Q&A: Opioids for pain prescribed more often to white patients
Primary care physicians more often prescribed opioids for low back pain to white patients than patients of historically underrepresented groups, according to findings published in JAMA Health Forum.
Bias creeps into many of the decisions that physicians make, Dan Ly, MD, PhD, MPP, an assistant professor in the division of general internal medicine and health services research at UCLA, told Healio Primary Care.
In a cross-sectional study, Ly and colleagues analyzed Medicare data on beneficiaries aged 66 years or older who sought care from a PCP for low back pain from 2007 to 2014. The researchers investigated trends in long-term use of opioids prescribed for 180 days or more.
The study cohort included 274,771 patients with at least one new episode of low back pain within 1 year. The mean age of beneficiaries was 77.1 years. Nearly 70% were women, 81% white, 6% Black, 6% Asian or Pacific Islander and 8% Hispanic. These patients were treated by 63,494 physicians.
Ly and colleagues’ analysis revealed that 11.5% (95% CI, 11.4-11.6) of white patients were prescribed an opioid in their first year of new low back pain, on average. However, opioids were prescribed to only 9.9% (95% CI, 9.3-10.6) of Black patients, 8.8% (95% CI, 8-9.6) of Asian or Pacific Islander patients and 10.5% (95% CI, 9.8-11.1) of Hispanic patients.
Compared with white patients, a physician was 1.5 percentage points (95% CI, -2.2 to -0.8) less likely to prescribe an opioid to a Black patient, 2.7 percentage points (05% CI, -3.5 to -1.8) less likely to prescribe an opioid for an Asian or Pacific Islander patient and 1 percentage point (95% CI, -1.7 to -0.3) less likely to prescribe an opioid for a Hispanic patient.
Patients from underrepresented groups were more likely to receive an NSAID prescription for their low back pain, according to the researchers. Meanwhile, white patients with low back pain who were prescribed an opioid were 0.4% to 1.3% more likely to develop long-term opioid use disorder compared with Asian or Pacific Islander, Black and Hispanic patients.
Healio Primary Care spoke more with Ly about the disparities in care illustrated by the study results.
Healio Primary Care: What prompted this research?
Ly: We know that minority patients were less likely to receive opioids than white patients, but this could have been due to minority patients seeing lower opioid-prescribing physicians. As far as I could tell, nobody had been able to examine whether the same physician prescribed opioids differently to their minority patients. I find that this is the case: the same physician was less likely to prescribe opioids to their minority patients with new low back pain, and instead was more likely to prescribe NSAIDs to their minority patients.
Healio Primary Care: You observed that white patients were prescribed opioids for low back pain more often than other racial or ethnic groups. Yet, opioid misuse is more common among white individuals. Can you talk a little about this?
Ly: I looked at a clinical situation. When opioid-naive patients develop new low back pain and see their PCP and examined whether minority patients of that physician receive different pain treatment than white patients of that same physician, it seems that white patients were more likely to receive opioids, even though, as you say, opioid misuse is more common among white individuals. It may be that physicians have less trust in their minority patients, which may drive some of these prescribing differences.
Healio Primary Care: What is the clinical relevance of the findings, both for patients of racial and ethnic groups who are not prescribed opioids as often for their pain and for white patients who may have a higher risk for becoming addicted to opioids?
Ly: Physicians appear to play a large role in the differential care that patients of different races and ethnicities receive. That is, when decisions are discretionary like pain treatment, minority patients appear to receive different care than white patients from the same physician.
Healio Primary Care: What do you think is driving these disparities in medication prescribing? In terms of unequal treatment of pain, how does this impact patients’ long-term health?
Ly: Unfortunately, I believe physician bias and differential trust in patients drives much of these differences in opioid prescribing.
This differential prescribing may have had the consequence of leading to more long-term opioid use in white patients.
Healio Primary Care: What should physicians be recommending for low back pain?
Ly: My expertise isn’t in the treatment of pain, including low back pain. However, recommendations often note opioids are a last resort. In the past, the ACP has recommended nonpharmacologic options such as heat and massage, and physical therapy may forestall the use of opioids. If medications need to be used, NSAIDs and muscle relaxants, if not contraindicated, should probably be tried before resorting to opioids.
Reference:
Ly DP. JAMA Health Forum. 2021;doi:10.1001/jamahealthforum.2021.2333.