The Pandemic Loosened Opioid Treatment Rules. In VA Care, White Veterans Got Most of the Benefit.

When COVID-19 shut down clinics in March 2020, federal regulators did something they had resisted for two decades: they let methadone patients take doses home and made it easier to start people on buprenorphine. The flexibilities were billed as an access expansion, and in raw numbers they were one.

A new analysis of national Veterans Health Administration records finds the expansion did not distribute itself evenly. Jessica A. Chen and Emily C. Williams of the University of Washington and VA Puget Sound tracked more than 110,000 veterans diagnosed with opioid use disorder between March 2018 and February 2022, building 48 consecutive monthly cohorts instead of comparing one year to another. The study appears in Addiction Science & Clinical Practice.

In March 2018 the system looked equitable. Black and White veterans received medication for opioid use disorder at nearly identical rates, 27.3 and 27.8 percent. By February 2022, White veterans had climbed to 35.0 percent and Black veterans to 29.3 percent. Hispanic White patients reached 33.2 percent; Hispanic Black patients fell to 26.2 percent, the lowest of any group.

What 48 Monthly Cohorts Showed

The two medications moved in opposite directions, and that is where the mechanism becomes visible. Buprenorphine receipt rose after the pandemic began, but almost entirely for White patients: from 27.9 to 29.8 percent, against 13.9 to 15.5 percent among Black veterans. White veterans were roughly twice as likely to receive it at the start of the period and twice as likely at the end.

Methadone went the other way, declining for everyone. Black veterans fell from 17.4 to 14.4 percent, Hispanic Black veterans from 17.1 to 11.9 percent, White veterans from 6.6 to 5.5 percent. Black veterans were therefore more than twice as likely as White veterans to be on the medication that requires daily clinic attendance, and far less likely to be on the one that can be prescribed in a doctor's office and carried in a pocket.

Both drugs save lives, but they impose different burdens. Daily methadone attendance collides with shift work, unreliable transportation and childcare in ways buprenorphine does not, so a system that routes Black patients toward the more restrictive option has not solved an access problem so much as relocated it.

The authors describe the findings as descriptive: the analysis documents who received which medication, not why the gaps opened. It was funded by the National Institute on Drug Abuse and shaped by veterans with lived experience of opioid use.

Why the Split Outlasts the Emergency

Most pandemic-era flexibilities are now permanent, which makes the study's warning a live policy question. Loosening a rule changes what is permitted; it does not change who gets told about the option, which clinic has a waivered prescriber on staff, or whose urine screen gets read as relapse rather than progress.

That has consequences for how medication-assisted treatment gets measured. A health system reporting a rising share of patients on medication can be telling a genuinely good story and still leave the gap untouched, because the aggregate number cannot see which drug each patient received. Disaggregating by medication and by subgroup — as this study does with Hispanic veterans, a category whose internal differences vanish in national statistics — is the difference between an access metric and an equity metric.

For the VA, the country's largest integrated health system, the finding lands on a population at elevated risk of fatal overdose — and on a decision clinicians make daily, rarely thinking of it as a civil rights question: which of the two opioid addiction medications to offer, and to whom.