Research to Change Policy — Using Evidence to Advance Health Equity for Substance Use Disorders

Racial and ethnic disparities in treatment access and outcomes among patients with substance use disorders (SUDs) have widened, despite substantial efforts to address the epidemic of drug overdose deaths in the USA. Overdose death rates are increasing faster in black, Latino, Native American, and Alaska Native populations than in white populations.1 Members of some of these groups also use medications for opioid use disorder (such as methadone, buprenorphine and naltrexone) at lower rates, have poorer health outcomes in context of the TUS and are more likely to be targeted by the police and incarcerated for drug use. possession than their white counterparts.2 Addressing the overdose epidemic requires addressing racial and ethnic disparities—as well as socioeconomic, gender, and geographic disparities—in the prevention and care of SUD. Prioritizing research that informs policy could help advance equity in SUD outcomes.

The existing disparities highlight potential areas for improvement, including translating research findings into practice. Opportunities exist to improve access to evidence-based treatment in underserved populations. Numerous trials have documented the effectiveness of medications for opioid use disorder and other TUD interventions. But these treatments are often less accessible to members of historically marginalized groups than to white patients. Ensuring that all people with SUD receive evidence-based treatment will require overcoming barriers to high-quality care, such as lower rates of adequate health insurance among Black, Latinx, Native American and Alaska Natives than among white populations; a shortage of community clinicians who treat the uninsured and underinsured; the stigma surrounding SUD; public sector underinvestment 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 telehealth models, creating mobile units for dispensing medications for opioid use disorders, supporting pharmacy supply of these drugs, adopting equity-focused collaborative models of care, and expanding access to high-quality care through partnerships between the criminal justice system and providers community, such as outpatient treatment programs and mental health clinics.3

Another possibility is to intervene to address the social determinants of health. Little research has been conducted on how to most effectively address the social determinants of health to improve DUU outcomes; approaches include focusing on underlying issues related to structural racism (for example, inequalities in housing, food, employment, and criminal justice systems based on race and ethnicity) and to help people recovering from SUD to participate more fully in society. For example, the positive effects of equitable access to housing and employment can help counter the maladaptive behaviors associated with DUDs that perpetuate drug use.

Research that examines the ways in which the social determinants of health affect engagement in DUD treatment and DUD-related outcomes could help reduce disparities in these areas. Studies focused on approaches to addressing social determinants in clinical practice – including partnership with community services (e.g., faith-based institutions, local businesses, and non-profit organizations) and engagement with communities themselves – and on the implementation of these approaches could also help to reduce inequities in care access and outcomes.

Prevention is another key area. It is important to develop and implement interventions that minimize the risk of people being unnecessarily exposed to or misused by opioids and other drugs. In addition to addressing the social determinants of health, preventive interventions could prioritize populations at high risk for SUD, such as people who are prescribed opioids for pain relief or people who have a family history of SUD or psychiatric disorders, but who may not have started using substances. For people who have started using drugs, early recognition and intervention could prevent the escalation of drug use and the transition to SUD. Some of these interventions have already been developed, but further research may be needed to ensure that they are acceptable and effective in various racial and ethnic groups and do not exacerbate inequalities.4

A final opportunity is to support data science. Achieving equity will require advances in data collection and modeling to support the end users of data – such as formal health care systems, de facto systems (e.g. the criminal justice system) and decision-makers – to ensure that approaches benefit all groups and do not perpetuate racism. Examples of such advances include the evaluation of existing data and algorithms to detect bias, the integration of information on substance use and social determinants of health into electronic medical records (with appropriate safeguards to protect patient confidentiality), the further harmonization of electronic medical record entries and other information and the linking of various databases, the improvement of data interoperability and the use of simulations or distributed research and data networks to assess the effects of ongoing or planned interventions in specific groups.

Ensuring that research reduces disparities will require several 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 what research matters most to communities, tailor interventions to increase acceptability, and use measures that matter to patients. People with personal experience with the SUD and their families could be involved during the design of the study and throughout the study period.

The second step is to adequately recruit members of historically underrepresented groups, including those with varying levels of education, and to ensure that studies are large enough to measure differences in outcomes by race and the ethnic group. Systematic reviews conducted by the Agency for Health Care Research and Quality and for the US Task Force on Preventive Services often find insufficient data to assess prevention and treatment approaches among underserved groups.5 Recruitment of representative study populations will require intentional efforts to ensure equitable awareness and to overcome distrust of medical research among these communities, which stems from a long history of exploitation and unethical research practices. . Using research methods (including data acquisition, measurement, and analytical approaches) that take cultural differences into account would broaden knowledge bases.

Third, investigators could increase the likelihood that programs will be adopted, effectively implemented, and sustained by establishing equitable partnerships with people who have or have had TUS and their families, clinicians, policy makers, payers, and providers. advocates and engaging these groups in generating evidence, including fully sharing study results with participating communities. Systems established for clinical trials often do not utilize existing community resources and partnerships. Developing and implementing interventions in partnership with communities could help bring effective approaches to underserved groups who are often excluded from research and policy decisions.

Fourth, it will be critical to diversify the scientific workforce, which will require a multi-pronged approach involving funders, professional organizations, and education and research institutions. Such an approach could include recruiting candidates from underrepresented groups for training opportunities, strengthening partnerships with institutions and scientific organizations serving these groups, and establishing grant programs that facilitate entry. researchers from diverse backgrounds.

Finally, disparities in SUD-related outcomes can only be eliminated if researchers measure the effects of policies and interventions on equity. Investigators could aim to identify the factors that most influence disparate outcomes to ensure that policies and interventions take these variables into account. 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 ethnicity, which would compound systemic biases. Studies could enroll a disproportionate number of patients with multiple coexisting conditions and assess the effects of these conditions on SUD-related health outcomes to better address issues affecting underserved populations. To ensure that scarce resources are devoted to interventions that support equity, investigators seeking to tailor interventions to the needs of specific racial and ethnic groups could compare their effects with and without adaptations and determine whether adaptation is needed.

Applying an equity lens to efforts to address the worsening epidemic of overdoses and other SOUTH-related harms is key 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 feedback in research design; engaging patients, communities, payers and decision makers; and re-examining choices about study outcomes and measurement strategies could transform our approaches to pursuing equity and ultimately improving the health and well-being of historically underserved groups.

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