Disparities in Health Care Hinder Access to MAT

Last spring a study published in JAMA Psychiatry made headlines when researchers found that whites were roughly four times more likely than blacks to receive a prescription for buprenorphine during an outpatient visit. This study followed on the heels of one published late last year in the Journal of Substance Abuse Treatment (JSAT) that found that underdosing of methadone was more common in treatment programs that served proportionately more blacks than whites. Taken together, these two studies illuminate racial disparities in two key areas of medication treatment for opioid use disorder (OUD): use and practice.

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“In a way, the results are not surprising because disparities are well documented for access, quality of care, outcomes, and overall health of minority populations in the U.S., especially for African Americans,” said Thomas D’Aunno, Ph.D., lead author of the JSAT paper. D’Aunno, the director of the Health Policy and Management program at the Wagner Graduate School of Public Service at New York University, has been researching the demographics of methadone treatment since the turn of the century.

“Over time, there has been a significant improvement in dose levels and disparity [in access], but both are still in need of improvement. That’s what the buprenorphine study shows, as well,” D’Aunno told Psychiatric News.

One underlying reason for the disparity may be that clinics that serve predominantly black patients may lack adequate resources, D’Aunno said.

“The clinics where African Americans go might be understaffed. The managers and staff might be less current on best practices and might lack the resources to improve the quality of care,” D’Aunno said. “For example, they may not have electronic medical records and may be unable to see what doses patients have been getting and what else they are taking.”

Insufficient resources may extend to the patients’ resources, particularly for treatment with buprenorphine. The JAMA Psychiatry paper found that from 2012 to 2015, patients paid out of pocket for nearly 40% of buprenorphine-related outpatient visits. Private insurance paid for 34% of buprenorphine-related outpatient visits, whereas Medicaid and Medicare paid for only 19% of such visits.

“Payment could be a major barrier for individuals with low financial resources who may not have cash or private insurance,” said lead author Pooja A. Lagisetty, M.D., M.Sc., an assistant professor in the Division of General Medicine at the University of Michigan. She added that cash-only buprenorphine clinics have proliferated in recent years, expanding access for those with the ability to pay.

Yet even where there may be a reasonable expectation of equal access, such as the Veterans Health Administration (VHA), there remain key differences in how blacks and whites receive medication treatment for OUD. A 2016 study in Drug and Alcohol Dependence found that blacks and other ethnic and racial minorities were more likely to receive methadone than buprenorphine compared with whites. A year later, a study in The American Journal on Addictions reported that black VHA patients were less likely to still be in treatment three years after initiating buprenorphine than white patients.

“You would think that the racial dynamics would be equalized at the VA because all veterans have access to VA services, but the study showed there’s still a pattern of difference in treatment,” said Helena Hansen, M.D., Ph.D., an associate professor in the Departments of Anthropology and Psychiatry at New York University, who was not involved in the research.

The Evolution of a Divide

The authors of the study in Drug and Alcohol Dependence wrote that the racial enrollment patterns for methadone treatment that were established before buprenorphine was approved for treating OUD remain largely unchanged, even though buprenorphine treatment has become more common. Hansen attributes these patterns to the different ways that OUD treatment evolved for blacks and for whites beginning in the 1970s.

“[President] Nixon’s war on drugs was aimed at black and brown inner cities. Buprenorphine was developed for a very different demographic,” Hansen said. She explained that the epidemic of prescription opioid misuse began in areas that were predominantly white, where people could afford the pills, so the treatment for that demographic was marketed differently.

“For the ‘suburban opioid problem,’ methadone was not deemed an appropriate response. Methadone was for ‘hardcore’ and ‘urban’ heroin use. It was cast in race- and class-coded language,” Hansen said. In other words, the presumption was that “suburban” pertained to middle-class whites, and “hardcore” and “urban” pertained, pejoratively, to blacks and other minorities.

There is another dilemma, however: Even though methadone treatment is available at low or no cost through Medicare and Medicaid, thus removing cost barriers, several studies have established that blacks are less likely to begin and maintain medication treatment for OUD than whites.

“Some of the answer may lie in a lack of trust,” said Andrew J. Saxon, M.D., a professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington and director of the Center of Excellence in Substance Abuse Treatment and Education at VA Puget Sound Health Care System.

“After many painful experiences of racism in the health care system, it could be that black patients are somewhat wary of taking a prescribed medication that produces physiologic dependence,” said Saxon, who is a member of APA’s Council on Addiction Psychiatry. He added that these experiences hark back to the Tuskegee Study of Untreated Syphilis in the Negro Male, a clinical study conducted between 1932 and 1972 by the U.S. Public Health Service in which participants were not told the true nature of the study and were not treated even after penicillin was shown to be effective.

Hansen said that the way methadone clinics were established in the 1970s also plays a role.

“The requirements for urine tests, the facilities that look like prisons or jails—these things understandably roused suspicion in black leaders for a medication that could be used an instrument of social control. The context is extremely important,” Hansen said.

Closing the Chasm

If history reveals the reasons for racial disparities in medication treatment for OUD, it may also point the way to solutions. Where the government failed in making methadone treatment palatable to the black community, one man succeeded: Beny Primm, M.D., a black physician who started several of New York City’s first methadone clinics. Primm later rose to prominence for his expertise in addiction treatment and HIV/AIDS and served in the presidential administrations of Ronald Reagan and George H. W. Bush.

Primm was able to introduce methadone treatment in predominantly black neighborhoods like Harlem because of his good standing in the community, and his success sprang from his comprehensive approach, Hansen said.

“His clinic became a network of clinics staffed by black providers in communities with black leaders. The clinics included education, counseling, and job placement, and they worked hard to address the context of methadone,” Hansen said.

Primm’s success illuminates the need for diversity among physicians and other health care professionals. “We need a cadre of health care professionals who reflect the racial and gender makeup of our society,” Saxon said. “Particularly for the physician workforce, a robust affirmative action plan is essential so that we have many more black physicians and psychiatrists in particular.”

D’Aunno called for stronger enforcement of mental health parity laws—legislation that covers treatment for mental illness on par with that of other medical illnesses—which would help address the problem of limited resources and allow greater access to care through appropriate insurance coverage.

Lagisetty also called for nationwide efforts.

“All programs and providers should be asking themselves if they feel they are providing evidence-based care equitably to all of their patients. If the answer is no, we need to change this,” she said. “This may include policies and resources to provide the appropriate education and resources to reduce bias and stigma among providers and members of the community, adequate reimbursement, and regulatory oversight to make sure we are providing high-quality, equitable care to all populations.”

On an individual level, psychiatrists and mental health professionals need to look within and examine their attitudes with respect to race, said Saxon.

“Each one of us needs to make strenuous efforts every day to observe our own behavior, especially toward our patients, and try to alter any racist components of our thoughts,” Saxon said. ■