Post written by Cathleen Beliveau
Nimah Haq, the Research Data Administrator at the Center on Substance Use and Health (CSUH), recently authored an article in the journal Drug and Alcohol Dependence as part of a special issue titled “Addressing long overdue social and structural determinants of the opioid overdose crisis.” The article investigates how race impacts care for patients with chronic pain. This analysis used data from the Cohort Study of Opioids, Pain, and Safety in an era of Changing Policy (COPING), a study conducted at CSUH from March 2017 to June 2021. COPING followed 300 uninsured or publicly-insured people with chronic non-cancer pain who were prescribed long-term opioids (3+ months). Yearly follow-up visits were conducted to learn about changes over time, such as their pain, functional status (e.g. mobility, balance), and opioid prescriptions.
In the United States over the past 20 years, the pendulum of opioid prescribing has swung from lax prescriptions to intense opioid stewardship measures (including urine drug screening, controlled substance agreements, and opioid dose reduction or opioid discontinuation). These measures are intended to curb the harms of opioid over-prescribing, opioid use disorders, and opioid overdose deaths seen in the last decade or so.
However, there have been significant mis-steps in U.S. efforts to reduce harms related to opioid prescribing. A previous CSUH study publication showed that discontinuing people from prescribed opioids often led to people seeking illicit opioids like heroin or non-prescribed opioid pain medications. For people with chronic pain, especially those who are not able to access alternative treatments like chiropractic care or physical therapy, being unwillingly discontinued from opioids by one’s provider can be a traumatic and painful experience. For non-White patients, racial disparities in access to care can exacerbate these harms.
This analysis, Race, Pain, and Opioids among Patients with Chronic Pain in a Safety-Net Health System by Nimah Haq, looked at the baseline data from each participant’s first visit and their medical chart data from the previous year. Medical chart data included information on opioid prescriptions (what kind, what dose, and when prescribed) and information on opioid stewardship activities (frequency of urine drug screening, use of pain medicine agreements, and distribution of naloxone).
The authors found that the maximum opioid dose (measured in Morphine Milligram Equivalents [MME]) was lower for Black participants than White participants in the preceding year. At the same time, Black participants reported higher average pain in the past three months (on a 0 to 10 scale) than White participants. On top of that, White participants were more likely to inject drugs – meaning they were likely at higher risk for problems related to opioid prescribing. The authors suggest that “these differences could represent bias away from prescribing opioids for chronic pain among Black patients and potentially suboptimal pain management.” They also suggest that it could be due to "patient-level factors (e.g., utilizing non-opioid pain coping strategies or being less likely to request additional opioids).” The extent to which this difference is caused by provider bias versus perceptions of racialized stigma is currently unclear. Data documenting inequitable pain medication prescribing for Black patients has existed for a long time; the scope of this analysis does not include measuring whether opioid stewardship activities exacerbate these pre-existing inequities.
The authors note that this finding is consistent with other analyses that looked at how opioid prescribing differs by race. However, the authors did not find a statistically significant difference in application of opioid stewardship activities such as urine drug screens, controlled substance agreements, or naloxone prescriptions between racial groups.
Racism is well-documented in medical systems and opioid prescribing practices in particular. This article from the American Association of Medical Colleges summarizes the many ways in which doctors dismiss and under-treat Black people seeking treatment for pain and other conditions. What can the medical field do, besides continuing to document these existing disparities through research? It is critical that evidence-based interventions are developed and implemented. Implicit bias trainings, workplace equity assessments, and diversification of the physician workforce are just a few places to begin. In the long term, greater investment into the health of uninsured and publicly insured individuals, such as the participants in this study, is critical to move towards health equity.
Full citation:
Haq N, McMahan VM, Torres A, et al. Race, pain, and opioids among patients with chronic pain in a safety-net health system. Drug and Alcohol Dependence. 2021;222:108671.