A Landscape Assessment on MOUD Use and Access Barriers for Black and Indigenous Clients
Opioid overdose deaths disproportionately impact Black and Indigenous communities. In 2021, Indigenous Minnesotans were ten times as likely and Black Minnesotans were three times as likely to die from opioid overdose than their white counterparts. These deaths are preventable: research shows that medications for opioid use disorder (MOUDs) are effective treatment options that reduce overall opioid use and prevent overdose. These medications reduce opioid cravings and manage withdrawal symptoms. There are currently three MOUDs approved by the United States Food and Drug Administration (methadone, buprenorphine, and naltrexone), and they each carry different federal regulations.
While medical professionals often view MOUDs as a key ingredient to successful opioid use treatment, Black patients receive MOUDs in emergency and inpatient environments at nearly half the rate of white patients, nationally. Black community members are also significantly less likely than their white counterparts to receive MOUDs from physicians or pharmacies. Furthermore, Black patients are less likely to use MOUDs within specialized treatment plans. While buprenorphine use has generally increased over the last two decades, increases in use and access are greater in higher-income white neighborhoods than in neighborhoods with higher concentrations of Black residents.
Findings
Based on a synthesis of our KIs and community member interviews, we identified four key themes describing the prevailing barriers to MOUDs and Black and Indigenous community members’ orientation to these medications:
“You have to reach a certain amount and reach certain steps to be able to get your take-homes, except for every weekend because they’re closed on Sundays, so you get one or two take-homes a week, but it makes it hard because not everybody can make it in every single day, you know what I mean? Sometimes that’s just not possible or sometimes you’re sick and stuff and then they penalize you for not making it.”
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Across interviews, community members shed light on the various procedural, interpersonal, material, systemic, and mental barriers they faced in their experiences with MOUDs—many of which challenged our assumptions about what truly limits access and use.
Contrary to our expectations, lack of awareness or knowledge of where to get these medications wasn’t a significant issue. Most people we spoke with were familiar with several MOUD options, including newer treatments like “the shot” (i.e., Sublocade), and could name pathways or even specific sites where they could access them. For some, the challenge was in gaining initial access, but for many, the most significant barriers emerged after they had gained entry and started engaging with the sites.
Community members described procedural challenges that often fail to account for the realities of their daily lives and frequently feel punitive rather than supportive. These included lengthy and rigid intake processes, extended wait times to receive medications (both in treatment clinics and at the emergency room), and penalties for missed appointments. For individuals already facing consistent instability, this is a burden that many can hardly sustain.
“I think it numbs you too much and people stay on it too much and it’s a curse, like I said, it’s just not healthy. I think it’s healthy to a certain extent.”
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Healthcare professionals often consider MOUDs the gold standard for opioid use disorder treatment, but community members were vocal in their difficulties taking the medications beyond procedural barriers. These difficulties stem from the physical realities of taking MOUDs (e.g., general symptoms and precipitated withdrawal), professionals’ inadequate communication around MOUDs, and stigmatizing beliefs about the medications in community and professional spaces. In addition to experiencing painful and upsetting precipitated withdrawal symptoms, some reported physical side effects from Suboxone, such as rashes, vomiting, and tooth loss. Others expressed unease about prolonged use, calling it something that “numbs you too much” or feels like “a curse.” According to these observations, MOUDs may not seem like a solution to some individuals, but rather like another dilemma. Perhaps, the problem lies not only in the way these drugs are administered, but also in the ways these medications affect people’s bodies and routines.
“I was drinking or whatever and I went to jail and I was on like a weekly dose where I only have to come in once a week to get my meds and after I got out of jail they’re making me go back every day now and that’s just messing with my whole schedule like I can, you know, I’m supposed to be at school at 9 o’clock in the morning, you know and now that I have to go back every day I’m late for school, I mean I’m late for work, just messed everything up. It feels like they kind of took that away.”
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Both community members and KIs emphasized that providers need to be prepared to meet patients where they are in their journeys. While many community members have had negative experiences in healthcare settings, their standout positive experiences stemmed from providers’ willingness to work with them in their treatments and approach them with more humanity. Community members discussed the need for doctors and other staff to work more collaboratively and compassionately with them to ensure that their treatment plan effectively supported their needs.
“I don’t really like [Suboxone] because it doesn’t help me at all, whatsoever. But the methadone, I feel like it will help me because there’s a lot of people out there that say “try methadone” to actually take you off of the opioids that I’m on. I am trying to go get on that.”
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Community members were open in their skepticism and criticism toward MOUDs. However, even those who have had negative experiences still stated that they believed MOUDs were a viable treatment option. One community member, who had negative experiences the four separate times she had tried Suboxone, said she still looks out for other MOUD options.
Research in Action (RIA) partnered with members of the Minnesota Department of Health (MDH) to conduct a landscape assessment on Black and Indigenous populations’ barriers to accessing and using medications for opioid use disorder (MOUDs). Our project partners (herein after referred to as the MDH project team) work within MDH’s Overdose Prevention Unit and the Infectious Disease Epidemiology, Prevention and Control Division. With this landscape assessment, our partners hope to directly address community-identified barriers and identify intervention points for future work on MOUD use and access.
The MDH project team connected us with recovery community organizations (RCOs) and syringe service programs (SSPs) that either received grants from MDH for SSP operations or were otherwise professionally connected to members of the MDH project team, most of whom were based in the Twin Cities metro area. We collaborated closely with these organizations to understand their perspectives on the issue and develop strategies that were responsive to the Black and Indigenous communities they serve.
Recommendations
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Community members had to navigate difficult circumstances surrounding the regulation of MOUDs and restrictive treatment practices. Reduced restrictions around methadone in response to the COVID-19 pandemic increased patient access to their treatment, reduced their exposure to stigmatizing social situations, and bolstered the agency they had over their treatment. While buprenorphine medications are less regulated than methadone, community members still reported restrictive practices around the medications’ availability that suggest this class of medications, in general, is not made fully accessible to patients.
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Community members stated that providers often are not understanding of their circumstances and are not equipped to meet them where they are in their journeys. However, community members’ positive treatment experiences stemmed from providers’ compassion, investment, and efforts to structure a treatment plan that truly works for a patient’s goals. Previous work on patient empowerment and success suggest that patient-directed care, even in highly-regulated methadone treatment contexts, is possible and leads to increased retention and better treatment outcomes. Treatments are also likely to be more accessible and supportive of community members when providers implement multidisciplinary, coordinated care efforts rather than a single physician coordinating all aspects of a patient’s treatment.
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Community members were primarily in favor of mobile MOUD options beyond the walls of traditional healthcare settings. Mobile clinics would disrupt common barriers by bringing necessary care to more accessible community sites, where people frequently gather or congregate. Mobile clinics would be particularly beneficial in reaching unhoused communities and those with limited access to transportation. Expanding MOUD access via mobile clinics would also require providers’ more direct participation in community health promotion outside of the walls of a clinic or hospital. Mobile clinics often rely on volunteer hours from physicians and other staff. Organizations cannot explore the viability of implementing a mobile clinic without express willingness from providers to engage in more progressive community health solutions that disrupt inequitable barriers. Previous assessments of mobile MOUD access suggest that they are a viable strategy to engage different community members in treatment while overcoming specific barriers like stigmatizing healthcare environments and limited clinic locations.,
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Community members’ variable experiences with healthcare providers and MOUDs highlight the need for a standardized and rigorous curriculum on MOUDs to ensure that providers are safely coaching their patients through their entire treatment. Providers often cannot correctly distinguish between different MOUD mechanisms, and lower levels of knowledge on MOUDs are associated with greater stigmatized attitudes toward patients who use opioids. This pattern suggests that a more holistic education on MOUDs for providers may address prevailing forms of stigma. Educational resources on MOUDs, rather than reiterating standard medical jargon, should uplift the realities of those with lived experience on these medications so that providers have greater context. These educational resources should also uplift treatment strategies recommended by those with lived experience such as incorporating cannabis, which can help patients navigate negative symptoms and potentially boost MOUD treatment retention.
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Community members are still navigating internal and external stigma around MOUDs. This stigma can affect people’s willingness to engage with MOUDs as a viable treatment option and their desire to continue long-term MOUD use. Both providers and community members who use opioids can stigmatize MOUDs as an indication that one isn’t actually in recovery, in addition to the belief that MOUDs should only be used as a temporary tool., These restrictive representations of recovery obscure the individualized nature of recovery as well as de-emphasize the reality that some rely on MOUDs as a tool to support their long-term well-being, like many other medications for chronic health conditions.
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Community members and informants closest to the topic at hand shared extensive wisdom and insight on what is contributing to use and access barriers for Black and Indigenous clients. However, we have only scratched the surface of community insights and community-identified solutions to enact actual systemic change. We recommend building on the learnings from this landscape assessment to implement a larger-scale project, where we can further implement our Equity in Action model to identify prevailing barriers and proposed solutions from Black and Indigenous community members.
