Medications for opioid use disorder (MOUDs) like methadone, buprenorphine, and naltrexone significantly lower the risk of deadly overdose and all-cause mortality. MOUDs are one of the safest and most effective treatments available today. Despite this, only one in five people receives them. Worse still, gross racial disparities exist in treatment levels. Research has shown that Black patients are 50% less likely to benefit from MOUDs than their White counterparts.
Pinpointing where these racial disparities creep into the treatment cycle, however, can be difficult. Various points of entry have been suggested, like differences in access to care or treatment from judges and clinicians. However, empirical evidence is needed to confirm these and understand how racial disparities are introduced. This was the goal of a recent publication in Drug and Alcohol Dependence.
The study included cross-service patient data on 6374 non-Hispanic White and Black individuals from January 1, 2015 to March 31, 2018, sourced from health, human, criminal and other services in Allegheny County, Pennsylvania, to determine the role these systems play in the relation between race and MOUD treatment.
A review of the literature revealed a variety of potential mediators, and an analysis of the data confirmed that several of these may be sources of racial bias in the treatment cycle, at least for the county in question.
First, the data agreed with previous studies in that 50.6% of White patients initiated MOUD treatment, compared to just 29.7% of Black patients. More importantly, however, five mediators were identified that mapped onto this racial disparity in a significant way: having a non-OUD substance abuse diagnosis (SUD); days spent in county jail; months spent with housing support; days in emergency care; and use of intensive non-MOUD SUD treatment.
Determining cause and effect in treatment cycles can be difficult. Increased emergency room visits may be a result of less frequent MOUD treatment. On the other hand, Black individuals’ stays in county jails tended to be longer by roughly 75%, and each additional day spent in county jail equated to a 0.3% decrease in initiation of treatment. Thus, a judges’ racial bias, whether conscious or not, may indirectly reduce a Black individual’s chances of initiating MOUD treatment due to a longer sentence than his or her White counterpart.
Jail policies are also a poor reflection of reality: although MOUD treatment in correctional settings reduces illicit opioid use post-release, most jails and prisons in the United States refuse to offer it. As arrests and jail time tend to be higher for Black Americans, offering MOUD in prison settings can do a lot to fill this gap—although, as the authors point out, re-examining racial bias in arrests is also key.
Use of “intensive non-MOUD SUD treatment” is also more common with Black individuals. In layman’s terms, this typically translates to cold-turkey rehab, a practice that is both significantly more painful and distressing for the patient and which boasts a significantly lower success rate. In some cases, this may come down to patient choice—but in many others, it may stem from clinician choices. Again, consciously or not, racial bias may result in some clinicians taking a “hard line” with certain patients that “just need to sober up”, and a more balanced, compassionate line with others who “merely need a helping hand.”
Housing instability is also known to disproportionately affect Black Americans. This is a prime example of how racial disparities in different systems can reinforce and amplify each other: housing instability leads to substance abuse, which can make it difficult to keep a job or may exclude one from housing programs, leading to more substance abuse, and so on. Plus, housing instability is itself a complex phenomenon, with any number of entry points for racial bias proper to the cycle.
The authors point to some important areas for opportunity. Health care providers, for example, in the treatment of HCV and HIV, may have the opportunity to refer their patients to treatment, thus helping to close the gap between Black and White patients.
The authors note several limitations to the study, mainly having to do with the population. First, data was restricted to Allegheny County, which not only reduces its generalizability, but treatment administered outside the context of Medicaid in Allegheny would not have been included. Thus, some individuals may have received MOUD treatment without it being registered in the study. Similarly, the limited size of the study precluded the authors’ ability to study individuals outside the non-Hispanic White and Black population.
Nonetheless, the study is important in that it brings real-world data to bear on a question that suffers from a general poverty of empirical evidence. Now that several points of entry for racial bias have been identified, they can be addressed in Allegheny County, and elsewhere, with greater precision and ease.
The article, “Racial inequity in medication treatment for opioid use disorder: Exploring potential facilitators and barriers to use”, was authored by Mara A.G. Hollander, Chung-Chou H. Chang, Antoine B. Douaihy, Eric Hulsey, and Julie M. Donohue.
