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Race, Economic Divides Emerge on Opioid Treatments

Dispensing pills

(Defense.gov)

9 May 2019. A new study highlights sharp differences by race and funding of prescriptions for buprenorphine, a promising treatment for opioid use disorder. A team from University of Michigan in Ann Arbor reports its findings in yesterday’s issue of the journal JAMA Psychiatry (paid subscription required).

The U.S. is in the midst of a large and growing public health emergency from prescription opioid drug abuse, as well as heroin and fentanyl sold on the street. National Institute on Drug Abuse reports overdose deaths from these drugs this year number more than 130 per day. A report by the National Academies of Sciences, Engineering, and Medicine in July 2017 spells out the full scope of the crisis beyond overdose deaths, with some 2 million Americans age 12 and older addicted to prescription opioid drugs and another 600,000 addicted to heroin.

Researchers from Michigan’s medical school and related departments, led by health services researcher Pooja Lagisetty, looked at patterns of prescribing the drug buprenorphine in response to this epidemic. Buprenorphine acts on the same receptors in the brain as opioids, providing enough satisfaction of those receptors without producing the intense “high” or serious adverse effects of abused drugs. It is one of 3 drugs now approved to treat opioid use disorder, and while new prescriptions must be written for each refill, buprenorphine can be taken at home, instead of dispensed at a clinic like methadone or naltrexone injections.

Lagisetty and colleagues sampled records from 2 national surveys of ambulatory care representing office and out-patient clinic visits, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, from 2004 to 2015. The researchers focused on visits where physicians prescribed buprenorphine, which overall were less than 1 percent of all ambulatory visits, but still rose in relative terms from 0.04 percent in 2004 to 0.36 percent in 2015. Despite those small percentages, between 2012 and 2015, some 13.4 million office or clinic visits occurred where buprenorphine was prescribed.

In that same 2012 to 2015 period, the vast majority of those receiving buprenorphine prescriptions were white. Some 12.7 million white patients were given buprenorphine prescriptions, compared to 363,000 for all other ethnicities, a ratio of 35 to 1. Those racial and ethnic discrepancies also increased since 2004. “We shouldn’t see differences this large,” says Lagisetty in a university statement, “given that people of color have similar rates of opioid use disorder.”

In addition, the way patients paid for office or clinic visits with buprenorphine prescriptions changed to some extent from 2004 to 2015. Over this period, more people paid for visits with buprenorphine prescriptions out of their own pocket than any other method, changing little from 38 to 40 percent. However, patients using private insurance for these visits rose from 20 percent in 2004 to about one-third (34%) in 2015. Yet at the same time, patients with Medicare and Medicaid as a percentage of buprenorphine recipients declined from 32 percent in 2004 to 19 percent in 2015. The data do not indicate how the medications themselves were funded.

States that expanded Medicaid coverage for 17 million more Americans in recent years may help gain access to buprenorphine for more lower-income people with opioid use disorder, but only if clinics accept Medicaid payments. “Cash-only buprenorphine clinics have proliferated in recent years,” notes Lagisetty, “which may be expanding access for those with the means to pay in certain regions.”

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