Yesterday’s 52nd Annual Conference of the American Society of Addiction Medicine focused this year’s Public Policy and Science Plenary Session on racism in opioid treatment and how the old and current African American opioid epidemic has been total different from the new White epidemic as viewed respectively by a patient advocate (Gardner), researcher (Hansen), and front-line treatment provider (Chapman). Buprenorphine, the most preferred Medication for Opioid Use Disorder (MOUD) is the only medication in the history of medicine designed, marketed, and regulated specifically for suburban (White) patients and discouraged for use in urban (Black) patients.

DC’s rise to #1 in 2020 in per capita overdose deaths is no accident! Beginning in 2017 my practice has been targeted 5 times for audit/investigations including DC Healthcare Finance (x2), AmeriHealth Caritas DC, United Health Care, and just last month by Express Scripts. As Dr. Hansen and I have documented for years, African patients (disproportionately Medicare and Medicaid) have been systematically relegated to low cost, dank, and impersonal methadone clinics while White patients have been steered to private practice (often cash only) buprenorphine boutiques for this relatively expensive, life saving medication.

The buprenorphine/opioid crisis in DC illustrates the classic example of corporate-regulatory incompetence and failure with its current Medicaid MCO contracting fiasco. Opioid use disorder patients are among the 19,000 (250,000 DC Medicaid residents) who cost upwards of $25,000 per year in medical costs alone (Fed Register Nov 2, 2020 estimate = $42,000). In addition, these neglected, untreated patients are often homeless, mentally challenged, and frequent fliers to jail and/or community support services costing another $70,000 in hidden taxpayer services. In an effort to better treat this elusive clientele, the city typically contracts with 3 competing Medicaid MCOs each with supposedly comparable patient profiles and provider networks. However these corporate executives know that if they can create administrative barriers to care they can alter this patient payer mix by encouraging complex, high cost patients in their pool to switch to one of the other 2 competing plans leaving themselves with fewer costly patients and higher profit margins. Pharmaceutical benefits management “prior authorizations” (PAs) are one of the major tools used against these patients, erroneously touted to control diversion of buprenorphine, but in reality it is just another sleazy mechanism to reduce access to care and thereby reduce their short term medication costs. Likewise, physician/providers who attract these high cost patients are simultaneously targeted with audits, onerous administrative burdens like PAs, and convoluted underpayment schemes.

After decades of public policy and regulatory neglect, DC is now the gentrification capital and COVID-19 poster child for Black Death combining COVID, overdose deaths, and rising juvenile homicides fostered by our multi-generations of abandoned youth due to misdiagnosed, undertreated, incarcerated or dead parents.

Edwin C Chapman, MD, DABIM, FASAM.