Pain, pills and bias: racial/ethnic and gender disparities in opioid prescriptions

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“I was kicked out of the hospital,” an HIV-positive black woman told public health researchers in Baltimore, Maryland, “because they were like, ‘Okay, well, we’ve got you. given enough medicine, you should be fine'”. “If they wanted to, they could have had me on pain management, and I wouldn’t go through what I’m going through today,” shared a black man in the same study. This pair is far from alone – black Americans are 22% less likely than their white counterparts to receive painkillers in all settings.

The transgender and gender diversity (TGD) community faces the opposite problem; its members are both disproportionately prescribed with opioids and addicted to them. In Massachusetts, 58% of LGBTQIA+ people ages 35-44 have been prescribed an opiate, while the rate for sex/gender majority is only 35%. Rates of prescription drug abuse among TGD Americans, in turn, are nearly three times that of the general population.

Closing the prescribing gap — whereby both minority groups receive the lowest dose of opioids needed — does not mean flooding black patients with pills or starving TGDs of them. Instead, understand the drivers of this disparity and then leverage what is known about each demographic group to protect the other.

The drivers of disparity are structural and individual

Every day, healthcare workers struggle to discern the intensity of their patients’ pain, whether to offer them opioids, and, if so, what doses to prescribe. Neglecting to treat pain is inhumane, but overprescribing such potent drugs fuels a systemic public health problem; the United States continues to suffer from a devastating opioid epidemic driven in large part by over-prescription, making healthcare workers understandably reluctant to dispense these drugs.

Without universal and enforceable guidelines for measuring pain, providers’ racial/ethnic biases, including the “overhumanization” of black people, lead them to underestimate patient distress and deny much-needed remedies. A 2016 study of more than 400 medical students in Virginia, for example, found that those who held false beliefs about racial biology “rated the black patient’s pain (compared to the white) as weaker and made less precise treatment recommendations”.

In the case of TGD, the link between healthcare worker bias and opioid regimens is less clear. One of the reasons for their disproportionate overprescription may be their unique medical needs. Transgender women are 49 times more likely to contract HIV than the general population, and 40% of this subgroup are prescribed opioids. TGDs able to access and pay for gender-affirming breast surgeries are also at high risk; a 2020 survey found that all 99 patients in its sample had been overprescribed. Social deprivation and suicide risk increase the odds of having a long-term opioid prescription for pain, and TGDs are particularly prone to both. Once exposed to these drugs, they are especially vulnerable to addiction, causing immeasurable suffering and fueling the opioid epidemic.

Bridge the gap by learning from both groups

Closing this drug gap will require a paradigm shift in the medical industry’s approaches to pain, stigma, and prescription. First, research institutes need to add to the “alarming” number of studies in this area. If black patients are under-prescribed because their pain is underestimated, then TGDs may be over-prescribed because their pain is overestimated. Researchers have developed excellent study designs to explore this relationship in terms of black patient pain – including implicit association tests and variations of the Roter interaction analysis system – which could easily be adapted to study the experiences of the TGDs.

Second, there is an urgent need for new approaches to assess and treat pain. Some pain scales are more accurate in diagnosing pain, but others are better suited to patients who are trying to express their pain. An integrated scale complemented by regularly enforced monitoring laws may be the best way forward. Additionally, non-opioid pain management options abound but are underutilized. Studies of alternative treatments during penile inversion vaginoplasties, for example, have shown marked declines in both postoperative pain and opioid abuse. Non-addictive diets such as these should also be used to treat pain in black patients.

Finally, provider biases about minority pain need to be challenged. Implicit bias training yields mixed results, so experts recommend instead ‘auditing long-standing practices that unfairly stigmatize [racial/ethnic and gender minorities] and do not take into account changing health inequalities. This may involve removing race/ethnicity and gender from diagnostic criteria, and screening for addiction risk with evidence-based surveys, as both would help move physical appearance away from the prescribing process.

The gap reflects systemic discrimination

Physicians and policy makers are not entirely convinced of the need for change. On the racial/ethnic front, medical experts propose that under-prescribing has a “protective effect” because fewer people can access opioids; the US Department of Health and Human Services counters that black people are still “not ‘protected’ from this epidemic”. As Clinical Psychologists Call Gender-Affirming Care Vital, Texas Attorney General Sayss that its benefits are outweighed by the risks of follow-up prescriptions.

Those who favor the status quo lose sight of how discrimination in the US healthcare system harms people of all identities — “negatively impacting trust, communication, and care-seeking behaviors,” according to one study published in the Journal of the American Medical Association. The following demographics, among many others, indicate that discrimination is a reason for delaying care, not seeking treatment, and witnessing “worsening disability”: people who give birth, the elderly, low-income people and people with disabilities.

The consequences of the opioid epidemic in the United States are not limited to overdoses; racial/ethnic and gender biases push marginalized people into impossible positions. “Black pain is never as valuable as white pain,” under-prescribed black patients lament, while over-prescribed TGDs admit, “I’ve lost people to opiates, I’ve lost myself.” Tackling minority pain is the responsibility of the majority, and closing the opioid prescribing gap would be a promising start.

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