Variation in receipt of pharmacotherapy for alcohol use disorders across racial/ethnic groups: A national study in the U.S. Veterans Health Administration

Highlights

• Disparities in receipt of pharmacotherapy for alcohol use disorders exist across race.

• Black patients are less likely than white to receive effective pharmacotherapies.

• Efforts are needed to increase alcohol use disorder (AUD) pharmacotherapy across populations; targeted efforts may be needed.

Abstract

Objective

Pharmacologic treatment is recommended for alcohol use disorders (AUD), but most patients do not receive it. Although racial/ethnic minorities have greater AUD consequences than whites, whether AUD medication receipt varies across race/ethnicity is unknown. We evaluate this in a national sample.

Methods

Electronic health records data were extracted for all black, Hispanic, and/or white patients who received care at the U.S. Veterans Health Administration (VA) during Fiscal Year 2012 and had a documented AUD diagnosis. Mixed effects regression models, with a random effect for facility, determined the likelihood of receiving AUD pharmacotherapy (acamprosate, disulfiram, topirimate or oral or injectable naltrexone ≤180 days after AUD diagnosis) for black and Hispanic patients relative to white patients. Models were unadjusted and then adjusted for patient- and facility-level factors.

Results

297,506 patients had AUD; 26.4% were black patients, 7.1% were Hispanic patients and 66.5% were white patients; 5.1% received AUD medications. Before adjustment, black patients were less likely than white [Odds Ratio (OR) 0.77; 95% Confidence Interval (CI) 0.75 −0.82; (p < 0.001)], while Hispanic patients were more likely than white (OR 1.09; 95% CI 1.01–1.16) to receive AUD medications. After adjustment, black patients remained less likely than white to receive AUD medications (OR 0.68; 95% CI 0.65–0.71; p < 0.0001); no difference between Hispanic and white patients was observed (OR 0.94; 95% CI 0.87–1.00; p = 0.07).

Conclusions

In this national study of patients with AUD, blacks were less likely to receive AUD medications than whites. Future research is needed to identify why these disparities exist.

Introduction

Alcohol use disorders (AUD) are common, with a lifetime prevalence of nearly 30% in the U.S. general population (Grant et al., 2015). Effective treatments are available and recommended by clinical guidelines (National Health Service, 2010, National Institute on Alcohol Abuse and Alcoholism, 2007). One evidence-based approach to treating AUD is the use of pharmacotherapy. Four evidence-based medications are recommended for AUD treatment (Jonas et al., 2014). Three are FDA-approved for treating AUD, including disulfiram (often called antabuse^®), acamprosate, and naltrexone, which is available both orally and via monthly injections (Lingford-Hughes et al., 2012). Another medication—topiramate— while not FDA-approved has strong meta-analytic support for treatment of AUD (Jonas et al., 2014). Use of pharmacotherapy is particularly promising for treating AUD because it may address often-cited barriers to receiving specialty addictions treatment (e.g., time, mandatory group settings, not being ready to abstain from drinking) (Cohen et al., 2007, Gastfriend et al., 2007, McLellan, 2007). However, a very small proportion of persons with AUD (4–12%) are treated pharmacologically (Harris et al., 2010, Harris et al., 2012, Mark et al., 2009). This may be due to a number of factors including costs, patient preference, and provider knowledge, skills, and beliefs (Harris et al., 2013, Mark et al., 2003, Oliva et al., 2011).

Receipt of evidence-based treatments for AUD may be particularly important in some population subgroups due to their higher vulnerability to the adverse effects of alcohol use. While the prevalence of AUD in the U.S. general population is lower among racial/ethnic minorities than among white persons (Grant et al., 2015), racial/ethnic minorities, particularly black individuals, often have more severe health (e.g., liver disease) and social (e.g., legal problems, arguments, accidents) consequences from AUD than whites (Mulia et al., 2009, Witbrodt et al., 2014, Zemore et al., 2016). Moreover, there have been greater increases in the prevalence of heavy episodic drinking among blacks than whites in the past decade (Dawson et al., 2015). In an earlier study of ours among patients in the United States Veterans Health Administration (VA), we found black patients had the highest rates of clinically diagnosed AUD relative to Hispanic and white patients (Williams et al., 2016). Therefore, racial/ethnic minorities, and black persons in particular, may represent a vulnerable population of patients with AUD for whom receipt of evidence-based treatments may be particularly important.

Several previous studies have described racial/ethnic differences in receipt of evidence-based alcohol interventions and treatments with somewhat mixed findings (Bensley et al., 2017, Cook and Alegria, 2011, Dobscha et al., 2009, Glass et al., 2010, Mukamal, 2007, Williams et al., 2012b, Zemore et al., 2014). However, whether receipt of medications for AUD varies across race/ethnicity is unknown. In this study, we describe racial/ethnic differences in receipt of medications for AUD disorders in a national sample of patients with clinically recognized AUD from the U.S. VA.