Drugs for addiction treatment are far underprescribed, especially by race, research shows

Despite the continued rise in opioids overdose deaths, one of the most effective treatments for opioid addiction is still drastically under-described in the United States, especially for black patients, according to a large new study.

From 2016 through 2019, barely more than 20 percent of patients diagnosed with opioid use 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 of a high-risk event such as 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. Use rates for methadone, another effective treatment, were generally even lower.

“It was disheartening to see treatments with buprenorphine or methadone being so low, even in patients who had just left the hospital with an overdose or other addiction 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 did.”

Access to medical care, a reason often used to explain racial disparities in treatment, wasn’t necessarily at work here, said Dr. Barnett, an associate professor at the Harvard TH Chan School of Public Health. Noting that all patients, regardless of race, saw a doctor about once a month, he said, “There are two more mechanisms that could account for these stark differences. One is where people of color get their health care, which we know is which is there strongly separatedand another is racial differences in patient confidence and demand for buprenorphine.”

Buprenorphine, often marketed under the brand name Suboxone, is a synthetic opioid that satisfies a patient’s craving 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 is also an opioid.

In the study, researchers from public health programs at Harvard and Dartmouth examined claims submitted through Medicare’s disability program for the prescription of buprenorphine and other addiction treatment drugs. The claims, for 23,370 patients nationwide, were made during the six months following an episode in which a healthcare provider determined they had an opioid use disorder.

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

Researchers did not examine the number of prescriptions actually written and compared them to those that were filled. But the findings suggested that far fewer prescriptions were written than needed across all racial groups: In the study, only 12.7 percent of black patients received buprenorphine in the six months following the precipitating event, compared with 18.7 percent of the Latino patients and 23.3 percent. percent of white patients.

Those black patients also received fewer supplies days at a time and held the buprenorphine regimen for a shorter period of time than Latino and white patients.

Doctor Ayana Jordanan addiction psychiatrist who teaches at NYU Grossman School of Medicine and was not involved in the new research, said the study showed the result of many intertwined issues in addressing addiction, especially for black patients.

She theorized that doctors often made automatic, unconscious assumptions about such patients: “They won’t fully participate in caring for themselves, so why go through the motions or take the time, compared to a white patient, to transition? everything?’ ”

Doctors often don’t emphasize the importance of the drug, nor fully explain how to use it, continued Dr. Jordan. While most black patients in this study were covered by Medicare and Medicaid, a modest co-payment may be required for these drugs, she said. For patients who struggle to afford food, transportation, and lodging, even a small outlay for medications can be a low priority. And, she added, studies show that such drugs are not often readily available from pharmacies in poorer communities of color.

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

In another finding of concern, patients in the study filled prescriptions at higher rates for drugs known to be life-threatening to opioid addicts than they filled prescriptions for the life-saving drugs. Those problematic drugs include pain relievers and anti-anxiety drugs that, especially when combined with street opioids, can slow breathing and blood pressure to dangerous levels.

Nearly a quarter of patients filled prescriptions for opioid painkillers, a disturbing finding given that they had already admitted their dependence on opioids during meetings with doctors. Prescription fill rates for benzodiazepines, such as Xanax, Valium, and Ativan, varied by race: 23.4 percent among black patients, 29.6 percent among Latinos, and 37.1 percent among white patients—all of which far exceeded the rates of the acquisition of buprenorphine by the patients.

“Many of these patients have chronic pain, for which they receive opioids, and they may have mental health comorbidities such as anxiety, for which they may receive benzos,” said Dr. Barnett. “Very often these patients will end up with more than one controlled substance, sometimes to counteract side effects of another. It’s a complex mix. But we are sure that these drugs together are a very bad combination.” The researchers also looked at a separate database of filled 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 builds heavily on previous research on racial disparities in prematurely terminated addiction treatment. It also complements study last month that underlined the delay in prescribing buprenorphine, despite not only a clear need, but also considerable efforts especially since the outbreak of the pandemic, to facilitate regulation of providers who prescribe the medication.

Dr Giselle Corbiean expert in 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 worrying reflection of failures across the U.S. health system.

“At multiple points along this cascade of treatment, we’re doing poorly,” she said. “We need to better understand the types of support that should be provided around patients and around the clinicians caring for them, to ensure that these preventable deaths are avoided. And so this study is really the canary in the coal mine for me.”