Pandemic-era opioid treatment flexibilities widened racial gaps in Veterans Health Administration care

When COVID-19 upended American healthcare in early 2020, federal regulators scrambled to keep people with opioid use disorder in treatment. Rules that had long required patients to visit clinics daily for methadone were relaxed, take-home doses of methadone expanded, and buprenorphine prescribing became easier to start. The changes were meant to widen access to the two most effective medications for opioid use disorder. But a new analysis of national Veterans Health Administration records suggests the benefits flowed unevenly: the racial and ethnic gaps in who received buprenorphine and methadone did not close during the pandemic, and in some cases widened.

The study, led by Jessica A. Chen and Emily C. Williams of the University of Washington and VA Puget Sound Health Care System, examined monthly treatment patterns among more than 110,000 veterans diagnosed with opioid use disorder between March 2018 and February 2022. Published in Addiction Science & Clinical Practice, the research drew on 48 monthly cohorts extracted from national electronic health records, covering outpatients aged 18 and older with a past-year opioid use disorder diagnosis. The team tracked receipt of any medication for opioid use disorder, including methadone, buprenorphine, and naltrexone, and then examined methadone and buprenorphine separately to see how each medication’s use changed over time and across racial and ethnic groups.

The analytical design was deliberately granular. Rather than comparing a single pre-pandemic year with a single pandemic year, the researchers constructed 48 consecutive monthly cohorts, allowing them to trace trends with unusual precision across the entire 2018 to 2022 window. The primary outcome was receipt of any medication for opioid use disorder in a given month. Secondary analyses split the picture by medication type, because methadone and buprenorphine are delivered through very different channels: methadone is dispensed only through federally regulated opioid treatment programs with strict supervision requirements, while buprenorphine can be prescribed by office-based clinicians and carried in a patient’s pocket.

At the start of the study window, the system looked remarkably equitable on the surface. In March 2018, non-Hispanic Black and non-Hispanic White veterans with opioid use disorder received any medication for opioid use disorder at nearly identical rates, 27.3 percent and 27.8 percent respectively. Hispanic Black patients started at 28.0 percent, essentially matching Hispanic White patients at 28.4 percent and Hispanic patients who were neither Black nor White at 27.0 percent. Four years later, that parity had eroded. By February 2022, 35.0 percent of non-Hispanic White patients were receiving medication, compared with only 29.3 percent of non-Hispanic Black patients. Among Hispanic patients, the same pattern emerged: Hispanic Black patients stood at 26.2 percent, while Hispanic White and Hispanic neither Black nor White patients had climbed to 33.2 percent and 33.7 percent respectively.

The medication-specific numbers reveal where the divergence originated. Buprenorphine receipt increased after the pandemic began, but the increase was strikingly unequal. Non-Hispanic White patients rose from 27.9 percent to 29.8 percent receiving buprenorphine, while non-Hispanic Black patients moved only from 13.9 percent to 15.5 percent and Hispanic Black patients from 11.6 percent to 15.1 percent. In other words, White veterans were roughly twice as likely as Black veterans to receive buprenorphine at both the start and the end of the study period, and the pandemic-era expansion of prescribing did little to narrow that chasm.

Methadone told the opposite story. Receipt of methadone declined after the pandemic began for every group, yet Black patients remained far more dependent on it than White patients. Non-Hispanic Black patients fell from 17.4 percent to 14.4 percent receiving methadone, and Hispanic Black patients from 17.1 percent to 11.9 percent, while non-Hispanic White patients declined only from 6.6 percent to 5.5 percent. The result is a persistent structural pattern: Black veterans with opioid use disorder were more than twice as likely as White veterans to be on methadone, the medication tied to daily clinic visits and rigid dispensing schedules, and far less likely to be on buprenorphine, the medication most compatible with ordinary life, employment, and privacy.

Why does this split matter clinically? Buprenorphine and methadone are both full-strength opioid agonist treatments that reduce overdose mortality and improve retention in care, but they impose different burdens. Methadone traditionally requires daily attendance at a specialized clinic, which can be difficult for people with inflexible jobs, unreliable transportation, or childcare responsibilities. Buprenorphine, by contrast, can be prescribed in routine medical settings and taken at home. When pandemic policies loosened methadone dispensing rules and eased buprenorphine initiation, the expectation was that both medications would reach more people, particularly those historically excluded. The VHA data show that overall access did expand, but the expansion accrued disproportionately to White patients, leaving the underlying hierarchy of treatment untouched.

The study’s authors are careful to frame the findings as descriptive rather than causal. The analysis documents trends in receipt by race and ethnicity across the pre-pandemic and pandemic periods; it does not identify the specific mechanisms that produced the widening gaps. Still, the implications are pointed. Pandemic-related policy changes were intended to expand access to medications for opioid use disorder, the researchers conclude, but their benefits may not have been equitably distributed across racial and ethnic groups. Improving equity, they argue, may require targeted approaches to reduce barriers to both buprenorphine and methadone, rather than assuming that broad flexibilities will lift all boats.

The research also carries methodological significance for how health systems monitor equity. By disaggregating Hispanic patients into Hispanic Black, Hispanic White, and Hispanic neither Black nor White subgroups, the study avoided treating Hispanic veterans as a monolithic category and surfaced disparities that aggregate statistics would conceal. Hispanic Black patients, for example, ended the study period with the lowest medication receipt of any subgroup examined, a finding invisible in analyses that collapse all Hispanic patients together. The work was supported by the National Institute on Drug Abuse and was informed by consultation from groups of veterans with lived and living experience of opioid use, including the Veterans’ Opioid Use disorder Inequities CommitteE and the Research with Expert Advisors on Drug Use panel.

For a health system caring for a population at elevated risk of fatal overdose, the message is sobering. The VHA is the largest integrated healthcare system in the United States, and its electronic health records offer one of the few national windows into how treatment patterns actually shifted when prescribing rules changed. The data show that between 2018 and 2022, the share of White veterans receiving buprenorphine grew while the share of Black veterans receiving methadone shrank, and the two trends combined to leave Black patients with less access to the most flexible, most widely available treatment option. As policymakers consider making pandemic-era flexibilities permanent, the study suggests that flexibility alone is not enough; without deliberate attention to who actually receives each medication, the same structural inequities will persist, and the promise of expanded opioid treatment will remain unevenly fulfilled.

Subject of Research: Racial and ethnic inequities in receipt of methadone and buprenorphine for opioid use disorder in the Veterans Health Administration before and after COVID-19

Article Title: Trends in receipt of methadone vs. buprenorphine by race/ethnicity before and after COVID-19 (2018–2022): a Veterans Health Administration study

Article References: Chen, J. A., Dunn, J. A., Maskey, P., Austin, E. J., Durland, M. L., Ravi, V., Warth, A., Brooks, J., Marshall, S., van Draanen, J., Jones-Smith, J., & Williams, E. C. (2026). Trends in receipt of methadone vs. buprenorphine by race/ethnicity before and after COVID-19 (2018–2022): a Veterans Health Administration study. Addiction Science & Clinical Practice. https://doi.org/10.1186/s13722-026-00730-x

Image Credits: AI Generated

DOI: 10.1186/s13722-026-00730-x

Keywords: opioid use disorder, medications for opioid use disorder, methadone, buprenorphine, health disparities, Veterans Health Administration, COVID-19, race and ethnicity, veterans, addiction treatment, health policy, Trends