This was a study of specialty treatment for opioid use disorders (OUDs) in publicly funded programs in the U.S. Investigators at Johns Hopkins who turned up this unexpected finding published their study online July 11 and in the September 1 issue of Drug and Alcohol Dependence.
(The term “specialty treatment programs” includes publicly or privately state-funded facilities licensed or certified by the local U.S. Substance Abuse Agency to provide substance abuse treatment in that state. Facilities that report data generally are those that receive drug agency funds from the state for providing drug treatment services).
Background
Opioid agonist treatment (OAT) is the standard of care in OUDs, yet most people in treatment—more than two-thirds of those whose data are included in this study—are not receiving it.
The authors wondered if racial or ethnic differences, or both, accounted for the differences in OAT receipt, or if other factors, such as differences in clinical need, were involved. They noted that several factors often interfere with the inclusion of medication into “traditional substance use care,” and patients’ access to treatment may be hindered by regulatory barriers and by medication-stigma. Moreover, methadone treatment often involves long waiting lists and extensive travel, and buprenorphine access tends to be limited, because certified providers are in short supply.
The Study
In this study of 94,202 patients, investigators used data from the 2014 Treatment Episode Dataset (TEDS-A).
They wondered:
- Are there racial or ethnic differences in the proportion of patients given OAT?
- If so, to what extent are they explained by differences in clinical need?
(The term clinical need refers to factors that help a clinician decide whether to treat a patient for a given condition. For example, a clinician might decide that a patient who frequently injects opioids should be given priority status for agonist treatment.)
- When differences aren’t due to clinical need, how important are treatment setting and other factors?
- Are racial/ethnic differences similar in the “heroin” and “other opioids” groups?
Characteristics of Clinical Need
| Heroin use | Heroin users may be more likely to use OTPs that offer agonist treatment |
| Older age | Agonist treatment may be a less likely choice for younger patients |
| More frequent use; Route of use |
Those who inject or use substances more frequently, with apparent or actual higher severity of disorder, may be more likely to be given agonist treatment |
| Use of benzodiazepines or alcohol | Could be considered a contraindication for agonist treatment |
Study Results
The following table summarizes key data from the study, including patients’ race and ethnicity, percentage of the study population, OAT receipt, primary opioid, and type of facility where patients received treatment.
Patients’ Characteristics, by Race and Ethnicity
| Characteristics(%) | White (76.7) |
Black (9.9) |
Hispanic (13.4) |
Total N = 94,202 |
|---|---|---|---|---|
| OAT Receipt | 25 | 43 | 39.8 | 28.7 |
| Primary Opioid | ||||
| Heroin Other |
54.9 45.1 |
76.7 23.3 |
75.5 24.5 |
59.8 40.2 |
| Outpatient | ||||
| Non-intensive Intensive |
44.1 9.8 |
50.7 13.7 |
50.3 6.0 |
45.6 9.7 |
| Residential | ||||
| Hospital Short-term Long-term |
0.3 8.8 5.4 |
0.1 6.9 6.6 |
0.1 5.8 7.4 |
0.3 8.2 5.8 |
| Detoxification | ||||
| 24-hour Ambulatory |
27.3 4.3 |
17.4 4.5 |
20.2 10.1 |
25.4 5.1 |
All values are statistically significant. (See the published reference for the complete table.)
As the table shows, blacks and Hispanics had a much higher likelihood than whites of receiving the preferred (agonist) treatment: 43% and 39.8%, vs. 25% for whites. The differences were evident only for those who used primarily heroin rather than other opioids.
Clinical need factors—such as heroin use—accounted for about three-fourths of the difference in the number of blacks and whites receiving OAT. The clinical factors also accounted for about half the difference in Hispanic vs. white patients. Another important factor: characteristics of the setting. Patients in ambulatory detoxification and non-intensive outpatient treatment were far more likely to be given agonist treatment than those in other settings.
Yet heroin use and other clinical factors did not completely explain the surprising finding mentioned earlier—that white OTP patients who use heroin are less likely than other patients to receive OAT. This finding contrasts with other research results, and the authors point out that it was not foreseen, in that minorities often receive a lower standard of health care than white patients. Additional studies are needed to account for the remaining differences.
Conclusions
Noting that OAT is considered the standard of care for patients with OUD, the authors found its underuse concerning. They commented that agonist therapy is the treatment recommended by federal government agencies, the recent Surgeon General, and SAMHSA, making it “ever more pressing that programs receiving public funding be held to treatment standards and be given the tools to administer evidence-based treatment that can help mitigate the harms of the ongoing opioid epidemic.”
This study emphasizes the need for improving patient care by making OAT available to more patients, especially white patients whose primary substance of use is heroin.
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Reference
Krawczyk N, Feder KA, Fingerhood MI, Saloner B. Racial and ethnic differences in opioid agonist treatment for opioid use disorder in a U.S. national sample [published online ahead of print July 11, 2017]. Drug Alcohol Depend. 2017;178:512-518. doi:10.1016/j.drugalcdep.2017.06.009.
