In the early years of the opioid crisis, overdose rates increased more rapidly among white compared with black Americans. Researchers have speculated that the racial disparity in overdose rates was the result of the under-treatment of black patients’ pain by health-care providers because of racial bias.
Unfortunately, this theory has led to misinformed conclusions within and outside of health care that black Americans actually benefited from this racial bias, that their lack of access to pain treatment “protected” them.
Calling racial bias protective is misguided and harmful for several reasons. There is widespread suffering and even death caused by the lack of pain treatment. There is also potential to further stigmatize racial minorities who do have opioid use disorder. Overshadowing all these factors is the persistent legacy of this nation’s history of deeply rooted, structural racism.
Researchers and policy makers alike have a responsibility to place data regarding opioid use disorder in the proper historical context and avoid further harm to communities of color and other minorities.
Unmanaged pain can lead to lost wages, difficulty engaging in social activities and declines in mental and emotional health. We have treated countless people who have turned to a street supply of pain medication because they couldn’t get care through traditional means. Self-medicating is often unsafe, especially due to risks associated with an influx of counterfeit pills that are pressed to look like Percocet or OxyContin but contain lethal amounts of fentanyl.
Beyond living with untreated pain, patients and their families suffer even more from the stress of encountering racism and implicit bias in health-care settings. Stress can become chronic and literally “get under the skin,” causing harmful changes in the body that over time contribute to poor health.
Any notion that the failure to treat black patients’ pain has protected them from opioid misuse has dangerous implications for the growing number of black Americans who do struggle with opioid use disorder. In fact, opioid overdose rates are on the rise among people of color.
In minority communities, racial discrimination is thought to increase the magnitude of existing stigma against substance users, creating a “double stigma.” Add to all that the common characterization of “innocent white victims” of over-prescribing by health-care providers, which can create the misimpression that black patients who do develop opioid use disorder are more to blame than white patients. Thus a third layer of stigma is created.
Treatment of opioid addiction is not immune from racism within health care. A recent research letter described black patients as 77% less likely than white patients to receive buprenorphine prescriptions, after accounting for insurance status and other factors that impact access to treatment. Buprenorphine is an evidence-based treatment for opioid use disorder proven to yield lasting recovery. Unlike methadone, another medication for opioid use disorder, buprenorphine is prescribed in private medical practices and can be used at home, avoiding the stigma and inconvenience of daily clinic visits. Communities of color risk further stigmatization and criminalization by not being able to take advantage of this medicine.
As health-care providers and health services researchers deeply invested in health equity, we urge fellow clinicians, researchers and policymakers to discuss the opioid crisis and how it affects minority communities with care. The words we use to describe both the history and current state of the epidemic matter because they help shape what change is and is not possible. Racism in health care still exists and is by definition harmful, and to suggest otherwise will stop us from developing effective strategies to help all Americans struggling with addiction.
Utsha Khatri (@UtshaKhatriMD) is an emergency medicine physician and first year fellow in the National Clinician Scholars Program in Philadelphia; Shoshana Aronowitz (@shoshiaronowitz) is a doctorally trained nurse, family nurse practitioner and first year fellow in the National Clinician Scholars Program; Eugenia South (@Eugenia_South) is former Robert Wood Johnson Clinician Scholar and current assistant professor of emergency medicine at the Perelman School of Medicine at the University of Pennsylvania.