Expert forum: Race, ethnicity, and opioids

  | December 7, 2016

Are patients treated differently for pain because of their race or ethnicity?
An analysis of prescribing patterns on the athenahealth network — based on more than 2 million primary care visits from 1.5 million patients — found markedly different rates of opioid prescriptions among white and minority patients.
White patients were most likely to receive opioids: Nearly 10 percent of white commercially insured patients and more than 16 percent of white Medicaid patients had an opioid prescription in 2016.
Asians, meanwhile, were less than half as likely as white Medicaid patients to be prescribed an opioid during that time.
Some public health experts say this new data confirms what has long been assumed: that minority groups are undertreated for pain, for reasons that could range from physician bias to patient behavior.
athenaInsight shared the data with doctors and scholars to learn how it connects to their experiences — and to their own research into racial disparities in medicine.
Here are their responses, edited and condensed. Add yours to the comment section below, or tweet us your thoughts @athena_insight.
Astha Singhal, BDS, MPH, Ph.D., assistant professor of health policy and health services research at Boston University's Henry M. Goldman School of Dental Medicine. Her research found that non-Hispanic blacks in the emergency room were much less likely than white patients to receive opioids for non-visible pain, such as backaches or stomach aches.
Singhal: We hypothesized that because these are vague conditions, the emergency room physicians will rely on subjective cues rather than the definitive conditions. Race and ethnicity might be one of those cues.
Kelly Hoffman, Ph.D., social psychologist and post-doctoral fellow at Northwestern University. As a doctoral candidate at the University of Virginia, she conducted research that found that racial biases contributed to physicians undertreating black patients' pain.
Hoffman: What we found is that white medical students and residents endorse these false beliefs about biological differences between blacks and whites — like blacks' skin is thicker, their blood coagulates more quickly. Half the sample endorsed these beliefs. This in turn contributed to racial bias in pain perception and treatment recommendation.
Singhal: If we were to do a similar study with primary care patients, we'd expect to see less of a disparity. That's because in the emergency room, the physician doesn't have an ongoing relationship with the patient. They're seeing the patient on a sporadic basis. They don't know the patient. The [athenahealth data] is somewhat surprising. These are primary care patients. They might have a longer-term relationship and we still see these disparities.
Hoffman: The white-black difference in the data didn't surprise me. Most of the racial disparities I found were between whites and blacks, and whites and Hispanics…White medical students and residents rated the pain of black patients lower than white patients, and were less accurate in treatment recommendations in black patients' pain.
Singhal: It is a very well-documented fact that the amount of perceived pain is different between different ethnicities — [as is] how aggressive different patients would be in expressing the pain and demanding pain relief.
Ho Luong Tran, M.D., president and CEO of the National Council of Asian Pacific Islander Physicians: The majority of the Hispanic and African-American patients seen by our network of physicians, they are more aggressive in asking for painkillers. Asians don't have that aggressivity …they assume that the person of authority — the doctor or medical provider — knows what's good for them. It's very much a culture of being stoic and saving face. And that transcends everything, all of your behavior and attitudes.
Eugene Welch, executive director of South Cove Community Health Center, which serves more than 32,000 Asian patients from 120 zip codes in Massachusetts: We find in the Asian population, they are not big drug users. If you spoke to me about smoking or gambling as an addiction, it's a completely different story. Knock on wood, so far, [opioid addiction] has not been a problem at our health center.
Tran: Asians have a lower rate of compliance to prescriptions: They can say, “yes, yes," but they don't follow through for two reasons. [Some recent immigrants] don't understand what the doctor said, and the doctor doesn't know. Or the patient disagrees with the doctor, but they would dare not say that. When they get home, they throw the pills away.
Welch: We find in Quincy, Mass., where there are more Caucasians [than in other South Cove clinics] they go around trying to shop prescriptions. The doctors get kind of leery when a patient is trying to indicate what we should be giving them for their pain. That means they [originally] got it someplace else, [and] that doctor stopped giving it to them.
Singhal: We found whites were more likely to get opioids. We think that might be contributing to the huge opioid epidemic we are seeing predominantly in the non-Hispanic white population. The entire white population is more at risk of getting addicted. There is much more of a supply for friends and family. This is part of a bigger problem. It might denote the undertreatment of pain for minorities, but it also might be a contributing factor to the opioid epidemic for the white population.
Allison Manning is a writer based in Boston.

Expert forum: Race, ethnicity, and opioids