Addressing racial bias in the treatment of pain


The opioid (painkiller) epidemic, with its seemingly indiscriminate reach, has embraced an alarming number of Americans. In the most recent statistics available, two million Americans either abuse or are dependent on prescription opioids. Even the death of internationally acclaimed artist, Prince Rogers Nelson, has now been attributed to fentanyl overdose, a strong prescription opioid whose illicit version has become a popular and problematic street drug.

Still, America’s spotlight on the opioid crisis largely overlooks a seemingly less appreciable problem and two sides of the same coin. Racial bias when prescribing pain medication is contributing to suffering in blacks and a disproportionate rate of deaths in whites. This may be the first time in modern medicine where we so clearly see provider bias on the same issue as a detriment to both races. While each is wholly unacceptable, the inherent hypocrisy underlying the recent attention to an epidemic that adversely and disproportionately affects whites is revealing.

Modern medicine repeatedly shows us traces of inadequate and unequal care for blacks — vestiges born from the ideologies of slavery. They serve as uncomfortable reminders of racist practices like lack of pain medicine for blacks during unwanted and unethical surgical experimentation. Just last year, research in the Journal of the American Medical Association (JAMA) Pediatrics, showed that of the almost 1 million children diagnosed with appendicitis, black children who reported moderate pain were less likely than white children to receive pain medicine. Similarly, those reporting severe pain were less likely to receive opioids compared to white children. Like others before them, Dr. Monika Goyal and her colleagues suggest that there is a different threshold to treat pain in black versus white patients.

Although other factors (e.g., stereotyping) certainly contribute, increasing evidence points to the harmful influence of racial bias in the treatment of pain. Media outlets recently cited a small, but relevant study at the University of Virginia — my own alma mater — which revealed that half of the white medical students and residents surveyed believed nonsensical, inaccurate and dehumanizing assertions about blacks.

Medicine’s early academic years are steeped in science. Yet, 40 percent of first-year and 42 percent of second-year students surveyed endorsed the idea that “blacks’ skin is thicker than whites.’”  At least one doctor there believes that “blacks’ nerve endings are less sensitive than whites.’” The authors point out that bias in the perception of pain affected how pain medicine was prescribed.

Notably absent from news coverage is the authors’ disclosure that in their study “…perceptions of whites’ frailty may shape racial bias in pain perception as much, if not more, than perceptions of blacks’ strength.” They also emphasize that a different kind of bias exists — one infused with preferentialism.

Misconceptions of weakness that encourage providers to offer more pain medicine for whites, as well as privilege, seem to be at play here. For my patients in the ER, a national quality measure for pain management of broken bones was initiated in 2012 in part because white patients were the recipients of better and timelier pain control. It turns out that we are not doing white patients any favors.

Non-Hispanic whites are being hit the hardest in the opioid epidemic. In January, the Centers for Disease Control (CDC) released data which suggests that opioid overdose deaths (prescription opioids today account for at least half) have increased at similar rates for whites and blacks. Though the rate of increase is similar, the numbers themselves tell a distinct story. Whites are dying at nearly double the rate of blacks and almost three times the rate of Hispanics. During the same time period, North Dakota and New Hampshire — two of America’s whitest states — experienced the greatest percentage increase in opioid deaths.

Although many details surrounding Prince’s death are not yet public, if prescribed fentanyl, Prince highlights an exception to the persistent under treatment of pain in blacks and proof of the obvious — regardless of race, anyone can fall prey to overdose. However, his global fame certainly lends itself to the consideration of privilege playing an unfortunate role.

Ongoing efforts and the public confrontation of the opioid epidemic are aimed at eliminating unnecessary prescriptions and bad outcomes like the premature death of our beloved musical legend. Focusing on these important targets is an obvious start to reduce addiction and overdose deaths. However, we must be as deliberate in addressing racial bias to prevent widening disparities in the treatment of pain in blacks and ever aware of the harmful effects of privilege on prescription practices.

With recently released guidelines for prescribing chronic opioids and a surge of new lawmaking efforts, now is the time to re-examine this complex problem in the context of racial injustice. It is only then that effective solutions can lend themselves to improved care — for everyone.

Leigh-Ann J. Webb is an emergency medicine physician.

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