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Racial Disparities in Treatment for Pain and Opioid Use Disorder How Did We Get Here and Where Are We Going?

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Racial Disparities in Treatment for Pain and Opioid Use Disorder How Did We Get Here and Where Are We Going? Racial Disparities in Treatment for Pain and Opioid Use Disorder How did we get here and where are we going? Dr. Pooja Lagisetty Assistant Professor University of Michigan Medical School Veterans Health Administration, Ann Arbor No conflicts of interest About Me . Primary Care and Addiction Medicine P hys icia n . Research focuses on understanding how stigma, bias and racism affects access to care for patients with chronic pain and substance use disorders . Became interested in addiction and racial disparities after growing up as a South Asian in Alabama Objectives . Review legislative history around addiction . Discuss current opioid misuse and overdose rates by race . Highlight disparities in access to treatment for pain and OUD . Underscore why these disparities continue A look at recent drug policy 1970s: A War on Drugs 1970 Controlled“America’s public Substances enemy number Act: drug one schedulein the United States is drug abuse. In order to fight and defeat this enemy, it necessary to wage a new all-out 1971 Nixonoffensive declares. I have War asked on the Drugs Congress to provide the legislative authority and the funds to fuel this kind of an offensive. This will be a worldwide offensive...It 1973 Drugwill be Enforcement government wide….and Administration it will be nationwide.” created Richard Nixon Narcotic AddictPress TreatmentConference, June Act: 17, 1971 1974 regulated methadoneSource: Richard clinics Nixon Foundation for treatment National Institute for Drug Abuse (NIDA) established 5 1980s: Increasing Enforcement Comprehensive Crime Control Act: enhanced 1984 penalties for violations of Controlled Substances Act Anti-Drug Abuse Act: 1986 . Established mandatory minimum sentences for drug-related offenses . Different penalties created for different forms/amts of same drug (powder vs crack cocaine) 1988 Anti-Drug Abuse Act: aimed at reducing drug supply 1980s: Increasing Enforcement Drug Convictions 14000 Drug convictions rose sharply: 12285 12000 . 1980: 5,244 10000 . 1986: 12,285 8000 6000 5244 51% of the increase of the total number of convictions during that 4000 time period were from drug convictions 2000 0 1980 1986 Race and Drug Criminalization • Amount of crack cocaine vs powder cocaine to trigger federal criminal penalties set at a disparity of 1:100 • Policy rested on incarcerating black and Latino crack users, leaving white powder cocaine users untouched Hansen & Netherland, Am J Public Health, 2016 Unequal Criminalization Persons Incarcerated for Drug Offenses by Race 300 250 200 150 100 50 Incarcerated Persons per 100,000 0 White Hispanic/Latino Black Carson & Sabol, 2012 2000s: A Shift Toward Treatment • As prescription opioid misuse among whites increased, policy shifted toward a treatment focus • Methadone was deemed inappropriate for the “suburban spread of narcotic addiction” • Middle-class opioid-dependent people were thought to be more often employed and unwilling to comply with daily observed dosing methadone clinics that carried stigma Hansen & Netherland, Am J Public Health, 2016 2000s: A Shift Toward Treatment • As prescription opioid misuse among whites increased, policy shifted toward a treatment focus • Methadone was deemed inappropriate for the “suburban spread of narcotic addiction” • Middle-class opioid-dependent people were thought to be more often employed and unwilling to comply with daily observed dosing methadone clinics that carried stigma Hansen & Netherland, Am J Public Health, 2016 2000s: A Shift Toward Treatment 2000 Drug Addiction Treatment Act (DATA 2000) . Amends the Controlled Substances Act . Allows ‘qualified physicians’ waivered through Center for Substance Abuse Treatment (CSAT) to prescribe schedule III, IV, and V medications in office-based setting . Buprenorphine is currently the only schedule III drug approved for opioid use disorder Why was the waiver put in place? Excerpts from the Congressional Record highlight why DATA 2000 was approved “[Buprenorphine] would be “Narcotic addiction is spreading available not just to heroin addicts, from urban to suburban areas. but to anyone with an opiate The current system, which tends problem, including citizens who to be concentrated in urban areas, would not normally be is a poor fit for the suburban associated with the term spread of narcotic addiction …” addiction.” Alan Leshner, NIDA Donna Shalala, HHS The Washington Post, 10/19/2000 Why was the waiver put in place? • DATA 2000 was intended to increase treatment access for rural areas and middle class drug users • Considered a shift toward leniency from heavily regulated methadone clinics The Washington Post, 10/19/2000 Was buprenorphine provided equally? Three years after approval of In contrast to methadone buprenorphine, patients taking patients: buprenorphine: . 91% were White . Less often White . Most were college educated . Less likely to be college and employed educated or employed . Dependent on prescription . Primarily used heroin opioids Hansen & Netherland, Am J Public Health, 2016 2010s: Increasing Access for Treatment 2016 Comprehensive Addiction and Recovery Act (CARA 2016) . NPs and PAs can prescribe buprenorphine . Expanded naloxone through co-prescribing, pharmacist distribution and to law enforcement . $103 million through Department of Justice for treatment alternatives to incarceration With the focus on treatment for the past 20 years, how well are we doing? Despite a focus on Overdoses have80,000 risen 18% 83,928in 2020 people due to COVID-192 estimated to die from overdoses in 2020 treatment, overdose 70,000 71,125 people deaths are record died from drug overdoses in 20191 breaking 60,000 50,000 Peak HIV deaths (1995) 40,000 30,000 20,000 18 1. National Center for Health Statistics. 2020. 2000 2010 2020 2. ODMAP. COVID-19 Impact on US National Overdose Crisis. 2020 A treatment gap remains People with OUD NSDUH, 2019 A treatment gap remains 20% received treatment People with OUD NSDUH, 2019 A treatment gap remains 35% received evidence based treatment People with OUD NSDUH, 2019 A treatment gap remains 40% engaged< in3% treatment for a year People with OUD NSDUH, 2019 Who does this epidemic affect? 10 million 1.6 million people with people had an chronic pain opioid use are prescribed disorder in 2019 opioids Pain Addiction NSDUH, 2019 Treatment for Pain Unequal Treatment for Pain Reviewed ED visits from 1993- 2005 from NHAMCS Reviewed all pain-re la te d vis its Measured if visits resulted in an opioid prescription Pletcher, et al., JAMA, 2008 Less likely to receive an opioid for pain % of ER Visits Resulting in Opioid Prescription, by Race, 1993 - 2005 35.0% 31.0% 30.0% 23.0% 24.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% White Black/African American Hispanic/Latino Pletcher, et al., JAMA, 2008 Less likely to receive an opioid for pain A 2012 meta-analysis showed that: Hispanics were Blacks were 22% le s s like ly & 29% le s s like ly to receive an opioid prescription than their White counterparts. Meghani, et al. Pain Medicine, 2012 Differences in dosing and wait times Not only a re minoritie s le s s like ly to re ce ive ANY pa in medication, but they’re also more likely to: Experience longer wait Receive lower doses of times to receive pain pain medications1 medication2 1. Cleeland, et al. Ann Intern Med. 1997 2. Epps, et al. Pain Manag Nurs, 2008 Why does this happen? Racial and ethnic minoritie s more like ly to experience miscommunication or misinterpretation about pain with medical providers Shavers, et al. J Health Care Poor Underserved. 2010 Why does this happen? Some doctors still choose to believe that pain levels are lower for Blacks than Whites or that minorities are ‘drug seekers ’ Shavers, et al. J Health Care Poor Underserved. 2010 Why does this happen? Physicians are more likely to underestimate the amount of pain that African American are experiencing Shavers, et al. J Health Care Poor Underserved. 2010 Isn’t less opioid prescribing a good thing? . Undertreating anyone’s pain because of race is unacceptable and discriminatory . Any benefit experienced by less prescribing is far outweighed by how policies and treatments for addiction have disproportionately harmed people of color. The transient benefit from less prescribing has passed and overdose rates are rising greater in non-White populations Who does this epidemic affect? 10 million 1.6 million people with people had an chronic pain opioid use are prescribed disorder in 2019 opioids Pain Addiction NSDUH, 2019 How common is opioid use and misuse? 49.5 Million received at least 1 opioid Rx 15% of US pop 10.3 Million misused opioids (heroin + Rx) 3.7% of US pop 2.0 Million had an OUD .7% of US pop 2019 CDC Annual Surveillance Report of Drug-Related Risks and Outcomes Does misuse differ by race? Little Difference in Opioid Misuse by Race/Ethnicity 5.0% 4.0% 4.0% 3.7% National 3.6% Average = 3.7% 3.0% 2.0% 1.0% 0.0% 2018 White Black/African American Hispanic/Latino 2018 National Survey on Drug Use and Health: Detailed Tables Overdose rates by Race/Ethnicity Rate per 100,000 of All Opioid Overdose Deaths, by Race/Ethnicity, 2017 25.0% 20.0% 19.4% National 15.0% 12.9% Average = 14.9% 10.0% 6.8% 5.0% 0.0% 2018 White Black/African American Hispanic/Latino 2019 CDC Annual Surveillance Report of Drug-Related Risks and Outcomes Black/Hispanic overdoses rising at a higher rate Individual who are Black and Hispanic are experiencing a faster increase in rates of drug overdose deaths involving opioids 2020 AHRQ Data Spotlght: Blacks Experiencing Fast-Rising Rates of Overdose Deaths
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