Provision of Medications for OUD— An Equity Lens

By Lauren DeSouza- Master of Public Health, Simon Fraser Public Research University – Canada
This article is reproduced herein with permission of the copyright holder.

The opioid overdose crisis remains a significant public health issue across the United States. Opioid overdoses and overdose mortality are racial and social equity issues. While the burden of opioid use and overdose initially impacted predominantly White Americans, the burden has shifted over time toward people of color. Since 2021, overdose death rates have increased for many racial and ethnic groups, including American Indian, Alaska Native, Asian, Black, and Hispanic populations, while decreasing among White populations.

Drug use has a disproportionate impact on communities of color, influenced by a range of complex and interconnected socioeconomic factors. Structural racism impacts communities’ access to resources to prevent and address drug use and overdose. Drug use in communities of color is often criminalized rather than addressed as a public health issue. And patients of color can be subject to racial bias from clinicians that impacts their treatment options.

The treatment used for OUD dramatically impacts patients’ recovery from an overdose or related incident. Despite a significant body of research around effective medications to treat OUD, not all patients receive the same or the most evidence-based treatments. In particular, Black and Hispanic patients are less likely to receive medications for opioid use disorder (MOUD).

A new study aimed to understand how race, ethnicity, and insurance type impacted patients’

A new study aimed to understand how race, ethnicity, and insurance type impacted patients’ access to medications for opioid use disorder.

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What did this study do?

This new study, published in June 2025 in JAMA Network Open, was a retrospective, longitudinal cohort study. In this type of study, researchers analyze existing data (collected in the past) that follows a group of people over a defined time period. Using previously collected data permits them to analyze trends and changes over time.

The researchers used data from the Institute for Health Equity Research Multipayer Claims Database from 2017 to 2022. This database covers a range of payer types, including commercial insurance, Medicaid, and Medicare Advantage. This database is more comprehensive than the single-payer databases used in previous studies. It also spans an extended time period, providing a more nuanced understanding of how race and insurance type impact patients’ access to medications for opioid use disorder (MOUD). The study’s time frame is significant because it captures key policy shifts, such as the expansion of telehealth and the relaxation of buprenorphine prescribing rules during the COVID-19 pandemic. This allows researchers to analyze the impact of these policy changes on access to MOUD.

Study criteria:

Data included individuals across all 50 states who experienced an opioid use disorder (OUD) event between January 2017 and December 2022.
OUD events included nonfatal opioid overdoses treated in emergency departments or inpatient settings; hospitalizations for injection drug use–related infections and inpatient or residential rehabilitation or detoxification care.
Insurance types included commercial, Medicare, Medicaid Advantage, and other.
Race and ethnicity were categorized as White, Black, Hispanic, Asian, and other.

The primary outcome of interest was the receipt of MOUD within 180 days after an index event.

Medications for Opioid Use Disorder (MOUD)

Three medications—buprenorphine, naltrexone, and methadone— are proven to reduce opioid use and mortality and are approved by the Food and Drug Administration. Buprenorphine and methadone have the most substantial evidence of success, but methadone is generally only given at highly regulated opioid treatment facilities. Thus, this study looked at buprenorphine and naltrexone, which are more commonly prescribed in various health care settings and are less disruptive to patients’ daily lives.

Buprenorphine is the most efficacious of the 3 MOUD options, more so than naltrexone, for its utility in promoting abstinence and treatment retention. As patients need to complete opioid withdrawal before starting naltrexone, providers do not prescribe it as often as buprenorphine.

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What were the results of the study?

The study included 176,997 OUD-related events involving 164,728 patients. Most (50.2%) OUD events occurred among White patients, followed by Black (13.2%), Hispanic (5.8%), and Asian (0.6%) patients. Most OUD events were nonfatal opioid overdoses. Overall, medication receipt was low for patients experiencing an OUD event; 19.3% of patients received buprenorphine, and 3.7% received naltrexone.

Differences by race

Black and Hispanic patients were significantly less likely to receive buprenorphine than White patients. The probability of receiving buprenorphine after an opioid-related health care event was 20.5% for White patients, 17.1% for Black patients, and 16.2% for Hispanic patients. In relative terms, Black patients were approximately 17% less likely and Hispanic patients approximately 21% less likely than White patients to receive buprenorphine. White patients and patients of color were prescribed naltrexone at similar rates.

These trends were consistent even when the researchers controlled for insurance type, suggesting that racial and ethnic disparities in access to MOUD persist independently of insurance coverage.

Differences by insurance type

Patients with Medicaid were more likely to be given buprenorphine compared to patients with other insurance types.

Patients with commercial insurance were more likely to be given naltrexone than patients with other insurance types.

Differences over time

The adjusted odds of receiving buprenorphine increased progressively each year of the study period, increasing by 105% between 2017 and 2021. The researchers did not observe significant year-over-year changes in naltrexone receipt.

How do race and insurance type impact which patients receive MOUD?

MOUD receipt among Black and Hispanic patients

In this extensive multipayer study, Black and Hispanic patients were significantly less likely than White patients to receive buprenorphine after an opioid‐related health event, even after adjusting for insurance type, comorbidities, geography, and other factors. The authors hypothesize several structural and systemic factors that may explain why Black and White patients with similar insurance and clinical profiles receive different treatments for OUD.

As a result of historical segregation, methadone clinics are more prevalent near racialized communities compared to near predominantly White communities. The proximity to methadone clinics increases the likelihood that patients from racial and ethnic minority groups will receive methadone. In contrast, predominantly White neighbourhoods have more buprenorphine providers per capita. While both medications are effective, methadone is more stigmatized and more disruptive to daily life than buprenorphine. The researchers emphasize that buprenorphine should be the first choice for all patients, not just White patients.

Clinician bias and patient perceptions of clinical bias may also impact buprenorphine prescribing. Implicit bias or systemic discrimination in clinician decision-making or in referral practices might also lead to lower rates of offering or prescribing buprenorphine for Black and Hispanic patients. In addition, patient‐level perceptions of bias or mistrust may discourage uptake or acceptance of buprenorphine when offered.

MOUD receipt and Medicaid

Patients covered by Medicaid were the most likely to receive buprenorphine. In recent years, Medicaid has been updated to reflect better the evidence on treating opioid use. The changes include offering all three forms of MOUD, using coordinated care models, and adopting harm reduction strategies. These changes have been associated with increased addiction treatment

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Interventions with Clinicians

Interventions to reduce clinician bias or the impact of clinical bias include standardizing OUD screening protocols, integrating MOUD across diverse care settings, and educating clinicians on culturally tailored strategies to deliver MOUD.

Improving Access to MOUD

Telehealth, community partnerships, and the expansion of MOUD to diverse care settings will enhance access to effective treatments for patients in underserved areas, particularly in communities of color. Additionally, policies are needed that reduce barriers to buprenorphine use; for example, eliminating the requirement for patients to remain abstinent during treatment, permitting patients to begin treatment at home, and offering mobile induction could all improve access.

There is also a need for public health campaigns to reduce MOUD stigma in racially and ethnically diverse communities.

Insurance Policy Improvements

Medicare, commercial, and other insurance types should improve their coverage to align with Medicaid’s adoption of evidence-based practices. All payers should cover the three forms of MOUD as essential health benefits and adopt coordinated care models and harm reduction strategies to improve access to MOUD for all patients.

Key takeaways

Black and Hispanic patients were significantly less likely to receive buprenorphine than White patients, but received naltrexone at similar rates.
Patients covered by Medicaid were the most likely to receive buprenorphine compared to patients with different insurance providers.
Racial disparities in buprenorphine prescription continue even after controlling for insurance payer, comorbidities, geography, and other factors. This indicates that structural racism and socioeconomic disparities influence Medication for Opioid Use Disorder (MOUD) prescribing.
Enhancing coverage for medication for opioid use disorder (MOUD) across various insurance payers, addressing clinician bias, and increasing access to treatment for opioid use disorder (OUD) are essential to achieve more equitable prescribing of MOUD and to reduce opioid-related deaths for all Americans.

References

Khatri UG, Lopez C, Yen Y, Ling EJ, Richardson LD, Ngai KM. Receipt of Buprenorphine and Naltrexone for Opioid Use Disorder by Race and Ethnicity and Insurance Type. JAMA Netw Open. 2025;8(6):e2518493. doi:10.1001/jamanetworkopen.2025.18493