Racial Differences in Opioid Use Disorder

SUMMARY POINTS

• Race influences the treatments of opioid use disorders.
• There is an opioid crisis and a health disparities crisis.
• Racial equity should include increasing access for treatment, funding harm reduction programs and expanding community-based services such as employment, housing, and recovery support for those with opioid use disorder. 

ANALYSIS

Background

The United States listed the opioid crisis as a public health emergency (1). Concurrently, the United States has a racial health disparities crisis that is evident as patients from various races receive different health care treatments (2). The opioid crisis has impacted all racial groups, with incidence rates of 11.9, 9.3%, and 9.6% in the White, Black, and Hispanic populations, respectively(3). 

Multiple studies have listed that racial disparities in pain treatment are associated with lower opioid use in minority patients during the beginning of liberalized opioid use in clinical settings (4). Disparities in pain treatment usually involve decreased access to medication by the patients, and biases in pain assessment and management by healthcare providers; and differential workers compensation for pain-related claims (5). A meta-analysis utilizing data from  1989-2011 found that Hispanic and Black patients had a 22% and 30% lower rate of obtaining an opioid prescription compared to white patients, respectively (5). In 2010, due to better regulation of opioid prescriptions, heroin use and other synthetically produced opioids increased, leading to a crisis of opioid related deaths (6).

Opioid Use Disorder (OUD) is the chronic use of opioids that leads to habitual drug seeking and includes reduced self-control, participation in risky behavior and social impairments (7). Although treatment for OUD, discrimination continues to affect the care provided to the minority population (7). It is known that treatment for OUD can reduce the overdose rate, increase patient involvement in addiction programs when discharged and decrease overall health care utilization (8). Unfortunately, communities that have a higher number of Black and Hispanic residents have reduced health care resources that can provide the recommended interventions for OUD. When controlling for factors such as overdose burden, socioeconomic status and hospital risk factors; minority communities are still less likely to have access to essential harm reduction services(8). 

FIGURE 1: U.S Drug Overdose death rate 

[SEE ARTICLE from the CDC]

Analysis

Only 20% of patients with OUD get treatment despite the studied benefits such as reduced risk of mortality (10). Research has shown that racial minorities are less likely to obtain treatment for OUD from health care providers when compared to white counterparts(8). In 2019, Black and Hispanic with diagnosed OUD were 30% less likely than White patients to be offered treatment (11). 

There have been numerous public strategies taken to improve opioid misuse. Unfortunately, public health campaigns primarily focus on White communities and ultimately decreased the rate of OUD and opioid related death for White patients alone rather than the combination with minority patients (12). As a result of minority patients receiving less community support and resources for OUD, individuals resort to self-medicating with fentanyl and heroin which increases opioid misuse within these populations (12). In 2019, opioid related mortality rates decreased by 0.3% in White patients but increased by 20% in Black patients (13). 

A quantitative analysis on the intersection of race and opioid use disorder treatment observed how race influences treatment for OUD. This study used patient information from the Treatment Episode Data Set Discharges (TEDS-D), a nationwide study utilizing data of patients discharged from substance use disorder (SUD) treatment programs (14). The dataset includes information on treatment episodes and admissions to SUD treatment programs including programs in public and privately owned facilities. TEDS-D also included information from institutions such as state prisons. The study only used information from patients with a DSM-IV diagnosis of OUD between 2013 to 2017. From this data, researchers observed that being a minority is linked with a reduced chance of being referred to treatment by a healthcare worker. Data also showed that compared to their White counterparts, minority patients had a reduced likelihood of receiving appropriate OUD medication as part of the treatment plan. This study, as with many others, concluded that change is required to address this problem. This study primarily focused on policymakers and how to implement these findings to create interventions for OUD that acknowledge race. Public health interventions could help to address the discrepancies in treatment gaps that this study identified.

Discussion

Additional studies are needed to develop more efficacious strategies to address race for OUD. Across multiple studies, it is noted that areas with more economic instability and distress reported higher drug use. There are other factors discussed such as income, housing instability, transportation, insurance, biases, and mistrust in the healthcare system that influence access to treatment. Interventions in the local, state, and national policy levels are critical to tackle these issues. 

Interventions such as linkage and retention in care while not criminalizing patients with OUD and access to treatment and harm reduction services are beneficial in minority communities. Ultimately, intervention and prevention strategies must include evidence based and culturally receptive tools that use social determinants of health to reduce biases surrounding treatment. These tools include culturally targeted campaigns and hiring community prevention liaisons or ambassadors to assist with decreasing mistrust and increasing accessibility to treatment and reduction services. Opioid misuse is preventable. Integrating efforts with an emphasis on childhood experiences that increase the risk for OUD, as well as applying trauma-informed care, is essential for improving minority communities that have been affected by years of discriminatory policies.