Dramatic Racial, Ethnic Disparities in Access to Buprenorphine

Batya Swift Yasgur, MA, LSW

May 13, 2019

Racial and ethnic minorities with opioid use disorder (OUD) have a significantly lower odds of receiving a prescription for buprenorphine compared with their white counterparts, new research shows.

Investigators used two large databases that included 13.4 million outpatient visits in 2012-2015 to compare buprenorphine prescriptions in white patients versus those of other races and ethnicities.

They found that white patients were 35 times more likely to have an outpatient visit that included a buprenorphine prescription compared with people of color.

Moreover, outpatient visits in which buprenorphine was prescribed increased by almost 40% in 2004-2007 and 2012-2015. Almost 40% of prescriptions were paid for in cash and almost 35% by private insurance, and the number of buprenorphine visits by self-pay patients dramatically increased.

"Our study basically showed that there are large racial discrepancies in which Americans receive buprenorphine, which is one of the evidence-based treatments for opioid addiction," lead author Pooja Lagisetty, MD, MSc, assistant professor, University of Michigan Medical School and clinician at the VA Ann Arbor Healthcare System, told Medscape Medical News.

"As a physician who treats patients with OUD, it is incredibly important for us to be thoughtful and make sure all patients have equal access to treatment, whether by race or by payment," she said.

The study was published online May 8 in JAMA Psychiatry.

Opioid Mortality Rising

Although opioid-related mortality rates continue to rise throughout the United States, growth in buprenorphine treatment for OUD "might be limited to communities with higher income and low percentages of racial and ethnic minorities," the authors write.

Buprenorphine is one of the approved treatments for treating OUD and can legally be prescribed in office settings.

To date, no national studies have investigated differences in the receipt of buprenorphine prescription by race/ethnicity and payment in office-based settings, the authors note. Although, they add, a previous study did report buprenorphine treatment disparities on the basis of race/ethnicity and income in New York City.

To investigate the question, the researchers combined 2004-2015 data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey outpatient department.

These surveys provide nationally representative estimates of ambulatory care provided in the United States by nonfederally employed physicians, as well as capturing physician-reported medications prescribed during each office visit, demographic characteristics of patients, and expected source of payment.

Researchers limited their sample to visits during which buprenorphine was prescribed in 2012-2015 to test the association of race/ethnicity with receipt of buprenorphine prescription using a logistic regression model adjusted for age, sex, and payment method.

National Snapshot

The number of buprenorphine ambulatory visits rose by 32% (from 0.04% to 0.36%) in 2004-2015, with 13.4 million visits taking place in 2012-2015.

During that latter period, prescriptions for buprenorphine were received at "considerably more" visits by white patients (12.7 million; 95% CI, 8.6 million-16.8 million) compared with patients of other races/ethnicities (363,000; 95% CI, 134,000-594,000).

Black patients were found to have a significantly lower odds of receiving a buprenorphine prescription after researchers accounted for payment method, sex, and age (adjusted OR, 0.23; 95% CI, 0.13 - 0.44).

The authors note that their analysis was not restricted to individuals specifically with OUD because the two databases used do not capture OUD prevalence. However, according to the 2017 National Survey on Drug Use and Health, the prevalence of OUD is similar in black and white adults (3.5% and 4.7%, respectively).

"Despite the enactment of both mental health parity legislation and Medicaid expansion, the proportion of self-pay buprenorphine visits remained relatively steady across the study period," the authors comment.

Citing a recent study suggesting that half of physicians prescribing buprenorphine in Ohio accept only cash, the authors note that their findings "suggest that this practice may be widespread and may be associated with additional financial barriers for low-income populations."

"The big take-home here is that OUD overdoses don't discriminate and affect all people, all races, and all socioeconomic backgrounds," Lagisetty commented.

"I think this study touched on and provides a national snapshot that perhaps our treatment for this condition isn't completely equitable, she said.

No Victory Yet

Commenting on the study for Medscape Medical News, Brendan Saloner, PhD, assistant professor of health policy and management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, who was not involved with the research, said that it "has long been a hope that because buprenorphine can be prescribed by office-based clinicians, it would help to 'mainstream' addiction treatment and make it a broadly accessible service that is reimbursed by insurance, like all other chronic diseases."

However, "the reality is different [and] buprenorphine patients remain disproportionately white and, while whites are more likely to have opioid addiction, the difference in prevalence alone is unlikely to explain this gap," he continued.

Another "big difference" is self-payment.

"Many patients opt to self-pay because their insurance is not sufficiently comprehensive or they do not want to disclose that they have a substance use disorder," he pointed out.

"Alternatively, buprenorphine treatment for many doctors is 'off the grid,' meaning that they prefer to operate outside of insurance programs — which is unfortunate because of the real financial burden it implies for patients," he said.

He noted one limitation of the study — the data end in 2015 and "we still do not know how much this picture will change with continued implementation of the Affordable Care Act Medicaid Expansion."

"My big take-home message is that policymakers need to not just declare victory if more patients are treated with buprenorphine, they should also pay attention to whether buprenorphine prescribers are in diverse communities and willing to accept all forms of insurance payment," he said.

"I hope that this study can spin on future studies and policies for ways to ensure that everyone has good access to treatment they need," Lagisetty added.

No study funding was disclosed. Lagisetty, coauthors, and Saloner have reported no relevant financial relationships.

JAMA Psychiatry. Published online May 8, 2019. Full text

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