Inequities in health care are pervasive, from access to quality of care, and a new study finds that common opioids such as codeine and morphine are more often prescribed to white patients than to Black patients treated within the same health system.
White patients received both more pills and stronger doses, according to the study, published Wednesday in the New England Journal of Medicine. In about 90% of the 310 health systems studied, the opioid dose prescribed to white patients was higher than the one prescribed to Black patients. On average, white patients received 36% more pain medication by dosage than Black patients, even though both groups received prescriptions at similar rates.
“There’s racial bias in the prescribing pattern, there’s just almost no other way to explain it,” said Nancy Morden, a family medicine specialist and health services researcher at the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H. “If we found this in half of the hospitals, maybe you could imagine something else, but it’s 90% of hospitals. I was shocked when I saw that,” said Morden, who is also the first author of the new study.
The findings confirm at least 20 years of data showing disparities in pain management. Most of the previous studies were done either at a national level or by looking at specific institutions. Both the broad and very narrow approaches fail to capture general trends across many different systems and could mean that differences in how white and Black patients’ pain was managed could be a result of where they got care, Morden said.
The new study set out to clarify whether there were other reasons to explain the differences by comparing opioid prescriptions filled in 2016 and 2017 by more than 600,000 patients with disabilities on Medicare who got their care within the same network of hospitals.
By studying disparities at the system level, you are “getting closer to the underlying phenomena,” said Salimah Meghani, a pain management disparities researcher at the University of Pennsylvania School of Nursing who was not involved with the study.
The researchers found that differences in opioid dosages existed even when patients were being seen by the same clinicians.
“[Black patients] get fewer pills, lower dose, lower potency — they just are getting less,” said Morden.
Black patients were also more likely to receive short-term opioid prescriptions, for less than a year’s time, than receive long-term ones. The disparities even held true for a population of cancer patients, who are usually treated long-term with opioids for their severe pain.
But because the study examined filled prescriptions versus the amount written by providers, the findings may not be painting a complete picture of the disparities in pain treatment. “They’re making a slight leap,” said Meghani about using filled prescriptions to draw conclusions about prescription patterns. Still, this limitation is “not a strong enough reason to explain away the disparities,” she said.
Racial bias — including the erroneous belief that Black patients feel less pain than white patients — could be behind these disparities. “[The disparities are] likely driven by how physicians approach or assess the perception of pain in Black versus white patients,” said Brian Bateman, an anesthesiologist and pharmacoepidemiologist at Brigham and Women’s Hospital in Boston, who was not involved in the study.
A patient’s socioeconomic background could also be playing a role, Morden said, as Black patients with low socioeconomic status are less likely to receive opioid prescriptions. This combination of factors leads to poor pain management in Black patients, the consequence of which is not yet understood, said Morden. Although these disparities — especially in how white people are more often prescribed long-term treatment — could partially explain the historically higher rates of opioid use disorder in white versus Black individuals, said Morden, “we’ve never really gotten our brain around the impact of undertreating pain on [Black] people’s lives.”
Opioids were prescribed with few or no restrictions prior to 2016, when, as the opioid epidemic continued, the CDC issued new prescribing guidelines, which prompted states to introduce prescribing limits. Because the new study was conducted using data from before and after these guidelines were introduced, “[the study] may be underestimating the actual size of disparities,” said Meghani.
Morden aims to motivate individual health systems to dive into their own data and look at disparities in their entire patient population, not just Medicare patients with disabilities. Meghani pointed out that there are many additional nuances that need examining, such as the type of opioid being prescribed, whether they are short- or long-acting, and, more importantly, how exactly opioids impact patients’ health outcomes, especially since lack of proper pain management could also affect patients’ mental health and ability to maintain jobs or schoolwork.
The study’s findings do not mean that Black patients should be prescribed more opioids, experts caution.
“It would be wrong to come away from this and say, in a really simplistic way, that this means opioids should be prescribed more liberally to Black patients,” said Bateman.
Rather, he suggested that the data should be used to develop guidelines for assessing and managing pain with racial disparities in mind and making sure that approaches are applied equitably.
Morden hopes that, in addition to sparking more studies, her research will impact policy and future public health guidelines. The 2016 CDC guidelines, for instance, while well-intentioned, may have yielded a one-size-fits-all approach that didn’t take individual patients’ circumstances into account, some experts have argued.
“You can only start change by making people aware of the need for change, and we hope that this [study] achieves that,” said Morden.