David Geffen School of Medicine, UCLA (University of California, Los Angeles).
Department of Emergency Medicine, UCLA.
JAMA Intern Med. 2019 Apr 1;179(4):469-476. doi: 10.1001/jamainternmed.2018.6721.
Most drug epidemics in the United States have disproportionately affected nonwhite communities. Notably, the current opioid epidemic is heavily concentrated among low-income white communities, and the roots of this racial/ethnic phenomenon have not been adequately explained.
To examine the degree to which differential exposure to opioids via the health care system by race/ethnicity and income could be driving the observed social gradient of the current opioid epidemic, as well as to compare the trends in the prevalence of prescription opioids with those observed for stimulants and benzodiazepines.
DESIGN, SETTING, AND PARTICIPANTS: This population-based study used 2011 through 2015 records from California's prescription drug monitoring program (Controlled Substance Utilization Review and Evaluation System), which longitudinally tracks all patients receiving controlled substance prescriptions in the state and contained unique records for 29.7 million individuals who received such a prescription from 2011 to 2015. Data were analyzed between January and May 2018.
A total of 1760 zip code tabulation areas (ZCTAs) in California, with associated racial/ethnic composition and per capita income.
The percentage of individuals receiving at least 1 prescription each year was calculated for opioids, benzodiazepines, and stimulants.
A nearly 300% difference in opioid prescription prevalence across the race/ethnicity-income gradient was observed in California, with 44.2% of adults in the quintile of ZCTAs with the lowest-income/highest proportion-white population receiving at least 1 opioid prescription each year compared with 16.1% in the quintile with the highest-income/lowest proportion-white population and 23.6% of all individuals 15 years or older. Stimulant prescriptions were highly concentrated in mostly white high-income areas, with a prevalence of 3.8% among individuals in the quintile with the highest-income/highest proportion-white population and a prevalence of 0.6% in the quintile with the lowest-income/lowest proportion-white population. Benzodiazepine prescriptions did not have an income gradient but were concentrated in mostly white areas, with 15.7% of adults in the quintile of ZCTAs with the highest proportion-white population receiving at least 1 prescription each year compared with 7.0% among the quintile with the lowest proportion-white population.
The race/ethnicity and income pattern of opioid overdoses mirrored prescription rates, suggesting that differential exposure to opioids via the health care system may have induced the large, observed racial/ethnic gradient in the opioid epidemic. Across drug categories, controlled medications were much more likely to be prescribed to individuals living in majority-white areas. These discrepancies may have shielded nonwhite communities from the brunt of the prescription opioid epidemic but also represent disparities in treatment and access to all medications.
在美国，大多数药物流行都不成比例地影响了非白人社区。值得注意的是，目前的阿片类药物流行在很大程度上集中在低收入的白人社区，而这种种族/民族现象的根源尚未得到充分解释。
研究通过种族/民族和收入，在医疗保健系统中接触阿片类药物的差异在多大程度上导致了当前阿片类药物流行的明显社会梯度，以及比较处方阿片类药物的流行趋势与兴奋剂和苯二氮䓬类药物的流行趋势。
设计、地点和参与者：这项基于人群的研究使用了 2011 年至 2015 年加利福尼亚州的处方药物监测计划（受控物质利用审查和评估系统）的数据，该计划纵向跟踪该州所有接受受控物质处方的患者，并包含了 2011 年至 2015 年期间接受此类处方的 2970 万个人的独特记录。数据分析于 2018 年 1 月至 5 月进行。
加利福尼亚州的 1760 个邮政编码区域（ZCTA），以及与之相关的种族/民族构成和人均收入。
每年计算至少有 1 次处方的个人的阿片类药物、苯二氮䓬类药物和兴奋剂的比例。
在加利福尼亚州，种族/民族-收入梯度上的阿片类药物处方流行率差异近 300%，收入最低/白人群体比例最高的 ZCTA 五分位组中，每年至少有 1 次阿片类药物处方的成年人比例为 44.2%，而收入最高/白人群体比例最低的五分位组中，这一比例为 16.1%，所有 15 岁及以上的人群中，这一比例为 23.6%。兴奋剂处方高度集中在主要是白人的高收入地区，在收入最高/白人群体比例最高的五分位组中，有 3.8%的人每年至少有 1 次兴奋剂处方，而在收入最低/白人群体比例最低的五分位组中，这一比例为 0.6%。苯二氮䓬类药物没有收入梯度，但集中在主要是白人的地区，在白人群体比例最高的 ZCTA 五分位组中，每年至少有 1 次处方的成年人比例为 15.7%，而在白人群体比例最低的五分位组中，这一比例为 7.0%。
阿片类药物过量的种族/民族和收入模式反映了处方率，表明通过医疗保健系统接触阿片类药物的差异可能导致了阿片类药物流行的巨大、明显的种族/民族梯度。在所有药物类别中，接受治疗的人更有可能是生活在白人为主的地区。这些差异可能使非白人社区免受处方类阿片药物流行的严重影响，但也反映了治疗和获得所有药物方面的差异。
