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.

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I think females and RNs are in the numbers never getting opoids!! I was undermedicated when having shingles and haven’t been ging any since!! I don’t even ask any more! Ever get anything unless I go to a clinic or the ER!! I get more pain relief with chiropractic adjustments at age 82!!

Name: 
Florence McFarlane BSN, RN retired
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I need opioids to function. Without pain I can leave a normal life without pain meds I have NO life except to suffer in in ungodly pain

Name: 
Elizabeth Baldwin
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When it takes 6months to see doctors they do there and don’t listen to I have to say I and the one who suffers all this time.I dare one to suffer one week, thatI must to for months

Name: 
Elizabeth Baldwin
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I am Native American. I recently had total knee replacement. My pain meds lasted, following the prescription, 3 days. My knee doctor said to go to my provider for pain meds before my next appointment with him. I went. I was told I shouldn’t need pain meds because it had been 4 days since the surgery. The next day I told physical therapist and they were horrified. So was my surgeon when I saw him the next week. I have always thought doctors look at me differently than non-natives.

Name: 
Deborah
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I’m a person of color never seeking opiods, never needed any but it is a shame & a crime if a physician who has sworn to do no harm is so in humane
Who are these people & how do they look at themselves in the mirror

Name: 
Dana Miller
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So your saying if your white and I don’t know you I’ll believe your in pain and give you opioid
But if your Black you are less likely to be treated with opioid under the same circumstances in the ED. Now I already know this because I am a white woman with biracial children and grandchildren and they will barely touch my children. They ask a few questions and send them packing. One had a SEVERE CONCUSSION that left her with short term memory lose and a Grandson that a a GRAND MAl SEIZURE and they refused to belive me and sent him home after giving him a Tylenol for a global headache and said he was dehydrated and passed out and they gave him an 8 Oz glass of water. No blood work! And I was a Neuro Critical Care Nursery. Both of these were my expertise as a nurse and they WOULD NOT treat them for any kind of severe pain
They did a CT of my daughters head to dx the concussion but sent her home.

Name: 
Kathy
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Please contact me I would love to offer Cannabis is an alternative for opioid addiction and also for chronic pain my name is Dr. Uma Dhanabalan and I state ‘Cannabis is not an entrance drug it is an exit drug from pharmaceuticals and narcotics.’
UpliftingHealthand Wellness@gmail.com
5084442324
TotslHealthCareTHC.com

Name: 
Dr Uma Dhanabalan
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Unfortunately, Cannabis is not an option for many. I live in Tx. I see a pain management Dr monthly for 5 yrs now. Last month she informed me the new guidelines recommend non narcotic treatment for my diagnosis. Im frquently drug tested. If I test positive ONCE for THC, Im fired from their practice. I cant smoke & be a nurse. Not to mention I wouldn’t even know where to get what I need. All the Cannabis here is to get high, high, high. Dont like the feeling & actually hightens pain.

Name: 
Patricia lara
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This entire report is flawed. Why? Because at the present time all people are not getting opioids because of the risk of addiction. When the real addiction is from street heroin. In fact, we (all prescribers and health care workers) are being told not to give opioids.Sad really when they are needed and not given . Medications are given out more to people that have the means to pay the co-pay also. Which is not defined in this report. Nor is gold standards of the study, P-score, control group, confounding variables? The national trend is to give less opioids.

Name: 
Sean D Baxter
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Ha!!!! I wish i could get opioids!!!! I have chronic pain, am a WHITE female and get NO help!!!! I finally had to beg recently to get tramadol for my osteoarthritis, Fibromyalgia, Lupus, Sciatica pain. These kinds of studies really piss me off….

Name: 
Dawn K
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Its difficult for ANYONE in pain to actually get pain medications…I don’t care what your numbers say

Name: 
Whitechick
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I have two brothers and one sister hooked on opioid pain killers prescribed to them. Thanks but no thanks. They are over prescribed in my opinion. By the way we are white.

Name: 
Stephen
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I’m eating Alleve like crazy since hip replacement because I’m afraid if I request another prescription I’ll be labeled a drug seeker in my medical records and that follows you forever. The 85 mile drive one way to my Drs office to pick up the prescription is a deterant but he’s the best with hips.

Name: 
Lena
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I suffer from a muscle disease and auto immune disease and disc degenerative disease I am in horrible pain and see a pain dr. I am Latina and when I go to get my meds filled the pharmacy tells me they’re out. I have to drive to ten different pharmacys then finally they will give my prescription with first calling the dr to make sure it’s legit and checking my id over and over. It’s sad for people who really need the medicines.

Name: 
Jessica shores
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Does it have anything to do with the stigma of drug abuse among blacks?

Name: 
Mary Anderson
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Reading this almost brought me to tears. Because I’ve lived it. I suffered for 18 yrs with degenerative Arthritis in both my hips starting in my late 20’s. Even after I was diagnosed, doctors would tell me how messed up I was. But still wouldn’t give me pain meds.

Name: 
Cassia Jiles
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The funny thing about this is that an opioid is the last thing I would want! If I were dying or in EXTREME pain maybe and only maybe. I am caucasian but I have said on numerous times to the doctor that I don’t need a prescription painkiller. This even while dealing with severe leg pain as a result of Sarcoidosis. Opioids should neither be pushed on people who don’t need them nor denied from those who legitimately do.

Name: 
Greg Leary
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I have had cervical and lumbar laminectomies. My neck has never been the same, but livable. My lumbar laminectomy was successful for about 10 years. But, I developed stenosis, another herniation, and arthritis. So, basically, a combination of my back original laminectomy failing and age. I can barely get out of bed most mornings. My doctor, who I have been seeing for eight years retired this year. I was moved to another doctor in the practice. I had been seeing his P.A. on and off for different situations such as pap smears, etc. But, went in to meet my new doctor to have my yearly physical. It just was my bad luck that I had the flu that week, actually several of my children had it as well. I wasn’t wearing makeup and had my hair in a ponytail, and was just feeling bad. So, I wasn’t at my best. I explained this to her. She didn’t even spend more than two minutes examining me or asking about my history. She jumped right into the fact that I was using hydrocodone for my back pain. Her arrogance was shameful and she went so far as to call me an addict. She spoke to me as if I didn’t understand addiction, how the medication worked, etc. I do. I explained that I am in healthcare. That I had worked on the leadership team of her company (am $11B hospital system), was a CIO of a pharmacy benefits company until I was laid off 1.5 years ago. She didn’t even listen, just assumed I was an idiot (she was actually speaking slowly to me like I wouldn’t understand her) and actually got angry with me when I said I did. She asked if I had PT (yes), had used muscle relaxants (yes), ibuprophen (no, I had gastric bypass years ago and can’t). What are people who are in pain suppose to do? Many of the people who abuse the drugs get them off the streets anyway. So, we are left to suffer and/or treated like drug seekers when we need relief. It is beyond frustrating. Count my pills. Test my urine. Or, come up with an alternative. Alternately, attach a machine to your back that give you pain 24/7 and then tell me about your quality of life.

Name: 
A Valentine
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I am a pharmacist working in the inner city and my non white patients are prescribed many opioids on a daily basis too much in fact so I disagree with this study

Name: 
Renita
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I discriminate against everyone. I do not prescribe opioids if the person has not had surgery, or has cancer. I will use comfort measures such as ice/heat, physical therapy, stretching, yoga, music therapy, or other forms of alternative pain management. As for medications acetaminophen (if the liver can handle it) and ibuprofen (if the kidneys can handle it).
As far as the surgical pain goes, opioids are only prescribed in the first week, after that the person should be up and about.
I realize people have pain, but there are SO many distraction techniques out there to decrease (may not take it totally away), people can use, that opioids should not be given.
How do I know? I can not take ANY form of opioids, it causes more pain than relief and the alternatives relieve 90% of the pain which is better than having the pain totally. I have MS, and suffer from chronic pain associated from that.

Name: 
Mary Beth Casey
Email: 
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I hate purely sociological studies that masquerade as medical ones. There are too many arbitrary variables for this to be a really valid study. Are they reaching their conclusions because of the idea that all races should experience the same levels of opioid use? If so, they are basing the core of their conclusion on a scientifically unsupported (and unsupportable) idea. Without a good baseline it’s impossible to know what we *should* be seeing, so how can we accurately determine if this is an unnatural observation? All of this is pure correlative data without any kind of causative links associated to it. The only statement we can reasonably make from the data provided is that there is a significant difference in opioid use among different racial and ethnic backgrounds.

Name: 
Boris
Email: 
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I am in a rural area where there is no specialty care. All of my patients are under medicated and mostly because of fear and conflicting rules. In one day I received information from one government agency to prescribe neurontin for pain, then another from another government agency that neurontin should not be written because it was going to soon be a controlled medication. The most infuriating is the new recommendation from the CDC that states benzodiazepines should be prescribed by a psychiatrist. In this area there are only about 3 mental health counselors who do not have prescription rights. Where do they suggest we send these patients? They have taken a recommendation that is Universal and applied it to an area that it is impossible to meet the demand. Each provider should be treated individually and the government needs to stay out of the providers office. The majority of my patients are elderly and have been in certain meds for >30 years and we are expected to stop treating them like they are no better than animals. Health care is a disaster. I have had 2 patients die because they could not get the medication or treatment that they need. Their insurance won’t approve treatment. And for the record Black patients and White patients are treated equally: Thanks to the government all races receive poor care EQUALLY!!!

Name: 
Sherri Robertson
Email: 
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Expert forum: Race, ethnicity, and opioids