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The Black opioid crisis reveals that barriers to treatment must come down

White patients are more likely to be prescribed life-saving medication. Lowering opioid deaths in Black communities requires urgent mobilization for equity.

Over 200 overdose prevention activists staged a protest on August 28, 2019 at Governor Andrew Cuomos New York City office to call out the Governor's inaction to enact the evidence-based overdose prevention policies that could save the lives of thousands of New Yorkers.Erik McGregor/LightRocket via Getty Images

Alarming reports of animal tranquilizers making their way into street drugs showed one deadly way the opioid overdose crisis is changing. But the crisis is transforming in another way: The face of the crisis used to be White and largely rural. Now, it’s Black.

At the start of the crisis in the late 1990s, Black communities were among the least affected. Now, urban Black communities are ground zero for overdose deaths: Since 2019, drug overdose death rates among Blacks exceed that of Whites.

Overdose deaths by race and ethnicity in 2019 and 2020.Alex LaSalvia

Black deaths increased by a whopping 44% from 2019-2020, but rose only 22% among White people with many of those deaths due to fentanyl use. Experts expect this trend to continue, further widening the racial disparity.

The image of the opioid crisis as only a “White issue” makes the problem worse. Moreover, overdose deaths in Hispanic communities continue to climb at concerning rates, but rates are currently only about half of what they are in Black communities. According to the Centers for Disease Control and Prevention, nowhere are overdose rates higher or have risen faster than among Black Americans.

The fact that Black rates are so high and continue to rise is strong evidence that what we’re doing isn’t working for Black communities. It’s a perfect example of how health systems need to look at the specific needs and assets within certain communities to bring about health equity.

For instance, it goes without saying that our approach to lowering opioid deaths in Black communities should, of course, be multipronged and emphasize prevention, harm reduction, treatment, and recovery. There is, however, one glaring and solvable issue staring us in the face and that gets little attention: Black people don’t get what might be the most effective treatment for opioid addiction: buprenorphine treatment.

Providers can be reluctant to prescribe addiction medications to Black people over unfounded fears that patients will misuse or sell them.

Buprenorphine, brand name Suboxone, is a medication that reduces cravings and withdrawal symptoms as patients seek to recover. The drug can cut risk of opioid overdose by up to 50% and patients receiving buprenorphine are more likely to get jobs, reduce drug use, and improve overall quality of life. It’s as effective as methadone, but also safer and has less restrictions.

Researchers call buprenorphine the “gold standard” opioid addiction treatment. It is quite literally a lifesaver for many patients living with opioid addiction. The problem is Black communities have very limited access to it, and it is rarely prescribed to Black people.

From 2012-2015 there was no increase in buprenorphine prescriptions for Black Americans, but White patients were 35 times more likely to be prescribed the medication. The frustrating part is that this disparity is not new and has existed for some time now.

Provider policies and racial bias contribute to low buprenorphine access for Black communities. Providers can be reluctant to prescribe addiction medications to Black people over unfounded fears that patients will misuse or sell them. Prescribers also tend to only accept cash or private insurance, which can be a roadblock for some Black patients.

Another barrier is geography. Prescribers largely don’t service areas with large numbers of Black residents. In fact, communities with the highest percentage of White residents are twice as likely to have buprenorphine prescribers as mostly Black neighborhoods. Not surprisingly, the situation is similar for Hispanic residents, as studies show buprenorphine prescribers aren’t generally located in predominantly Hispanic neighborhoods either.

So where do we go from here? First, we need massively more awareness about the shocking racial disparity in treatment access. Policymakers, treatment providers, federal agencies, researchers and news media should all be shining a light on overdose deaths in Black communities, and the need for better access to buprenorphine.

Next, get rid of bureaucratic barriers that limit prescribing. On Dec. 29, 2022, the federal government eliminated the need for providers to undergo an extensive registration process to obtain a Drug Enforcement Administration waiver to prescribe buprenorphine. Providers serving Black communities can now prescribe the drug in the same way they would any other medication. This is a welcome move that should facilitate broader prescribing in Black communities.

But simply changing regulations won’t be enough to improve access to treatment.

So we also need to find innovative ways to incentivize providers serving Black communities to prescribe this treatment. Doctors providing care in these communities could be offered financial incentives, infrastructure grants, or free training to encourage taking more patients who could benefit from this.

We need to get buprenorphine covered by more insurance companies and at a higher rate. Medicare and Medicaid offer some coverage, but it is often insufficient, and billing complexities mean patients sometimes are delayed weeks before receiving treatment. For providers who are able, it’s critical they accept a wider variety of payment options for buprenorphine patients, rather than cash-only.

More Black people receiving buprenorphine is not a panacea, but it is a strategy likely to yield significant dividends. Even a moderate uptick in Black people receiving this treatment would likely result in fewer Black people dying.

Khary Rigg, PhD, is an associate professor of Mental Health Law & Policy at University of South Florida, and a Public Voices Fellow of AcademyHealth in partnership with TheOpEdProject.