Health Equity and Treatment for Women with Opioid Use Disorder

Abstract: Over the past two decades, there has been substantial growth in opioid consumption in pregnancy,1, 2 diagnoses of opioid use disorder (OUD) among pregnant women,3-5 and neonatal complications from in utero opioid exposure.3, 5-9 Untreated OUD among pregnant women leads to poor outcomes for the mother and infant;10 however, treatment with medications for OUD is highly effective,11 especially for pregnant women.10 Medications for OUD, including buprenorphine and methadone, improve treatment retention,12 reduces relapse risk,12-15 reduces HIV-risk,12, 16 reduces criminal behavior,14 reduces risk of overdose death17 and improves birth weights.18 Despite evidence that treatment is effective in mitigating adverse outcomes from OUD, most patients in need of treatment do not receive it.19 Further, there is evidence that that non-white patients are less likely to receive medications for OUD when compared to white patients,20 and there is emerging evidence that this inequity extends to pregnant women with OUD.21 There is an urgent need to understand the underlying structures that lead to inequities in access to medications for OUD, particularly at the intersection of pregnancy and race. The proposed project aims to leverage access to the sample included in the parent grant and apply an intersectionality social justice health equity lens advance Aim 1a and Aim 1b of the parent grant. We seek to determine if and how implicit bias is attributing to differential access to medication among pregnant women as a function of contextualizing and recognizing the ways in which race, gender, class, and place, e.g., state, rural, urban) constitute intersecting systems of oppression that lead to differential health outcomes of pregnant women who are OUD. Specific attention will be given to conducting a deeper dive of ways in which predisposing factors, with a specific focus on the extent to which patient’s access, care and treatment vary based on patient characteristics. We will leverage data obtained from our randomized field experiment (NIDA R01DA045729) and will use a social justice framework. Further, we use qualitative data from “secret shoppers” to determine if non-white patients were more likely to face stigma or rude treatment when attempting to access treatment Specific Aim 1: To determine if racial concordance between secret shoppers, treatment providers and the communities that surround clinic locations influenced ability to obtain an appointment for treatment, and to determine if this varied by pregnancy status and treatment provider type, after accounting for other community-level factors (e.g., social vulnerability index). Hypothesis: We hypothesize that practices and communities with that are >50% non-white will be more accepting of non-white patients. Specific Aim 2: Using qualitative methods we will explore a) the extent to which non-white secret shoppers describe stigmatizing and racial discriminatory experiences when attempting to obtain an appointment for treatment at OTPs or outpatient buprenorphine providers when compared to white secret shoppers, b) and will determine if this varies by pregnancy status.

Vanderbilt University Medical Center