Applying Critical Race Theory to investigate the impact of COVID-19-related policy changes on racial/ethnic disparities in medication treatment for opioid use disorder

阿片类药物使用障碍(OUD)是一种常见且往往致命的慢性疾病，可以有效地治疗 药物(Moud)。激动剂(美沙酮、丁丙诺啡)是降低过量用药风险的一线治疗方法。 与非西班牙裔白人患者相比，黑人和西班牙裔/拉丁裔患者接受丁丙诺啡治疗的可能性较小。 这引发了人们对股权的担忧，因为丁丙诺啡可能比丁丙诺啡更安全、更容易获得，而且更少受到羞辱 美沙酮对许多患者来说。新型冠状病毒(新冠肺炎)大流行导致在 提供Moud，包括启动丁丙诺啡的远程医疗。这些政策可能会减少 通过降低护理壁垒来降低现有的差距，但如果它们不是同等有益的，可能会加剧差距 跨组。新冠肺炎相关政策变化提供了前所未有的机会来审视其影响 结构性干预--放松穆德限制--对结构性种族主义和 歧视(SRD)。在公共卫生关键种族实践的指导下，该组织认为 医疗服务的可获得性是由SRD产生的，该项目将使用混合方法来评估 Moud访问可能已更改，以回应退伍军人健康委员会中的新冠肺炎相关政策 美国最大的物质使用护理提供者--国家药品监督管理局(VA)以及SRD如何做出贡献。不平等 在全国范围内，丁丙诺啡的使用是一个严重的问题-研究估计患有OUD的黑人患者 与观察到类似差异的白人患者相比，使用丁丙诺啡的可能性降低了50%-60% 在西班牙裔/拉丁裔患者中。建议的研究可以指导国家和卫生系统的具体政策。 关于新冠肺炎后继续使用Moud宽松处方指南的决定以及在哪里 为解决SRD及其后遗症提供目标资源。从这一历史事件中吸取的教训可以影响 未来的政策和实践，至关重要的是对差距和潜在机制的影响 应理解差异，以优化与公平有关的政策变化。这项研究的目的是：1)研究 新冠肺炎穆德策略后收到穆德的更改和保留的更改在黑色和 西班牙裔/拉丁裔与非西班牙裔白人OUD患者的比较；2)检查社区水平如何 结构性种族主义的后遗症影响新冠肺炎前后的变化 西班牙裔/拉丁裔OUD患者；以及3)定性检查OUD护理的经历和对 在黑人和拉美裔/拉丁裔OUD患者中实施新冠肺炎相关政策的情况。 目标1-2是使用布莱克的国家退伍军人电子健康记录(EHR)数据的观察性队列研究， 西班牙裔/拉丁裔和非西班牙裔白人OUD患者。目标3采用定性研究设计，包括 对患有OUD的黑人和西班牙裔/拉丁裔VA患者进行半结构化电话采访。分层随机 样本将根据性别和穆德收据在新冠肺炎之前/之后进行平衡。调查结果将被传播 通过国家渠道为未来的穆德政策和干预措施提供信息，以改善公平。

Opioid use disorder (OUD) is a common and often fatal chronic condition that can be effectively treated with medications (MOUD). Agonists (methadone, buprenorphine) are first-line treatments that reduce overdose risk. Black and Hispanic/Latinx patients are less likely to receive buprenorphine than non-Hispanic White patients. This raises equity concerns, as buprenorphine may be safer, easier to access and less stigmatizing than methadone for many patients. The novel coronavirus (COVID-19) pandemic resulted in increased flexibility in the provision of MOUD, including telemedicine initiations for buprenorphine. These policies may reduce existing disparities by lowering care barriers but could exacerbate disparities if they are not equally beneficial across groups. COVID-19-related policy changes present an unprecedented opportunity to examine impacts of a structural intervention—relaxed MOUD restrictions—on disparities generated by structural racism and discrimination (SRD). Guided by Public Health Critical Race praxis, which posits that racial/ethnic disparities in healthcare access are produced by SRD, this project will use mixed methods to evaluate how disparities in MOUD access may have changed in response to COVID-19-related policies in the Veterans Health Administration (VA), the nation's largest provider of substance use care, and how SRD contributes. Unequal access to buprenorphine is a significant problem nationally—studies estimate that Black patients with OUD are 50-60% less likely to access buprenorphine compared to White patients with similar disparities observed among Hispanic/Latinx patients. The proposed research can guide national and health-system-specific policy decisions regarding the continuation of relaxed MOUD prescribing guidelines post- COVID-19 and where to target resources to address SRD and its sequelae. Lessons learned from this historical event can influence future MOUD policy and practice, and it is essential that the impact on disparities and mechanisms underlying disparities be understood to optimize policy changes with regard to equity. This study aims to: 1) examine how changes in receipt of MOUD and retention following COVID-19 MOUD policies differ between Black and Hispanic/Latinx compared to non-Hispanic White patients with OUD; 2) examine how community-level sequelae of structural racism influence pre/post COVID-19 changes in MOUD receipt for Black and Hispanic/Latinx patients with OUD; and 3) qualitatively examine experiences of OUD care and perceptions of implementation of COVID-19-related policies among a sample of Black and Hispanic/Latinx patients with OUD. Aims 1-2 are observational cohort studies using national VA electronic health record (EHR) data for Black, Hispanic/Latinx, and non-Hispanic White patients with OUD. Aim 3 uses a qualitative study design involving semi-structured phone interviews with Black and Hispanic/Latinx VA patients with OUD. A stratified random sample will be balanced on gender and MOUD receipt pre/post COVID-19. Findings will be disseminated through national channels to inform future MOUD policies and interventions to improve equity.