Racial and ethnic disparities in emergency department-initiated buprenorphine across five health care systems

Abstract

Background: Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood.

Methods: This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity.

Results: Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45-0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48-0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56-1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09-1.83) and adjusted models (aOR 1.41, 95% CI 1.08-1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99-1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64).

Conclusions: Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.

FIGURE 1

Bubble plot of the proportion of Black and White patients receiving buprenorphine (either administered or prescribed at discharge) by ED. The color of the bubble indicates the type of ED (blue is academic and gray is community) and the size of the bubble is representative of the proportion of participants from each ED in the study, with larger bubbles representing proportionally more patients. The dashed lines connect each unique ED. There was no significant interaction between type of ED and the proportion of patients receiving buprenorphine by race (interaction p = 0.97).

FIGURE 2

Bubble plot of the proportion of Hispanic and non-Hispanic patients receiving buprenorphine (either administered in the ED or prescribed at discharge) by ED. The color of the bubble indicates the type of ED (blue is academic and gray is community) and the size of the bubble is representative of the proportion of participants from each ED in the study, with larger bubbles representing proportionally more patients. The dashed lines connect each unique ED. There was no significant interaction between type of ED and the proportion of patients receiving buprenorphine by ethnicity (interaction p = 0.64).