narcan to revive him. "I died in that chair," Hargrove said the next day, recounting the scene while at his sister's apartment.
Chapman said: "This was really scary, and you hate to see a stable patient become unstable for no reason just because of red tape."
The day after the overdose, Hargrove was finally able to take his buprenorphine. "I'll just have to stretch it out like I've been doing," he further told Chapman nail phone
That afternoon, Hargrove walked into a pharmacy in Anacostia, took his medication, pulled out a brown buprenorphine tablet and put it in his mouth. "I'll feel better in about three minutes," he said before walking to the bus stop.
He would later learn that the insurer, responding to Chapman's urgent appeal, had approved an additional daily dose - only after his near-fatal overdose.