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.