(2) Race and Insurance Influence on Medications for Opioid Use Disorder

Background & Introduction: Opioid use disorder (OUD) affects approximately 2.5 million Americans annually, contributing to significant morbidity and mortality. Medications for opioid use disorder (MOUD), including methadone and buprenorphine, are the cornerstone of OUD treatment. However, substantial disparities in MOUD use persist, particularly across racial and insurance status demographics. Methadone remains predominantly prescribed in lower-income and minoritized populations, while buprenorphine utilization is higher in white, privately insured individuals. This study leverages Epic’s Cosmos database to quantify these disparities, examining MOUD prescription patterns from 2014 to 2024. Understanding these trends is critical to addressing systemic inequities and improving access to all MOUD treatment modalities.

Methods: This retrospective cohort study analyzed de-identified patient data from the Epic Cosmos database, encompassing ~33,000 clinics and ~246 million patients. Individuals diagnosed with OUD were divided into three groups for the inclusion criteria: those who had never received methadone or buprenorphine, those who had methadone added to the medication list, and those who had buprenorphine added to the medication list (including sublingual and injectable formulations). Methadone and buprenorphine were the focus of this study, as these two medications are most commonly prescribed for OUD. Variables analyzed included race and insurance type. Outcomes measured were MOUD prescription prevalence and type across demographic categories. Statistical analyses employed logistic regression to identify associations between demographics and MOUD prescription patterns.

Results: Preliminary findings revealed significant racial and socioeconomic disparities in MOUD prescriptions. Black and Hispanic/Latino patients were more likely to receive methadone compared to white patients (p < 0.01). Conversely, buprenorphine prescriptions were disproportionately higher among white patients with private insurance (p < 0.01). The removal of the federal X-waiver regulation in 2023 did not eliminate disparities but modestly increased buprenorphine access across all populations.

Conclusion & Discussion: This study highlights enduring disparities in MOUD prescribing practices that reflect broader systemic inequities. Methadone’s concentration in low-income and minoritized underscores barriers to accessing buprenorphine, despite its superior safety profile and ease of use. The persistence of these disparities post-X-waiver removal suggests additional structural interventions are needed to promote health equity in OUD treatment. A limitation to utilizing the Cosmos database is the reliance on methadone prescriptions as a self-reported metric within Epic. Methadone's delivery through highly regulated clinics, e.g. opioid treatment programs (OTPs), which may not be included in the Prescription Monitoring Program (PMP), increases the chances of inaccurate reporting within the Epic database. Future efforts should focus on increasing buprenorphine availability in underserved areas and reducing stigma associated with MOUD use in minoritized populations.

References: Nedjat S, Wang Y, Eshtiaghi K, Fleming M. Disparities in medications for opioid use disorder based on race/ethnicity and gender: A systematic review. *Res Soc Adm Pharm.* 2024;20(3):236-245.

Jackson DS, Nguemeni Tiako MJ, Jordan A. Disparities in addiction treatment: Learning from the past to forge an equitable future. *Med Clin North Am.* 2022;106(1):29-41.

Degenhardt L, et al. Buprenorphine versus methadone for the treatment of opioid dependence: A systematic review. *The Lancet Psychiatry.* 2023;10(6):386-402.