Systemic disparities in access and treatment are causing needless deaths in communities of color. It’s time we made things right.
The data on addiction treatment makes three things clear: First, Black people are less likely than Whites to receive treatment for opioid use disorder (OUD).[1] Second, when Black people do get treatment, their time in treatment is shorter than for White patients, which decreases the effectiveness of treatment.[2] Note: We’ve known for years that longer lengths of stay in addiction treatment are associated with better long-term outcomes.
And third, when Black patients receive medication for OUD—often called “MOUD”—they are more likely than White patients to be prescribed methadone, whereas white patients are more likely to receive buprenorphine (Suboxone).[3] [4] These two well-known MOUDs are comparable in terms of medical efficacy, but the ways they are obtained and administered are strikingly different.
The two-tiered system for obtaining MOUD
A person on methadone needs to go to a certified opioid treatment program three to five days a week to obtain their dose of methadone. Often these clinics are understaffed, and wait times can be long. This interferes with a person’s ability to be present at work, or care for kids at home. All of which significantly impacts the quality of life for those who need methadone to keep their potentially fatal addiction in remission.
Contrast that to buprenorphine. Any outpatient doctor who has a buprenorphine “waiver” can prescribe this medication to a patient with OUD. Many of these providers are cash pay or only take private insurance—thus those with public insurance are cut out. The patient takes their buprenorphine prescription to their pharmacy, and walks out with their monthly supply. The meds can be taken in the comfort of their own home without any travel time to a clinic or wait time once there. Therefore there is little disruption to work or home life.
Given those logistical realities, it’s no wonder that a person on methadone—more likely a Black person than a White person—is less apt to even start their MOUD treatment, never mind continue it to the point of sustainable remission from OUD.
There’s another prescribing and reimbursement glitch that further compounds this disparity. In certain states, many physicians who are authorized to prescribe buprenorphine only take private insurance or self-pay. This means it’s harder to find an addiction specialist who takes Medicaid or Medicare. The cited reason many addiction psychiatrists or addiction medicine doctors don’t take Medicaid is because Medicaid reimbursement rates are far lower than with private insurance, which itself tends to be lower than cash pay rates.
Related inequities in our healthcare system
There’s a long history of neglect by the predominantly white medical establishment when it comes to medical school training, the medical research that is done, and the medical care received by people of color.
In the hospital or in a doctor’s office, we practitioners often don’t have the training or don’t take the time to truly meet people where they are and speak to them in a meaningful, empathetic, and culturally attuned manner. There’s also the ongoing problem of disparate educational opportunities and disproportionately low rates of admission and matriculation of black people from medical schools, which perpetuates the predominantly white physician workforce.
The Black community has a long-standing, justifiable mistrust of the medical community, in part because of racist practices ranging from micro-aggressions to outright abuse. Take for example the Tuskeegee Study of Untreated Syphilis in the Negro Male. This abhorrent experiment wasn’t shut down until 1972 after continuing for four decades as a way to “observe the natural history of untreated syphilis,” as the CDC describes it on its web page.
Until Black people have equal access to specialty providers—including in the mental health and addiction treatment setting—the disparities we see in OUD treatment will persist. Along with equity in access, people of color deserve medical care that accounts for a person’s history, trauma (including intergenerational, racialized trauma), and culture.
It is the responsibility of the predominantly white medical community to develop that cultural competency and to make the effort to understand their patients’ cultural reality. Or at the very least, to acknowledge what they as providers don’t know or can’t ever know experientially. It is the responsibility of the medical and policy establishments to impact the social determinants of health associated with the treatment disparities under discussion here.
So often, however, these actions and responsibilities are not taken up by those in positions to do something about them. Rather, the can gets kicked down the road, the disparities persist, and the treatment gaps widen.
5 ways to make addiction treatment more equitable
I offer the following as solutions:
- Bring more parity to insurance reimbursements. If people on Medicaid or Medicare can’t get access to buprenorphine because the local doctor who prescribes it only takes private insurance, that’s a problem. Federal or state governments could remedy this by raising Medicaid and Medicare reimbursement rates to approximate private insurance rates—currently they are a small fraction. They could also reduce the administrative burden of public insurance, thereby making it more attractive to more providers, including smaller practices that don’t have the staff to handle all the paperwork.
- Require cultural competency in medical education. The problem of whiteness in medicine and lack of diversity of providers is a major hurdle to overcome. But it must be done. Medical and academic institutions taking an active role in examining and dismantling systemic racism and unconscious bias in their organizations is a necessary starting point.
- Develop community-based outreach strategies to teach people about addiction and addiction treatment. Large-scale, one-size-fits-all media campaigns on addiction and addiction treatment often do not resonate with Black communities and other communities of color. We need to be smarter and more targeted with our messaging. People have to see themselves in these efforts.
- Use trusted messengers who are already in place to spread the word. Related to bullet #3 above, top-down promotional campaigns from large advocacy groups don’t always reach their audience. Or they’re not seen as trustworthy or culturally relevant. Better to tap into trusted people in the community to get the word out about addiction, treatment, evidence-based medication options, and so on. This means religious leaders, community organizers, labor union reps, barbers and hairdressers, local celebrities, and community members in recovery.
- Make buprenorphine more accessible via existing MOUD distribution channels. With methadone clinics already in place, for example, it makes sense to promote and prescribe buprenorphine at these centers. Many people with OUD opt for methadone because they think it’s the only option, or the best option, or the closest option to where they live. Emergency room doctors are often the first providers to prescribe buprenorphine after treating someone for an overdose. At those moments, linkage to ongoing treatment is the first step to building a sustainable recovery.
Look in the mirror and start with your own workplace
We in the healthcare field need to look honestly at ourselves and the medical institutions and practices we belong to. Listen to the experiences and voices of your Black colleagues and patients. When we recognize our biases and own our role in the problems, we can take steps to bring about change.
Ask yourself, who are you not serving and why? Whose voices are you not hearing or centering, and why? Can you attract more diverse clinicians to your practice or institution? What are the barriers to that, and how can they be removed?
Can you bring in leadership-level staff with diverse backgrounds to be meaningfully involved in decision making within your practice?
If you are not authorized in your organization to make the above-mentioned changes, are you speaking up about them? If not, why not?
Making these sorts of changes, and speaking up when that is necessary, are difficult but necessary things to do. Physicians took an oath to “first, do no harm,” but silence is harm. As is inaction.
It’s time to move forward to correct these disparities. The lives of our patients from communities of color depend on it.
References
1. https://store.samhsa.gov/sites/default/files/pep20-05-02-001.pdf, pp.7-8
2. https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2798512
3. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2732871
4. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2764663
