Opioid Disparities Shed Light on Potential Implicit Bias in Medicine

A new study revealing unequal opioid and pain medication prescription access between White and Black patients is calling into question the prevalence of implicit bias in medicine.

The research, published in the New England Journal of Medicine, showed that Black patients are less likely than White patients to get an opioid for pain management, even when receiving care in the same hospital. Although the researchers were careful to call for further investigation into the drivers behind this trend, they suggested inaccurate implicit biases about pain tolerance across racial groups could be at play.

Opioids for pain management are tricky, the team acknowledged in the study. Although opioids can be effective for alleviating acute pain and pain associated with advanced cancer, the medical community has increasingly shied away from over-prescribing opioids for fear of fueling the already raging opioid epidemic.

“Prescribers are challenged to balance these risks with their desire to relieve suffering,” the researchers wrote.

“Historically, this search for balance manifests as more liberal use of opioids for White patients than for Black or Brown patients. Given the complicated trade-offs, we do not yet know which group has fared better overall, but it is hard to imagine that the influence of race in these decisions — given that there is no known physiologic basis — reflects high-quality, equitable care.”

The team noted that limited opioid prescriptions might be protective for Black and Brown people, but that kind of paternalistic approach ignores the very real pain some Black and Brown patients experience.

The team sought to better understand differences in opioid prescriptions by looking at prescribing rates in Medicare patients ages 18 to 64 in and across healthcare organizations. By looking at a population comprised largely of workers with a disability, and by zeroing in on trends within a single institution, the researchers sought to better identify how disparities are playing out.

By and large, those disparities are stark. The team found that White patients were more likely to receive an opioid for pain management than Black patients. And even when Black patients did get an opioid prescription, chances are their White counterparts got a higher dosage. These trends were relevant even among those receiving care within the same hospital.

Across 310 different health systems, 50 percent of Black patients and 52 percent of White patients got any opioid prescription, a statistically significant but small difference, the team said. However, when looking at dosage, there was a bigger discrepancy. The mean annual dose was 36 percent lower for Black people than it was for White people, the team said.

Those findings rang true even when looking at an individual health system. Although the rate of opioid prescription receipt was only slightly lower for Black patients than White patients, 91 percent of health systems prescribed higher doses for White patients than Black.

For three-quarters of health systems, the annual mean dose for Black patients was at least 15 percent lower than for White patients.

The researchers did not investigate the reasons for these disparities, they emphasized as a caveat. That is a critical area for further research.

However, they did posit that implicit bias in medicine could be at play here.

“These opioid-receipt patterns probably reflect both overtreatment of White patients and undertreatment of Black patients,” the researchers wrote. “The findings should prompt systems to explore the causes and consequences of these biased patterns and to develop and test efforts to eliminate the influence of race on the receipt of pain treatment.”

“Could these findings result from something other than racial bias?” they continued. “We do not have the nuanced clinical data necessary to assess the appropriateness of the observed patterns of opioid receipt. Even when clinical data are available, the quality of pain management is hard to assess owing to the complex nature of this care.”

Previous literature about conscious and unconscious bias in medicine suggest to the researchers that those issues could be at play. For example, the medical field has been plagued by common, untrue myths that Black patients experience less pain than White patients, or that they are more likely to misuse opioid drugs. Although proven untrue, these notions could obscure clinicians’ prescribing decisions.

Additionally, poor patient-provider relationships could be erecting barriers. Particularly, patient-provider racial discordance—when the patient and the provider are of difference races—can sometimes lead to poor patient trust, limited empathy, and stunted communication, the researchers said. In turn, that could lead to unequal and potentially ineffective pain management prescribing practices.

And this could move even further beyond the interpersonal patient-provider interaction.

“We expect that systemic structural racism contributes as well,” the researchers posited. “Such systemic factors may include, for example, racially segregated neighborhoods and a lower density of pharmacies and continuity care clinics in predominantly Black neighborhoods than in predominantly White neighborhoods.”

Again, the researchers emphasized the limited evidence they have regarding implicit bias in medicine and the role it might play in opioid prescribing disparities. This is a crucial area for further research, they reiterated.

“We do not know whether or how these differences affect patient outcomes, because both opioid underuse and overuse can cause harm. We do know that skin color should not influence the receipt of pain treatment,” the researchers concluded.

“Our overall observations and system-specific reporting should prompt action by providers, health system administrators, and policymakers to explore root causes, consequences, and effective remediation strategies for racially unequal opioid receipt.”