Racial and ethnic disparities in access to treatment and outcomes among patients with substance use disorders (SUD) have widened, despite substantial efforts to address the epidemic of overdose deaths in the United States. Overdose death rates are increasing faster in American and Alaskan Black, Latino and Indian populations than in white populations.1 Members of some of these groups also use opioid use disorder medications (such as methadone, buprenorphine, and naltrexone) at lower rates, have worse health outcomes in the context of the SOUTH, and are more likely to be targeted by the police and jailed for drug possession over their white counterparts.2 Addressing the overdose epidemic requires the elimination of racial and ethnic disparities – along with socioeconomic, gender and geographic disparities – in the prevention and treatment of the SOUTH. Prioritizing research that informs policy could help promote equity in SOUTH-related findings.
Existing disparities highlight potential areas for improvement, including translating research findings into practice. Opportunities exist to improve access to evidence-based treatment in disadvantaged populations. Numerous studies have documented the efficacy of medications for opioid use disorder and other SUD interventions. But such treatments are often less available to members of historically marginalized groups than to white patients. Ensuring that all people with SOUTH receive evidence-based treatment will require overcoming obstacles to high-quality care, such as lower rates of adequate health insurance among populations of Black, Latino, and American and Indian Indians. ‘Alaska with respect to white populations; a shortage of community doctors treating uninsured and underinsured people; stigma surrounding the SOUTH; insufficient investment by the public sector in historically marginalized communities; and limited access to digital tools in many of these communities. Possible approaches to address these needs include developing evidence-based and culturally informed telemedicine models, building mobile drug delivery units for opioid use disorder, supporting drug delivery by pharmacies. , the adoption of collaborative care models focused on equity and expanding access to high-quality care through partnerships between the criminal justice system and community-based providers, such as outpatient treatment programs and mental health clinics.3
Another opportunity is to take action to address the social determinants of health. There has been limited research examining how to most effectively address the social determinants of health to improve outcomes related to SOUTH; approaches include focusing on underlying issues related to structural racism (e.g., inequalities in housing, food, employment and criminal justice systems based on race and ethnic group) and helping those recovering from the SOUTH to participate more fully to society. For example, the positive effects of equitable access to housing and work can help tackle maladaptive behaviors associated with SUDs that perpetuate drug use.
Research considering the ways in which social determinants of health influence engagement in the treatment of SOUTH and SUD-related outcomes could help reduce disparities in these areas. Studies have focused on approaches to addressing social determinants in clinical practice, including collaborating with community services (e.g., religious institutions, local businesses, and non-profit organizations) and engaging with communities themselves, and on Implementing these approaches could also help reduce inequalities in access to care and outcomes.
Prevention is another key area of concern. It is important to develop and implement interventions that minimize the chances of people being unnecessarily exposed to opioids and other drugs or misusing them. In addition to addressing the social determinants of health, preventive interventions could prioritize populations at high risk of SUD, such as people who are prescribed opioids for pain or people who have a family history of SUD or psychiatric conditions but could not having started drug use. For people who have started using drugs, early recognition and intervention could prevent the escalation of drug use and the transition to a SUD. Some of these interventions have already been developed, but further research may be needed to ensure that they are acceptable and effective across various racial and ethnic groups and do not exacerbate inequalities.4
One last opportunity concerns the support of data science. Achieving equity will require advances in data collection and modeling to help end-users of data, such as formal, de facto health systems (e.g. the criminal justice system) and policymakers, ensure that approaches go right. benefit all groups and do not perpetuate racist structures. Examples of such advances include evaluating existing data and algorithms for identifying biases, including information on substance use and social determinants of health in electronic health records (with adequate safeguards to protect patient privacy), promoting harmonization of electronic health record entries and other information and linking various databases, improving data interoperability and using simulations or distributed searches and data networks to assess the effects of ongoing or planned interventions in groups specific.
Ensuring that research reduces disparities will require multiple steps. The first step is to include members of underrepresented groups in the development of preventive interventions and treatments. Engaging such groups could help researchers determine which research is most important to communities, tailor interventions to increase acceptability, and use measures that are relevant to patients. Individuals with personal experience with SUD and their families may be involved during study design and throughout the study period.
The second step is to adequately recruit members of historically underrepresented groups, including those with different educational levels, and ensure that studies are large enough to measure differences in outcomes based on race and ethnic group. Systematic reviews conducted by the Agency for Healthcare Research and Quality and the U.S. Preventive Services Task Force often find insufficient data to evaluate prevention and treatment approaches among disadvantaged groups.5 Recruiting representative study populations will require deliberate efforts to ensure equal awareness and overcome distrust in medical research among these communities, which stems from a long history of exploitation and unethical research practices. The use of research methods (including data acquisition, measurement and analytical approaches) that take cultural differences into account would broaden the knowledge base.
Third, researchers could increase the likelihood of programs being adopted, implemented effectively and supported by establishing fair partnerships with people who currently have or have previously had SUD and their families, doctors, policy makers, funders and supporters, and by involving these evidence-producing groups, including fully sharing the study results with participating communities. Systems created for clinical trials often do not use existing community resources and partnerships. Developing and implementing interventions in collaboration with communities could help bring effective approaches to disadvantaged groups who are often excluded from research and policy making.
Fourth, it will be essential to diversify the scientific workforce, which will require a multi-pronged approach involving funders, professional organizations and teaching and research institutions. Such an approach could include recruiting candidates from underrepresented groups for training opportunities, strengthening partnerships with scientific institutions and organizations serving these groups, and creating grant programs that facilitate the entry of researchers from diverse backgrounds.
Finally, disparities in outcomes related to the SOUTH cannot be eliminated unless investigators measure the effects of policies and interventions on equity. Investigators could aim to identify the factors that have the greatest influence on disparate outcomes to ensure that policies and interventions address these variables. They will also need to consider the complex nature of disparities to avoid attributing outcomes associated with systemic inequalities to inherent differences based on race or ethnic group, which would aggravate systemic bias. Studies could enroll disproportionate numbers of patients with multiple coexisting conditions and evaluate the effects of these conditions on SOUTH-related health outcomes to better address problems affecting disadvantaged populations. To ensure that scarce resources go to interventions in support of equity, researchers seeking to tailor interventions to the needs of specific racial and ethnic groups could compare their effects with and without adaptations and determine if adaptation is necessary.
Applying an equity goal to efforts to address the worsening epidemic of overdose and other SOUTH-related harms is critical to eliminating racial and ethnic disparities and improving health outcomes. Such an approach could also serve as a framework for reducing disparities in other patient populations. Consider community input in research design; involve patients, communities, taxpayers and policy makers; and reviewing choices regarding study outcomes and measurement strategies could transform our approaches to pursue equity and ultimately improve health and well-being in historically disadvantaged groups.