Medicaid Study Finds Racial Gaps in Buprenorphine After Overdose Care

Only 14 percent of Medicaid enrollees who survived an opioid-related emergency filled a buprenorphine prescription within 30 days of leaving care, and Black and Hispanic patients were significantly less likely than White patients to start the medication or stay on it, according to a study published September 29 in the Journal of General Internal Medicine.

The analysis drew on complete Medicaid claims from 19 states for 2016 through 2019, assembling one of the largest cohorts ever used to examine who receives medication for opioid use disorder after an acute crisis. Researchers from Henry Ford Hospital, Stanford University, the University of Washington, and Yale University identified 234,944 acute opioid-related events involving 169,721 beneficiaries between the ages of 18 and 64.

An event qualified if it was a nonfatal emergency department visit, an acute inpatient admission, or a rehabilitation or detoxification stay tied to an opioid overdose, opioid withdrawal, or an infection caused by injection drug use. Those are the encounters addiction medicine specialists treat as the most reliable opening for treatment — a patient has just survived an overdose or a serious hospitalization and may be unusually willing to accept help.

What the claims actually show

The gap between that opening and actual treatment is wide. Across all 234,944 events, 14.08 percent of patients filled a buprenorphine prescription within 30 days. Naloxone, the overdose-reversal nasal spray, was filled by 3.78 percent. Retention — defined as at least 150 days of buprenorphine on hand within 180 days — reached 4.62 percent.

Fewer than one in seven patients started the medication most strongly linked to staying alive after an opioid crisis, and fewer than one in twenty stayed on it long enough to get the full protective benefit.

The cohort was 68.1 percent White, 11.5 percent Black, and 11.1 percent Hispanic, with a mean age of 37.5 years; 43.4 percent were female.

The first 30 days diverge by race

After adjustment for age, sex, medical and psychiatric comorbidities, prior treatment history, the diagnosis that prompted the visit, state of residence, and calendar year, the disparities held across every care setting the researchers examined.

Black patients had 21 percent lower adjusted odds of filling buprenorphine within 30 days after an emergency department visit (adjusted odds ratio 0.79), 28 percent lower odds after an inpatient admission (0.72), and 17 percent lower odds after a rehabilitation or detoxification stay (0.83). Hispanic patients showed 20 percent lower odds after emergency visits (0.80) and 17 percent lower odds after inpatient admissions (0.83).

Retention is where the divide widens

The gaps grew sharper among patients who did manage to begin treatment. Black patients had 36 percent lower adjusted odds of still being on buprenorphine at 180 days after an emergency visit (0.64), 49 percent lower odds after an inpatient stay (0.51), and 37 percent lower odds after a rehab or detox admission (0.63). Hispanic patients had 30 percent lower odds after emergency visits (0.70) and 34 percent lower odds after inpatient admissions (0.66).

An odds ratio of 0.51 means that a Black patient hospitalized for an opioid-related crisis had roughly half the chance of a comparable White patient of still being on medication six months later. Retention is the strongest single predictor of buprenorphine's mortality benefit; research has tied interruptions in the medication to sharp increases in overdose risk.

Why Medicaid is the lens

The choice of Medicaid claims is deliberate. The program is the dominant payer for people with opioid use disorder in the United States and covers a population carrying a disproportionate share of the overdose burden. Because it insures patients across state lines and across every type of acute care setting, it offers a near-complete view of how the treatment system performs in practice rather than in clinical trials.

The authors used hierarchical logistic regression, a method suited to claims data because it accounts for patients clustered within states and years, and tracked fills at three days and 30 days alongside the 180-day retention measure.

What the authors say should change

The paper's findings land on a system that has repeatedly been documented as unequal. Earlier work, including a 2023 analysis in the New England Journal of Medicine, established that buprenorphine access splits along racial lines. This study extends that picture to the specific moments when a patient is most reachable and shows the disparity persists through both initiation and continuation.

The implication for clinicians is that a discharge plan is not the same as a filled prescription, and for policymakers that equity in opioid addiction treatment depends on what happens in the days after someone leaves an emergency department or a hospital bed. The researchers call for interventions aimed at the transition out of acute care — warm handoffs, same-day prescribing, and follow-up that does not depend on a patient navigating the system alone.

Naloxone access showed a similar scarcity: fewer than four in 100 patients left with the reversal spray, even though naloxone is designed for the households and bystanders most likely to witness an overdose. The study appears as fentanyl continues to drive tens of thousands of American deaths a year, a toll that makes each missed post-crisis prescription consequential.