Background: As the drug-related overdose crisis and COVID-19 pandemic continue, communities need increased access to medications for opioid use disorder (MOUD) (i.e., buprenorphine and methadone). Disparities in the type of MOUD prescribed or administered by racial and ethnic categories are well described in the outpatient clinical environment. It is unknown, however, if these disparities persist when MOUD is provided in acute care hospitals. Methods: This study assessed differences in the delivery of buprenorphine versus methadone during acute medical or surgical hospitalizations for veterans with opioid use disorder (OUD) by racial categories (Black Non-Hispanic or Latino vs. White Non-Hispanic or Latino). Data were obtained retrospectively from the Veterans Health Administration (VHA) for federal fiscal year 2017. We built logistic regression models, adjusted for individual and hospital-related covariates, and calculated the predicted probabilities of MOUD delivery by racial categories. Results: The study cohort (n = 1,313 unique patients; N = 107 VHA hospitals) had a mean age of 57 (range 23 to 87 years), was predominantly male (96%), and composed entirely of Black (29%) or White (71%) patients. White patients were 11% more likely than Black patients to receive buprenorphine than methadone during hospitalization (p = 0.010; 95% CI: 2.7%, 20.0%). Among patients on MOUD prior to hospitalization, White patients were 21% more likely than Black patients to receive buprenorphine (p = 0.000; 95% CI: 9.8%, 31.5%). Among patients newly initiated on MOUD during hospitalization, there were no differences by racial categories. Conclusion: We observed disparities in the delivery of buprenorphine versus methadone during hospitalization by racial categories. The observed differences in hospital-based MOUD delivery may be influenced by MOUD received prior to hospitalization within the racialized outpatient addiction treatment system. The VHA and health systems more broadly must address all aspects of racism that contribute to inequitable MOUD access throughout all clinical contexts.
SordoL, BarrioG, BravoMJMortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. Bmj.2017;357:j1550.
2.
BeethamT, SalonerB, GayeM, WakemanSE, FrankRG, BarnettML.Therapies offered at residential addiction treatment programs in the United States. JAMA2020;324(8):1251–806.
3.
BuschAB, GreenfieldSF, ReifS, NormandS-LT, HuskampHA.Outpatient care for opioid use disorder among the commercially insured: use of medication and psychosocial treatment. J Subst Abuse Treat.2020;115:108040.
4.
MattickRP, BreenC, KimberJ, DavoliM.Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev2014;2:CD002207.
5.
Substance Abuse Mental Health Services Administration. Federal guidelines for opioid treatment programs. In. Vol Vol HHS Publication No.(SMA) PEP 15-FEDGUIDEOTP2015; 2015.
6.
National Academies of Sciences, Engineering, and Medicine. Medications for Opioid Use Disorder save Lives. Washington, DC: The National Academies Press; 2019.
7.
PriestKC.Commentary on Jin et al. (2020): regulatory and allocative policies inform access to opioid agonist therapy. Addiction.2020;115(12):2255–2256.
8.
HansenH, RobertsSK.Two tiers of biomedicalization: methadone, buprenorphine, and the racial politics of addiction treatment. Adv Med Soc2012;14(12):79–102.
9.
JamesK, JordanA.The opioid crisis in black communities. J Law Med Ethics.2018;46(2):404–421.
10.
HansenH, ParkerC, NetherlandJ.Race as a Ghost Variable in (White) opioid research. Sci Technol Hum Values.2020;45(5):848–876.
11.
NetherlandJ, HansenHB. The war on drugs that Wasn't: wasted whiteness, “Dirty Doctors,” and race in media coverage of prescription opioid misuse. Cult Med Psychiatry.2016;40(4):664–686.
12.
HansenH, SiegelCE, CaseBG, BertolloDN, DiRoccoD, GalanterM.Variation in use of buprenorphine and methadone treatment by racial, ethnic, and income characteristics of residential social areas in New York City. J Behav Health Serv Res.2013;40(3):367–377.
13.
SchiffDM, NielsenT, HoeppnerBBAssessment of racial and ethnic disparities in the use of medication to treat opioid use disorder among pregnant women in Massachusetts. JAMA Netw Open.2020;3(5):e205734.
14.
GoedelWC, ShapiroA, CerdáM, TsaiJW, HadlandSE, MarshallBD.Association of racial/ethnic segregation with treatment capacity for opioid use disorder in counties in the United States. JAMA Netw Open.2020;3(4):e203711.
15.
PriestKC, McCartyD, LovejoyTI.Expanding access to medications for opioid use disorder: program and policy approaches from outside the Veterans Health Administration. J Gen Intern Med.2020;35(Suppl 3):886–890.
16.
RutherfordPA, ProvostLP, KotagalUR, LutherK, AndersonA.Achieving Hospital-Wide Patient Flow. IHI White Paper Cambridge: Institute for Healthcare Improvement. 2017.
17.
PriestKC. Hospital-based services for opioid use disorder: a study of supply-side attributes. Dissertations and Theses.2019; p. 4829.
18.
EnglanderH, WeimerM, SolotaroffRPlanning and designing the Improving Addiction Care Team (IMPACT) for hospitalized adults with substance use disorder. J Hosp Med.2017;12(5):339–342.
19.
VelezCM, NicolaidisC, KorthuisPT, EnglanderH.It's been an experience, a life learning experience: a qualitative study of hospitalized patients with substance use disorders. J Gen Intern Med.2017;32(3):296–303.
20.
LiebschutzJM, CrooksD, HermanDBuprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern Med.2014;174(8):1369–1376.
21.
EnglanderH, DobbertinK, LindBKInpatient addiction medicine consultation and post-hospital substance use disorder treatment engagement: a propensity-matched analysis. J Gen Intern Med.2019;34(12):2796–2803.
22.
PriestKC, LovejoyTI, EnglanderH, ShullS, McCartyD.Opioid agonist therapy during hospitalization within the Veterans Health Administration: a pragmatic retrospective cohort analysis. J Gen Intern Med.2020;35(8):2365–2374.
23.
BoydRW, LindoEG, WeeksLD, McLemoreMR.On racism: a new standard for publishing on racial health inequities. Health Affairs Blog2020;10.
24.
KaplanJB, BennettT.Use of race and ethnicity in biomedical publication. JAMA2003;289(20):2709–2716.
25.
JonesCP.Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health2000;90(8):1212.
KilbourneAM, SwitzerG, HymanK, Crowley-MatokaM, FineMJ.Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health.2006;96(12):2113–2121.
28.
Stata: Statsitics/Data Analysis [computer program]. College Station: StatCorp LLC; 2017.
29.
R: A language and environment for statistical computing [computer program]. Vienna, Austria: R Foundation for Statistical Computing; 2018.
30.
WickhamH, AverickM, BryanJWelcome to the tidyverse. Joss. 2019;4(43):1686.
31.
WickhamH.The split-apply-combine strategy for data analysis. J Stat Soft.2011;40(1):i01.
32.
FoxJ, WeisbergS.An [R] Companion to Applied Regression, Third Edition. Vol 2. Thousand Oaks, CA: SAGE Publications; 2019.
33.
dplyr: A Grammar of Data Manipulation. [computer program]. Version R package version 0.8.32019; 2019.
34.
icd: Comorbidity Calculations and Tools for ICD-9 and ICD-10 Codes [computer program]. 2019.
35.
DormannCF, ElithJ, BacherSCollinearity: a review of methods to deal with it and a simulation study evaluating their performance. Ecography2013;36(1):27–46.
36.
FagerlandMW, HosmerDW.A generalized Hosmer–Lemeshow goodness-of-fit test for multinomial logistic regression models. Stata J.2012;12(3):447–453.
37.
AndersenR.Nonparametric methods for modeling nonlinearity in regression analysis. Annu Rev Sociol.2009;35(1):67–85.
38.
RogersW.Regression standard errors in clustered samples. Stata technical bulletin1994;3(13).
39.
ManhapraA, StefanovicsE, RosenheckR.Initiating opioid agonist treatment for opioid use disorder nationally in the Veterans Health Administration: who gets what?Subst Abus.2020;41(1):110–120.
40.
FinlayAK, HarrisAH, TimkoCDisparities in access to medications for opioid use disorder in the Veterans Health Administration. J Addict Med.2021;15(2):143–149.
41.
EssienUR, SileanuFE, ZhaoXRacial/ethnic differences in the medical treatment of opioid use disorders within the VA healthcare system following non-fatal opioid overdose. J Gen Intern Med.2020;35(5):1537–1544.
42.
ManhapraA, QuinonesL, RosenheckR.Characteristics of veterans receiving buprenorphine vs. methadone for opioid use disorder nationally in the Veterans Health Administration. Drug Alcohol Depend.2016;160:82–89.
43.
ManhapraA, PetrakisI, RosenheckR. Three-year retention in buprenorphine treatment for opioid use disorder nationally in the Veterans Health Administration. Am J Addict.2017;26(6):572–580.
44.
MarchandK, BeaumontS, WestfallJConceptualizing patient-centered care for substance use disorder treatment: findings from a systematic scoping review. Subst Abuse Treat Prev Policy.2019;14(1):37.
45.
GryczynskiJ, SchwartzRP, SalkeverDS, MitchellSG, JaffeJH.Patterns in admission delays to outpatient methadone treatment in the United States. J Subst Abuse Treat.2011;41(4):431–439.
46.
CioeK, BiondiBE, EaslyR, SimardA, ZhengX, SpringerSA.A systematic review of patients’ and providers’ perspectives of medications for treatment of opioid use disorder. J Subst Abuse Treat.2020;119:108146.
47.
ProG, ZallerN.Interaction effects in the association between methadone maintenance therapy and experiences of racial discrimination in US healthcare settings. PLoS One.2020;15(2):e0228755.
48.
PriestKC, EnglanderH, McCartyD. Now hospital leaders are paying attention: a qualitative study of internal and external factors influencing addiction consult services. J Subst Abuse Treat.2020;110:59–65.
49.
SametJH, BotticelliM, BharelM. Methadone in primary care – one small step for congress, one giant leap for addiction treatment. N Engl J Med.2018;379(1):7–8.
50.
CalcaterraS, BachP, ChadiAMethadone matters: what the United States can learn from the global effort to treat opioid addiction. J Gen Intern Med.2019;34(6):1039–1042.
51.
HHS Releases New Buprenorphine Practice Guidelines, Expanding Access to Treatment for Opioid Use Disorder [press release]. 2021.
52.
JordanA, MathisML, IsomJ.Achieving mental health equity: addictions. Psychiatr Clin North Am.2020;43(3):487–500.
53.
JordanA, BabuscioT, NichC, CarrollKM.A feasibility study providing substance use treatment in the Black church. J Subst Abuse Treat.2021;124:108218.
54.
WenH, HockenberryJM, BordersTF, DrussBG.Impact of medicaid expansion on medicaid-covered utilization of buprenorphine for opioid use disorder treatment. Med Care.2017;55(4):336–341.
55.
EarpBD, LewisJ, HartCL.Racial justice requires ending the war on drugs. Am J Bioethics.2021;2021:1–29.
56.
CulbertL. Fumano D. B.C. to offer Canada's first, permanent safe drug supply in response to overdose crisis. Vancouver Sun. 2021.
57.
BluthenthalRN.Structural racism and violence as social determinants of health: conceptual, methodological and intervention challenges. Drug Alcohol Depend.2021;222:108681.
58.
GliedS, Lleras-MuneyA.Technological innovation and inequality in health. Demography2008;45(3):741–761.
59.
AtkinsR.Instruments measuring perceived racism/racial discrimination: review and critique of factor analytic techniques. Int J Health Serv.2014;44(4):711–734.
60.
GroosM, WallaceM, HardemanR, TheallKP.Measuring inequity: a systematic review of methods used to quantify structural racism. J Health Disparit Res Pract2018;11(2):13.
61.
ChengHG, PhillipsMR.Secondary analysis of existing data: opportunities and implementation. Shanghai Arch Psychiatry.2014;26(6):371–375.
62.
National Academies of Sciences E, Medicine. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press; 2017.
63.
KlingerEV, CarliniSV, GonzalezIAccuracy of race, ethnicity, and language preference in an electronic health record. J Gen Intern Med.2015;30(6):719–723.
64.
KingC, EnglanderH, PriestKC, KorthuisPT, McPhersonS.addressing missing data in substance use research: a review and data justice-based approach. J Addict Med.2020;14(6):454–456.
65.
NoblesM.History counts: a comparative analysis of racial/color categorization in US and Brazilian censuses. Am J Public Health.2000;90(11):1738–1745.
66.
EnglanderH, KingC, NicolaidisCPredictors of opioid and alcohol pharmacotherapy initiation at hospital discharge among patients seen by an inpatient addiction consult service. J Addict Med.2020;14(5):415–422.
67.
JoudreyPJ, ChadiN, RoyPPharmacy-based methadone dispensing and drive time to methadone treatment in five states within the United States: a cross-sectional study. Drug Alcohol Depend.2020;211:107968.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
