VA Study: Buprenorphine Gaps by Race Widened During Pandemic

When federal regulators loosened the rules around opioid addiction medication in 2020, the intent was straightforward: keep patients in treatment while clinics and prescribers were disrupted. Four years of Veterans Health Administration records suggest the benefits landed unevenly. In March 2018, 27.8 percent of non-Hispanic White veterans diagnosed with opioid use disorder received a medication for it, compared with 27.3 percent of non-Hispanic Black veterans — near parity. By February 2022, the figures were 35.0 percent and 29.3 percent.

The study, published October 16 in Addiction Science & Clinical Practice, tracked more than 110,000 veterans across 48 consecutive monthly cohorts between March 2018 and February 2022. Jessica A. Chen and Emily C. Williams of the University of Washington and VA Puget Sound Health Care System led the work, which drew on national electronic health records for outpatients 18 and older with a past-year diagnosis.

How the researchers measured access

Rather than comparing one pre-pandemic year to one pandemic year, the team built a month-by-month series. The primary outcome was whether a patient received any medication for opioid use disorder — methadone, buprenorphine or naltrexone — in a given month. Secondary analyses separated methadone from buprenorphine, because the two drugs reach patients through very different channels. Methadone is dispensed through federally regulated opioid treatment programs with supervised dosing, while buprenorphine can be prescribed by office-based clinicians and taken at home.

That distinction turned out to carry most of the story.

Buprenorphine growth favored White patients

Receipt of buprenorphine climbed after the pandemic began, but the climb was lopsided. Non-Hispanic White patients moved from 27.9 percent to 29.8 percent. Non-Hispanic Black patients moved from 13.9 percent to 15.5 percent, and Hispanic Black patients from 11.6 percent to 15.1 percent. White veterans were roughly twice as likely to receive buprenorphine at the start of the study period and roughly twice as likely at the end of it.

Methadone ran the opposite direction. Use declined for every group after March 2020: non-Hispanic Black patients fell from 17.4 percent to 14.4 percent, Hispanic Black patients from 17.1 percent to 11.9 percent, and non-Hispanic White patients from 6.6 percent to 5.5 percent. The gap did not close so much as compress. At the end of the window, Black veterans remained more than twice as likely as White veterans to be receiving methadone — the medication that requires regular clinic attendance — and far less likely to be receiving the one that fits around work and family life.

A Hispanic category that hid its own worst result

The analysis split Hispanic patients into three groups rather than treating them as a single category, and the split changed what the data showed. Hispanic patients who were neither Black nor White reached 33.7 percent by February 2022, and Hispanic White patients 33.2 percent. Hispanic Black patients ended the period at 26.2 percent, the lowest of any subgroup tracked — a result that disappears when all Hispanic veterans are counted together.

What the authors do and do not claim

The paper is descriptive. It documents who received which medication before and after the policy changes, but it does not identify why the gaps moved the way they did, and the authors do not present their findings as causal. Their conclusion is narrower and more pointed: flexibilities intended to widen access did not distribute their benefits evenly, and closing the gap may require targeted work on the specific barriers to each medication rather than an assumption that looser rules help everyone equally.

The research was funded by the National Institute on Drug Abuse and informed by consultation with veterans who have lived experience of opioid use, including two advisory groups named in the paper.

For the VHA, the largest integrated health care system in the country, the records offer one of the few national views of how treatment patterns actually shifted when prescribing rules changed. The pattern echoes what researchers have found outside the VA: a study published this month in the Journal of General Internal Medicine reported that among Medicaid enrollees treated for an opioid-related emergency, Black and Hispanic patients were least likely to start or stay on buprenorphine afterward.

Both medications remain effective. The question the VA data raises is not whether the pandemic-era changes expanded treatment, but who ended up with the version of treatment that is easiest to sustain.