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）是一种常见且通常致命的慢性疾病，可以通过以下方法有效治疗 药物（MOUD）。激动剂（美沙酮，丁丙诺啡）是降低过量风险的一线治疗。 黑人和西班牙裔/拉丁裔患者接受丁丙诺啡的可能性低于非西班牙裔白色患者。 这引起了公平问题，因为丁丙诺啡可能比其他药物更安全，更容易获得，也更少受到侮辱。 美沙酮对很多病人来说新型冠状病毒（COVID-19）大流行增加了 提供MOUD，包括丁丙诺啡的远程医疗启动。这些政策可能会减少 通过降低护理障碍来消除现有的差距，但如果它们不是同样有益的， 跨群体。与COVID-19相关的政策变化提供了一个前所未有的机会，可以检查 对结构性种族主义造成的不平等进行结构性干预-放宽MOUD限制， 歧视（SRD）。在公共卫生关键种族实践的指导下， 本项目将使用混合方法评估 MOUD访问可能已经改变，以应对退伍军人健康中的COVID-19相关政策 管理（VA），全国最大的物质使用护理提供者，以及SRD如何贡献。不平等 获得丁丙诺啡是全国性的一个重大问题-研究估计， 与观察到相似差异的白色患者相比，使用丁丙诺啡的可能性低50-60% 在西班牙裔/拉丁裔患者中。拟议的研究可以指导国家和卫生系统的具体政策 关于在COVID-19后继续放宽MOUD处方指南以及在何处 有针对性地提供资源，以解决SRD及其后果。从这一历史事件中吸取的教训可以影响 未来的MOUD政策和实践，至关重要的是， 对差异的理解应有助于优化公平方面的政策变化。本研究的目的是：（1）研究 在COVID-19 MOUD政策之后，Black和 西班牙裔/拉丁裔与非西班牙裔白色OUD患者的比较; 2）检查社区水平 结构性种族主义的后遗症影响了COVID-19前后黑人MOUD收据的变化， 西班牙裔/拉丁裔OUD患者;和3）定性检查OUD护理的经验和对OUD护理的感知。 在黑人和西班牙裔/拉丁裔OUD患者样本中实施COVID-19相关政策。 目的1-2是使用黑人的国家VA电子健康记录（EHR）数据进行的观察性队列研究， 西班牙裔/拉丁裔和非西班牙裔白色OUD患者。Aim 3采用定性研究设计， 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MOUD收据在COVID-19前/后进行平衡。将传播调查结果 通过国家渠道，为未来的城市发展部政策和干预措施提供信息，以提高公平性。

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.