Black and Hispanic Medicaid Patients Get Less Buprenorphine After Opioid Crises, Study Finds

A sweeping analysis of Medicaid records from 19 states has revealed stark racial and ethnic gaps in who receives lifesaving medications after the most dangerous moments of opioid addiction: emergency department visits, hospitalizations, and detox admissions for overdose, withdrawal, or injection-related infections. The study, published in the Journal of General Internal Medicine, found that Black and Hispanic patients were consistently less likely than White patients to fill prescriptions for buprenorphine, the gold-standard medication for opioid use disorder, and less likely to stay on the drug once they started. The findings arrive amid a fentanyl-driven overdose crisis that continues to kill tens of thousands of Americans each year, and they point to a troubling conclusion: the moments when patients are most likely to engage with treatment are not being converted into care equitably.

The research team, led by emergency physician Hazar Khidir of Henry Ford Hospital and including investigators at Stanford University, the University of Washington, and Yale University, assembled one of the largest cohorts ever used to study this question. Drawing on 100 percent Medicaid claims files from 2016 through 2019, they identified 234,944 acute opioid-related events among 169,721 beneficiaries aged 18 to 64. To qualify, an encounter had to involve a nonfatal emergency department visit, an acute inpatient admission, or an inpatient rehabilitation or detoxification stay tied to opioid overdose, opioid withdrawal, or an infection caused by injection drug use. These are precisely the clinical junctures that addiction medicine specialists call teachable moments, when a patient has survived an overdose or been hospitalized for a serious infection and may be uniquely receptive to starting treatment.

The technical design of the study matters for interpreting its results. The researchers tracked three primary outcomes: whether patients filled a buprenorphine prescription within 30 days of discharge, whether they filled a naloxone prescription, the nasal spray that reverses opioid overdoses, within the same window, and whether they achieved what the field calls buprenorphine retention, defined as at least 150 days of the medication on hand within 180 days of the encounter. They also examined early engagement, measured as fills within just three days. To isolate the effect of race and ethnicity from other factors, the team used hierarchical logistic regression, a statistical approach well suited to claims data because it accounts for patients being clustered within states and years. The models adjusted for age, sex, comorbid medical conditions, prior treatment history, the specific diagnosis that brought the patient in, the state of residence, and the calendar year.

The baseline numbers alone are sobering. Across all 234,944 events, only 14.08 percent of patients filled a buprenorphine prescription within 30 days, and just 3.78 percent filled naloxone. Only 4.62 percent were retained on buprenorphine at 180 days. In other words, after surviving an overdose or being hospitalized for a life-threatening infection from injection drug use, fewer than one in seven Medicaid beneficiaries started the medication most strongly associated with keeping them alive, and fewer than one in twenty stayed on it long enough to derive its full protective effect. The cohort was 68.1 percent White, 11.5 percent Black, and 11.1 percent Hispanic, with a mean age of 37.48 years and 43.36 percent female.

When the researchers compared racial and ethnic groups after statistical adjustment, the disparities emerged clearly and consistently. Compared with non-Hispanic White patients, Black patients had significantly lower adjusted odds of filling buprenorphine within 30 days across every setting studied: the odds were 21 percent lower after emergency department visits (adjusted odds ratio 0.79, 95 percent confidence interval 0.71 to 0.88), 28 percent lower after inpatient admissions (0.72, 0.63 to 0.83), and 17 percent lower after rehab or detox stays (0.83, 0.71 to 0.97). Hispanic patients fared similarly, with 20 percent lower odds after emergency visits (0.80, 0.73 to 0.88) and 17 percent lower odds after inpatient admissions (0.83, 0.75 to 0.93). These are not marginal differences confined to one corner of the health system; they span the entire acute care continuum.

The retention findings were even more alarming. Among patients who did manage to start buprenorphine, Black patients had 36 percent lower adjusted odds of being retained at 180 days after an emergency department encounter (0.64, 0.55 to 0.74), 49 percent lower odds after an inpatient stay (0.51, 0.43 to 0.60), and 37 percent lower odds after rehab or detox (0.63, 0.48 to 0.82). Hispanic patients showed 30 percent lower odds after emergency visits (0.70, 0.62 to 0.79) and 34 percent lower odds after inpatient admissions (0.66, 0.56 to 0.78). An odds ratio of 0.51 means that, after accounting for every measured confounder, a Black patient hospitalized for an opioid-related crisis had roughly half the chance of a comparable White patient of still being on medication six months later. Retention is the single most important predictor of buprenorphine’s mortality benefit; studies have shown that interruptions in medication dramatically raise overdose risk.

The study’s focus on Medicaid is deliberate and consequential. Medicaid is the dominant payer for people with opioid use disorder in the United States, covering a population that bears a disproportionate share of the overdose burden. Because the program insures patients across state lines and across every type of acute care setting, it offers a rare, near-complete window into how the treatment system actually performs. Prior work had already documented a racial divide in buprenorphine access: a 2023 analysis in the New England Journal of Medicine found racial inequality in the receipt of medications for opioid use disorder, and studies of emergency departments across five health systems showed that Black patients were less likely to be started on buprenorphine during their visits. The new study extends that evidence to the post-discharge period and to inpatient and detoxification settings, using a multi-state design that rules out the possibility that the gaps are an artifact of any single state’s policy or any single hospital’s practice.

Why do these disparities persist even after adjusting for diagnosis, comorbidity, and prior treatment? The authors and the broader literature point to a layered set of mechanisms. On the provider side, clinicians may offer buprenorphine less often to patients of color, a pattern documented in emergency department studies and consistent with a bifurcated treatment system in which White patients are more often steered toward office-based medication while Black and Hispanic patients are channeled toward abstinence-oriented or criminal-legal pathways. On the structural side, counties with high levels of racial and ethnic segregation have less treatment capacity for opioid use disorder, meaning that even a motivated patient may leave a hospital without a nearby prescriber. Medicaid itself adds friction: prior authorization requirements and managed care formulary restrictions vary by state and can delay or block fills, and pharmacy deserts are more common in predominantly Black and Latino neighborhoods. Naloxone distribution, meanwhile, has historically under-reached communities of color even as fentanyl has made overdose risk universal.

The consequences of these gaps are measured in lives. Buprenorphine reduces mortality during treatment, and the period immediately after an overdose or hospital discharge is one of extreme vulnerability, with overdose risk elevated for weeks. Every failure to initiate or sustain medication during a transitional window compounds that risk. The study’s authors argue that improved transitional care, warm handoffs from emergency departments and hospitals to community-based treatment, overdose education, take-home naloxone, and follow-up appointments, combined with targeted Medicaid reforms such as streamlined coverage of medications and enhanced payment for transitional care management, could close the gap. The elimination of the federal buprenorphine waiver requirement, often called the MAT Act, has removed one prescriber-level barrier, but the new findings suggest that prescriber-level change alone will not be sufficient.

What makes this study resonate beyond the specialty literature is its scale and its consistency. Nearly a quarter of a million acute opioid-related events, spanning 19 states and four years, all point in the same direction: at the moments when the health system has the greatest leverage over the trajectory of opioid use disorder, Black and Hispanic patients are systematically less likely to receive and keep the treatment that best prevents death. The opioid crisis has often been described as having shifted demographically, with rising overdose rates among Black Americans in recent years, yet the treatment infrastructure has not kept pace with that shift. As policymakers weigh Medicaid reforms and health systems build out addiction consult services and emergency department buprenorphine programs, the study offers a clear benchmark: equitable access must be measured not just in who walks through the door, but in who leaves with a prescription filled, and who is still taking their medication six months later.

Subject of Research: Racial and ethnic disparities in buprenorphine and naloxone receipt and retention among Medicaid beneficiaries after acute opioid-related care

Article Title: Racial and Ethnic Disparities in Buprenorphine and Naloxone among Medicaid Beneficiaries after Emergency Department Visits and Hospitalizations

Article References: Khidir, H., Nedelec, L., Sebok-Syer, S. S., Sabbatini, A. K., Shin, I., Melnick, E. R., & Lin, M. P. (2026). Racial and Ethnic Disparities in Buprenorphine and Naloxone among Medicaid Beneficiaries after Emergency Department Visits and Hospitalizations. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10838-0

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10838-0

Keywords: opioid use disorder, buprenorphine, naloxone, Medicaid, health disparities, emergency department, hospitalization, treatment retention, overdose, addiction medicine, health equity, transitional care