Author: Katherine Gallagher

Racial Disparities in Opioid Use Disorder Treatment

Over the past twenty-five years, the United States has experienced an increasingly devastating opioid crisis.  According to the Department of Health and Human Services (HHS), in the late 1990s, pharmaceutical companies offered reassurance to the medical community that patients would not become addicted to opioid pain relievers, leading healthcare providers to begin prescribing them at greater rates.  Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before it became clear that these medications could indeed be highly addictive.  

The Centers for Disease Control and Prevention (CDC) outlines the rise in opioid overdose deaths in three distinct waves.  The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids increasing since at least 1999.  The second wave began in 2010, with rapid increases in overdose deaths involving heroin.  The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl.  The market for illicitly manufactured fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills, and cocaine.  In 2017, HHS declared a public health emergency to address the national opioid crisis and announced a five-point strategy with the following priorities: improve access to prevention, treatment, and recovery support services; target the availability and distribution of overdose-reversing drugs; strengthen public health data reporting and collection; support cutting-edge research on addiction and pain; advance the practice of pain management. 

The COVID-19 pandemic has created a devastating public health crisis and has posed significant challenges for health care delivery, including opioid use disorder (OUD) treatment.  Like the opioid crisis, the COVID-19 pandemic has had a disproportionate impact on racial and ethnic minority groups, particularly those who use drugs.  For example, one recent study showed that Black people with OUD are not only at significantly increased risk for COVID-19, but also have greater odds of hospitalization and mortality.  This reflects how Black communities have been subjected to the dual burden of disproportionate COVID-19 deaths and rising overdose mortality.

Methadone has been successfully used for over forty years to treat OUD and must be dispensed through specialized opioid treatment programs.  To receive the treatment, individuals have to show up every day for ninety days to receive their dose.  Only after that, are they able to take home a weekly bottle.  To get a full month’s worth of take-home methadone, individuals need to have been going to the clinic for two years.

Buprenorphine reduces cravings without becoming addictive itself and has been found to have similar effectiveness as methadone for treating OUD when given at a sufficient dose and for sufficient duration.  However, unlike methadone, buprenorphine can be prescribed by certified health care providers.  This eliminates the need to visit specialized treatment clinics, thus expanding access and providing an option for individuals with OUD who are unwilling or unable to attend a licensed methadone treatment program.

While both methadone and buprenorphine have been shown to reduce opioid misuse compared to abstinence-only interventions, buprenorphine has the greatest potential for widespread dissemination due to its relative ease of use and safety.  However, findings from several studies suggest buprenorphine and methadone treatment rates are correlated with race and ethnicity.

The following recommendations have been proposed by public health professionals and, if adopted, could help address the racial disparities in access to medications for OUD.  First, the requirement that a health care provider must complete a course before they are able to prescribe buprenorphine should be lifted. Second, newly diagnosed OUD patients should be offered both buprenorphine and methadone as treatment options.  Furthermore, patients currently receiving methadone should be offered the option to transition to buprenorphine.  Third, policies and regulations should be changed to allow pharmacy-led methadone dispensing.  Steps such as these must be taken to ensure all Americans, regardless of race or ethnicity, have equal access to health care.  Otherwise, this would be a missed opportunity to improve public health. 

I Can’t Breathe – Health Disparities in the Impact of Air Pollution

Prior to the 2021 United Nations Climate Change Conference (COP26), the World Health Organization (WHO) released a special report on climate change and health. The ten recommendations in the report propose a set of priority actions from the global health community to governments and policymakers, calling on them to act with urgency on the current climate and health crises. One of the recommendations focuses specifically on creating energy systems that protect and improve climate and health in order to save lives from the harmful effects of air pollution. Not long after the WHO’s report was released, ProPublica, a nonprofit organization headquartered in New York City that focuses on investigative journalism, released what it is calling “the most detailed map ever of cancer-causing industrial air pollution.” The map is based on an analysis of Environmental Protection Agency (EPA) data and exposes the sources of cancer-causing industrial air emissions down to the neighborhood level. 

According to the Natural Resources Defense Council (NRDC), air pollution is the release of pollutants that are detrimental to human health and the planet as a whole into the air. Most air pollution comes from industrial plants burning fossil fuels for energy use and production, which releases gases and chemicals into the air. The air pollution from these industrial plants alone is elevating the cancer risk of an estimated quarter of a million Americans. The Clean Air Act(CAA) was designed to protect public health by setting pollution standards. However, the worsening impact of climate change will not only make it harder to meet these standards but will continue to exacerbate air pollution. The effects of air pollution depend on three factors: the type of pollutant(s), the length and level of exposure, and individual health risks. For example, smog can irritate the eyes and throat and also damage the lungs. Even worse, people who suffer from asthma or allergies can experience asthma attacks and intensified symptoms. Soot can penetrate the lungs and bloodstream and worsen bronchitis, lead to heart attacks, and even hasten death. Benzene can cause leukemia and ethylene oxide can lead to lymphoma and breast cancer. 

Over the last couple of decades, study after study has found that the burden of air pollution is not evenly shared and has impacted racial minorities at a much higher rate. These findings are corroborated by the “hot spots” identified in ProPublica’s map, which are disproportionately Black. These disparities have roots in historical practices, such as redlining. According to an organizer for the Sierra Club, “[c]ommunities of color, especially Black communities, have been concentrated in areas adjacent to industrial facilities and industrial zones, and that goes back decades and decades, to redlining.” The COVID-19 pandemic has further contributed to the burden placed on these communities. The already high rates of respiratory and cardiac illnesses due to air pollution have contributed to the disproportionate toll the pandemic has taken on communities of color. The overwhelming message from COP26 has been that we have reached a turning point and bold legislation addressing longstanding racial disparities as a top concern for climate policy will be critical not only in combatting environmental racism but in saving the world.