A Racial Divide in How Opioid Prescriptions Are Overseen

Black subjects are more likely to have opioids cut off after a failed drug test.

Posted Aug 31, 2018

Taking illicit drugs like cocaine or marijuana concurrently with opioids—even if those opioids are prescribed legally—has been identified as a moderate predictor of later opioid dependence or misuse. For this reason, regular drug testing is recommended for any patient directed to use opioids long-term, with patients who fail drug tests more closely monitored and their opioids slowly tapered off if the behavior continues.

A large new study, however, found that these guidelines are unevenly applied. To examine how doctors react to illicit drug use among patients taking opioids, researchers examined a cohort of more than 15,000 veterans undergoing long-term opioid therapy through the Department of Veterans Affairs (VA).

Monkey Business Images/Shutterstock
Source: Monkey Business Images/Shutterstock

The researchers found that between 2000 and 2010, only about 21 percent of subjects were asked to take a urine drug test within the first six months of treatment. And despite the fact that white people—and white men in particular—demonstrate higher rates of opioid abuse and opioid-related deaths (and were prescribed significantly higher doses of opioids on average), black patients were twice as likely to be drug tested. White males, in fact, were the group least likely to be administered a urine test. Black patients were also more likely than white patients to have their opioid prescription discontinued if they failed a test even once.

Among the one in four subjects who tested positive for cannabis or cocaine—the two illicit drugs specifically examined in the study—nearly 90 percent were permitted to refill their opioid prescriptions within the following 60 days. Those who weren’t, however, were significantly more likely to be black: black subjects who tested positive for marijuana were more than twice as likely as white subjects who tested positive to have their opioids discontinued, and three times as likely if they tested positive for cocaine.

“There have been racial disparities in health care for a long time, and pain management is where it’s most striking,” says Kelly Hoffman, a psychologist now at the research and development startup Future Laboratories who has published several studies indicating that black people are widely perceived as having a greater tolerance to pain than white people and are regularly undertreated for pain. “It’s a very pervasive bias,” impacting children and adults (both black and white), as well as large swaths of the medical community, says Hoffman, who was not involved in the veterans study. “Our work focuses on a mechanism early in the process—perceiving pain in the first place. [This study’s] findings show bias after pain has already been perceived.”

Though she notes that the study was unable to identify the causes of the disparity, she speculated that interrelated biases might have been at play. “Perhaps there are stereotypes or assumptions that physicians have that a black patient is more likely to abuse the opioids,” she says. Another possibility, she speculates, is that because black patients are already likely to be receiving lower doses than white patients, clinicians may conclude that discontinuing opioids altogether after a failed drug test will be easier or less risky than slowly tapering them off or initiating additional monitoring.

To focus specifically on the divide between black people and white people—which prior research suggests is the most pronounced healthcare disparity, the study’s authors write—other races were excluded from the sample. This is common, Hoffman says, but left them unable to account for similar biases that are regularly experienced by other people of color. “The primary focus tends to be black and white,” she says. “But these racial disparities in pain have also occurred for Hispanic individuals.”

More specific guidelines—outlining who should be tested, how the results should be interpreted, and exactly what steps should be taken afterwards to decrease the risk of overdose or abuse—may help decrease the disparity found in the study. “There are studies finding that when there are more established protocols that take out the subjective nature [of pain management], that was shown to be helpful,” Hoffman says.

Leslie Hausmann, an associate professor in the Department of Medicine at the University of Pittsburgh who also studies racial disparities in healthcare, says that since the study focused solely on a particular cohort of veterans, it may not generalize to the population or even veterans as a whole.

Hausman, who was not involved in the study, also cautions that the definition of long-term opioid therapy used by the researchers—opioid prescriptions lasting three months or longer—may partially explain the low rate of drug testing as of six months after the initiation of therapy. “Someone with only a three-month supply would not have a urine drug screen in months four through six,” but would still be counted in the data.

Still, the significant disparity, as well as the overall lack of drug testing—consistent with what past studies have shown—suggests that “there’s a lot of room for improvement in how patients are monitored once opioid therapy is initiated,” she says. “Dispensing and monitoring practices for prescription opioids look very different depending on whether patients are black or white.”