Racial and Ethnic Disparities in Emergency Department-Initiated Buprenorphine Across 5 Healthcare Systems

Author Department

Emergency Medicine

Document Type

Article, Peer-reviewed

Publication Date



Background: Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood.

Methods: This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 ED's across 5 healthcare systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic versus community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity.

Results: Black patients were less likely to receive buprenorphine (6.4% [51/801] versus White patients 8.5% [268/3154], OR 0.59, 95%CI 0.45-0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type and urbanicity (aOR 0.64, 95%CI 0.48-0.84) but not when discharge diagnosis was included (aOR 0.75, 95%CI 0.56-1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] versus non-Hispanic patients 11.6% [475/4098]) in unadjusted (OR 1.57, 95%CI 1.09-1.83) and adjusted models (aOR 1.41, 95%CI 1.08-1.83) but not including discharge diagnosis (aOR 1.32, 95%CI 0.99-1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p=0.97) and ethnicity (interaction p=0.64).

Conclusion: Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community ED's. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician and community level.