Health Equity in Opioid Dependency Treatment: Differences in Opioid Treatment for Black and Latino Patients

September 22, 2020

Each day in the United States, 128 people die from opioid overdose—that’s 67,367 people who died from overdose in 2018, an increase of 57% from 2010. In 2017, the US Department of Health & Human Services (HHS) declared opioid addiction a public health emergency.

Opioid overdose deaths by race/ethnicity in 2018 were 76% non-Hispanic White; 13% non-Hispanic Black; and 9% Hispanic. But these numbers don’t paint the full picture. Concurrent with the rise of synthetic opioids, the overdose death rates for Black and Hispanic populations have significantly risen.

Who is most likely to use opioids?

Really anyone. Though the current opioid epidemic seems to harm young and middle-aged White men the most, there are disparities in how this data is collected and presented. And further, the current opioid misuse demographics don’t take into account the population of Black and Latino Americans in prison due to the “War on Drugs” in the 1990s and early 2000s, which criminalized rather than medically treated people for opioid addiction—a striking demonstration of health inequity.

Risk factors for opioid addiction include the following: poverty, unemployment, family and/or personal history of substance misuse, regular contact with high-risk people and environments, history of severe depression or anxiety, and stressful circumstances.

What are the demographics of America’s opioid epidemic?

During the first wave of the opioid epidemic in the United States, from 1979 to the mid-1990s, the epidemic affected Black and White Americans fairly equally and was largely driven by heroin. 

Then, pharmaceutical companies began marketing prescription opioids like morphine, hydrocodone, and oxycodone for treatment of chronic pain in White rural areas in the 1990s, which ultimately changed medical standards for how we diagnose and treat pain. This resulted in increased mortality among Whites, while mortality for Black Americans stayed constant. 

The next wave of the epidemic began in 2010, with rapid increases in overdose deaths involving heroin (after many people became addicted to opioids in the 1990s with the rapid influx of available prescription opioids).

The current wave of the opioid epidemic began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly fentanyl. Fentanyl is often found within heroin, counterfeit pills, and cocaine, and many people don’t realize they’ve used fentanyl until it’s too late. Fentanyl overdose rates are currently rising at 79% per year for Whites and 107% per year for Black Americans.

Research demonstrates that medical providers are twice as likely to prescribe opioids to White patients as compared to Black patients, largely due to implicit (or explicit) biases and lack of sensitivity to Black patients’ pain. Dr. Andrew Kolodny, Director of Opioid Policy Research at Brandeis University, states that, “The Black patient is less likely to become addicted to opioids because they’re less likely to be prescribed,” which is a critical point given prescription opioid misuse is a substantial risk factor for heroin use. 

But recently, the overdose death rates for Black and Hispanic populations have significantly risen, largely due to synthetic opioids like fentanyl. From 2013-2017, non-Hispanic Blacks experienced an 18-fold increase in mortality due to synthetic opioids (other than methadone), compared to a 12.3-fold increase for Hispanics, and 9.2-fold increase for non-Hispanic Whites.

And further, American Indian and Alaska Native (AI/AN) populations had the second highest opioid overdose rates in 2017 (15.7 deaths/100,000 population) and 2018 (14.2 deaths/100,000 population), second only to non-Hispanic Whites. This ethnic disparity is often overlooked, as not all data sets appropriately separate racial/ethnic data to represent Indigenous populations.

What is health equity?

Health equity means that all people have the opportunity to be as healthy as possible… but health is not created equally. In order for all people to have this opportunity, we must remove barriers to good health… that is, people need homes, healthy foods, stable employment, access to medical care and education, and more. When the US finally addresses the underlying conditions that truly affect health, then we’ll live in a more health equitable society.

What are health disparities?

Health disparities are preventable differences in health outcomes between different groups of people. And these disparities span various identities, such as race/ethnicity, sexual orientation, gender identity, socioeconomic status, age, disability status, geographic location, and more.

Why do health disparities exist?

Health disparities largely exist due to disinvestment in the underlying conditions that truly shape health—the social determinants of health—like supportive housing, healthy foods, education, early childhood care, stable employment, the environment, and public health practice itself. Instead, the US spends more money on medical, curative care compared to its peer nations, rather than on the social drivers of health.

Health disparities in treatment for opioid addiction: buprenorphine/naloxone (Suboxone) is concentrated among White patients

White patients who self-pay or use private insurance accounted for nearly 74% of buprenorphine prescriptions from 2012-2015. Accordingly, during this time period, there were 12.7 million buprenorphine visits for White patients, compared to 363,000 visits for minority patients. White patients are 35 times more likely to be prescribed buprenorphine/naloxone (Suboxone) than non-White patients, though rates of opioid addiction are not dramatically different among races. And further, research shows that minority patients are significantly less likely than White patients to be retained in buprenorphine treatment one year later. 

Another study demonstrates that minority patients are more likely to be prescribed methadone than buprenorphine/naloxone (Suboxone)—an important disparity, given buprenorphine is widely considered to be safer than methadone with decreased risk for sedation and overdose.

Moreover, buprenorphine/naloxone (Suboxone) can be prescribed by licensed and trained medical providers in any treatment setting, whereas methadone is strictly regulated by the government and can only be provided through federally licensed outpatient treatment programs. Thus, for minority patients who are more frequently prescribed methadone, this makes access to evidence-based treatment even harder.

This encapsulates the current state of health inequity in America—but we can, and must, do better.

What is Bicycle Health’s role in addressing health equity?

Here at Bicycle Health, our providers, staff, and leadership recognize these health disparities, and as a healthcare organization, we’re committed to a more equitable approach to buprenorphine treatment. As we seek to address disparities in opioid addiction and access to evidence-based treatment, Bicycle Health will continue to support local, state, and national-level policies that address the social influencers of addiction, as well as work to dismantle the structural racism that underlies the health disparities discussed here.

Amidst the opioid epidemic, it’s vital that health professionals, researchers, advocates, and policymakers work together to address these health disparities.

Telemedicine has the exciting potential to alleviate health disparities—by removing geographic barriers, no time needed off from work, no childcare needed, no transportation fees, decreased stigma when seeking treatment in the privacy of one’s home, and more. You can read more about the role of telemedicine here.

Bicycle Health providers, staff, and leadership are committed to you, our patients. To learn more about how Bicycle Health’s model seeks to make buprenorphine treatment more accessible and equitable for all, feel free to read more about how it works, or communicate with a team member by emailing us at coach@bicyclehealth.com.

Header image by KSRE Photo under a Creative Commons Attribution 2.0 Generic license.

About the Author

Rebekah L. Rollston, MD, MPH

Dr. Rollston is a Family Medicine Physician at Cambridge Health Alliance, Affiliate Editor-in-Chief of the Harvard Primary Care Blog, and Founder of Doctors For A Healthy US, LLC. She earned her Medical Degree from East Tennessee State University Quillen College of Medicine and her Master of Public Health from The George Washington University. Her professional interests focus on social influencers of health & health disparities, addiction medicine, sexual & reproductive health, homelessness & supportive housing, and rural health.

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