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Racial and Ethnic Inequities in Buprenorphine and Methadone Utilization Among Reproductive-Age Women with Opioid Use Disorder: an Analysis of Multi-state Medicaid Claims in the USA

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Abstract

Background

Associations between race/ethnicity and medications to treat OUD (MOUD), buprenorphine and methadone, in reproductive-age women have not been thoroughly studied in multi-state samples.

Objective

To evaluate racial/ethnic variation in buprenorphine and methadone receipt and retention in a multi-state U.S. sample of Medicaid-enrolled, reproductive-age women with opioid use disorder (OUD) at the beginning of OUD treatment.

Design

Retrospective cohort study.

Subjects

Reproductive-age (18–45 years) women with OUD, in the Merative™ MarketScan® Multi-State Medicaid Database (2011–2016).

Main Measures

Differences by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, “other” race/ethnicity) in the likelihood of receiving buprenorphine and methadone during the start of OUD treatment (yes/no) were estimated using multivariable logistic regression. Differences in time to medication discontinuation (days) by race/ethnicity were evaluated using multivariable Cox regression.

Results

Of 66,550 reproductive-age Medicaid enrollees with OUD (84.1% non-Hispanic White, 5.9% non-Hispanic Black, 1.0% Hispanic, 5.3% “other”), 15,313 (23.0%) received buprenorphine and 6290 (9.5%) methadone. Non-Hispanic Black enrollees were less likely to receive buprenorphine (adjusted odds ratio, aOR = 0.76 [0.68–0.84]) and more likely to be referred to methadone clinics (aOR = 1.78 [1.60–2.00]) compared to non-Hispanic White participants. Across both buprenorphine and methadone in unadjusted analyses, the median discontinuation time for non-Hispanic Black enrollees was 123 days compared to 132 days and 141 days for non-Hispanic White and Hispanic enrollees respectively (χ2 = 10.6; P = .01). In adjusted analyses, non-Hispanic Black enrollees experienced greater discontinuation for buprenorphine and methadone (adjusted hazard ratio, aHR = 1.16 [1.08–1.24] and aHR = 1.16 [1.07–1.30] respectively) compared to non-Hispanic White peers. We did not observe differences in buprenorphine or methadone receipt or retention for Hispanic enrollees compared to the non-Hispanic White enrollees.

Conclusions

Our data illustrate inequities between non-Hispanic Black and non-Hispanic White Medicaid enrollees with regard to buprenorphine and methadone utilization in the USA, consistent with literature on the racialized origins of methadone and buprenorphine treatment.

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Acknowledgements

Nuri Farber MD and the Psychiatry Residency Research Education Program (PRREP) of Washington University; Laura Bierut MD and Patricia Cavazos-Rehg PhD of the K12 Career Development Award Program in Substance Use and Substance Use Disorder at Washington University; Jeremy Goldbach PhD and Kathleen Bucholz PhD of the Transdisciplinary Training in Addictions Research (TranSTAR) T32 Program of Washington University; Matthew Keller MS and John Sahrmann MA from the Center for Administrative Data Research (CADR) of Washington University. In addition, we acknowledge Matt Keller MS, John Sahrmann MS, and Dustin Stwalley MA and the Center for Administrative Data Research (CADR) at Washington University for assistance with data acquisition, management, and storage.

Funding

This project was funded by R21 DA044744 (Richard Grucza/Laura Bierut). Effort for some personnel was supported by grants T32 DA015035 (Kevin Xu, PI: Kathleen Bucholz, Jeremy Goldbach), K12 DA041449 (Kevin Xu, PI: Laura Bierut, Patricia Cavazos-Rehg), R25 MH11247301 (K Xu, PI: Nuri Farber/Ginger Nicol), K23 DA053507 (Caitlin Martin), K23 DA048169 (Davida Schiff), and R01 DA047867 (Hendrée Jones), but these grants did not fund the analyses of the Merative™ MarketScan® Multi-State Medicaid Database data performed by Dr. Xu. CADR is supported in part by the Washington University Institute of Clinical and Translational Sciences via grants UL1 TR002345 (from the National Center for Advancing Translational Sciences of the National Institutes of Health).

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Authors and Affiliations

  1. Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA

    Kevin Y. Xu MD, MPH & Laura J. Bierut MD

  2. Division of General Academic Pediatrics, Mass General Hospital for Children, Boston, MA, USA

    Davida M. Schiff MD, MSc

  3. Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA

    Hendrée E. Jones PhD

  4. Department of Obstetrics and Gynecology and VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, VA, USA

    Caitlin E. Martin MD, MPH

  5. Division of Maternal-Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA

    Jeannie C. Kelly MD, MS & Ebony B. Carter MD, MPH

  6. Alvin J Siteman Cancer Center, Barnes Jewish Hospital, St. Louis, MO, USA

    Laura J. Bierut MD

  7. Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, St. Louis, MO, USA

    Richard A. Grucza PhD

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  1. Kevin Y. Xu MD, MPH
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Contributions

Concept: Xu, Carter, Schiff, Grucza.

Design: Xu, Carter, Schiff, Grucza, Jones, Kelly, Martin, Bierut.

Analysis of data: Xu.

Interpretation of data: Xu, Carter, Schiff, Grucza, Jones, Kelly, Martin, Bierut.

Drafting of manuscript: Xu, Carter, Schiff, Grucza.

Obtained funding: Grucza, Bierut.

Administrative, technical, or material support: Grucza, Bierut.

Critical revision for important intellectual content: Xu, Carter, Schiff, Grucza, Jones, Kelly, Martin, Bierut.

Dr. Kevin Xu was the only individual who had access to the data and the only one to perform analyses. All of the other authors did not have access to the data, although contributed to the interpretation of data.

Corresponding author

Correspondence to Kevin Y. Xu MD, MPH.

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Conflict of Interest

All authors report no conflicts of interest. LJB is listed as an inventor on US Patent 8080371, ‘Markers for Addiction’, covering use of SNPs in determining the diagnosis, prognosis and treatment of addiction. All other authors declare no financial interests. All authors do not have any financial or non-financial relationships with organizations that may have an interest in our submitted work.

Positionality Statement

The authors acknowledge that their social identities inevitably influence their science. Perinatal substance use disorders is an area that holds special significance for the lead author, as his medical training overlapped with a surge in maternal overdoses during the COVID-19 pandemic, which were concomitant with rollbacks in perinatal health access in Missouri. While the lead author, who identifies as a US Chinese-American male physician-scientist, has had lived experiences of racism, he has not been pregnant, nor has personally suffered from addiction, and seeks to approach this topic area with humility. He has thus worked to build an interdisciplinary team of co-authors with a diverse array of backgrounds and areas of clinical expertise. The majority of authors, including the co-last author, are female scientists. The authors’ academic ranks include full professor, associate professor, assistant professor, and instructor/new faculty member. The institutions where the authors are employed span private universities, public universities, academic medical centers, public safety-net hospitals, and non-profit substance use disorder treatment centers in multiple states. As part of their commitment to rigorous antiracist science, the authors have sought to contextualize their results with conceptual models, cite prior work of scientists from historically marginalized groups, use people-first and affirming language, and thoroughly acknowledge the methodological limitations influencing their race/ethnicity data.

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Ebony B Carter, MD, MPH, and Richard A Grucza, PhD, share co-last authorship.

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Xu, K.Y., Schiff, D.M., Jones, H.E. et al. Racial and Ethnic Inequities in Buprenorphine and Methadone Utilization Among Reproductive-Age Women with Opioid Use Disorder: an Analysis of Multi-state Medicaid Claims in the USA. J GEN INTERN MED 38, 3499–3508 (2023). https://doi.org/10.1007/s11606-023-08306-0

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