Feb 11, 2019 | 8:35 AM
Doug Biggers, whose son, Landon, died of an opioid overdose
in La Quinta, Calif., holds a door open for Landon's daughter, Aubrey. (Jae C.
Hong / Associated Press)
Across California, a blessing has become a curse for
patients who dwell in overwhelmingly white communities: their ready access to
opioid pain relievers.
A new study of prescribing
practices across all of California’s 1,760 ZIP codes helps explain why opiates,
some of medicine’s most addictive drugs, have wreaked more havoc on white
communities than on communities of color.
The answer, at least in part, appears to lie in unconscious
physician biases about race, ethnicity and pain that more typically leave
minority patients underserved and undermedicated, authors of the new study
said.
The resulting disparity in care may have briefly shielded
minority communities from harm, said study leader Joseph Friedman, a medical
student at UCLA. But for far longer and in many more instances, he said,
“systematic racism within the healthcare system has led to … insufficient
treatment” of minority patients’ physical and psychic pain.
The findings from California
were published Monday in the journal JAMA Internal Medicine. They appeared
alongside a report chronicling the
changing racial mix of opioid fatalities in New York City and an analysis from the Centers
for Disease Control and Prevention showing that while doctors cut their rate of
opioid prescribing by 20% between 2015 and 2017, current levels remain almost
three times higher than they were in 1999.
The California study reveals that, between 2011 and 2015,
residents of neighborhoods with the highest proportions of white people were
more than twice as likely to be prescribed an opioid pain reliever than were
residents of neighborhoods where whites were most scarce.
In ZIP codes dominated by whites who were not of Latino or
Asian heritage, opioid prescriptions flowed freely during the study period. And
they were by far most generously offered in low-income white communities.
However, in ZIP codes with the highest proportion of
minority residents, not even high income levels could close a yawning race and
ethnicity gap in opioid prescribing.
The result is now all too
familiar: an epidemic that has cut a swath of death and destruction through
poor, rural white communities while largely sparing minorities.
(That has begun to change in recent years as the opioid
street drugs heroin and fentanyl have become cheaper and more widely available,
ensnaring more minority users. Between 2016 and 2017, the biggest increase in
opioid-related drug overdose deaths — 56% — was seen among African Americans, according to the CDC.)
The new research offers a revealing glimpse of how addiction
to opioids may have gained a foothold first in California’s rural white
communities while largely bypassing black, Latino and Asian neighborhoods.
Combing through the anonymous prescription records of close to 30 million
Californians, the researchers found that in each of the five years they
studied, roughly 24% of Californians left a doctor’s office at least once with
a prescription for an opioid narcotic.
These maps show the overlap of opioid prescriptions and the
affluence of neighborhoods in Los Angeles County. (JAMA Internal Medicine)
But the geographic distribution of those prescriptions was
far from random.
In ZIP codes where incomes were lowest and minorities were
fewest, 44.2% of all residents ages 15 and older received a prescription for an
opioid medication in each year of the study. Meanwhile, in ZIP codes where
incomes were lowest and the population skewed most toward blacks, Latinos or
Asian Americans, just 20.3% received such a prescription each year.
Even in California’s most affluent minority neighborhoods,
the volume of opioid prescriptions didn’t come close to the blizzard of
prescriptions issued to those in overwhelmingly white neighborhoods. Across the
state, 16.1% of residents there took home an opioid prescription in each of the
study’s five years.
In the wealthiest ZIP codes where minorities were least
prevalent, a quarter of residents received an opioid prescription in all five
years. But as the income of these very white communities declined, opioid
prescribing increased steeply.
Getting a prescription for opioids is certainly not an
automatic gateway to abuse, addiction or death. But a recent report by the National
Academies of Sciences, Engineering and Medicine found that, among people
prescribed opioid pain relievers, at least 8% develop "opioid use
disorder" and 15% to 26% engage in problematic behaviors that suggest they
have become dependent. The report also noted that 600,000 Americans were using heroin
in 2015, and a majority said they had started as prescription opiate users.
So leaving a doctor’s office with a prescription for opioids
is at least a key marker of a person’s risk for addiction and death, Friedman
said.
The higher the proportion of white residents in a
neighborhood the higher the rate of opioid overdose deaths. The trend was
similar for opioid prescription rates. (JAMA Internal Medicine)
Friedman and his coauthors underscored that the disparities
they saw in opioid prescribing were by no means a fluke. Indeed, they uncovered
a larger pattern of unequal medication prescribing that puts minorities at a
stark disadvantage relative to white people.
Compared to Californians living in mostly minority
communities, residents of the state’s whitest ZIP codes were roughly three
times more likely to have been prescribed other controlled substances,
including anxiety-reducing benzodiazepines and stimulants used in treating attention deficit/hyperactivity
disorder, they found.
Collectively, findings like these suggest that something
more subtle is at work than just money, insurance coverage and access to
healthcare, experts said.
Like all Americans, medical professionals bring what
psychologists call “implicit biases” with them to work. While discrimination,
hopelessness and poorer health are widely believed to make chronic pain a more common condition among minorities than among
white patients, this bias leads doctors to mistrust or minimize a minority
patient’s reporting of physical and mental distress. Their skepticism may be
unconscious, but many studies have documented it. And they’ve linked such
attitudes to less aggressive treatment of minority patients’ pain.
In study after study, doctors
in primary care, emergency rooms and orthopedic care have been
found to prescribe less medication — and less potent medication — to minority
patients who describe the same symptoms and intensity of pain as do white
patients. Among the motivations cited: concern that pain reports reflect
drug-seeking behavior, or that minorities are more likely to fall prey to
addiction.
Other drivers include more subtle beliefs about the pain
thresholds.
A 2016 study by psychologists
at the University of Virginia found that in a group of 222 white medical
students, half felt that at least one of 11 false beliefs about racial
differences was “possibly,” “probably” or “definitely” true. For example, asked
whether they believed that the nerve endings of African Americans are less
sensitive than those of whites, 8% of the first-year medical students and 14%
of the second-year students said that claim was possibly, probably or
definitely true.
“Medicine has a long, unsavory history of expecting people
of color to tolerate larger levels of pain,” said Dr. Steven Woolf of
Virginia Commonwealth University, who was not involved in the new study. “For
the opioid epidemic it had a silver lining, but the discrimination is fatal
when the denied treatment is lifesaving, such as cancer screening. This is why
African Americans have higher mortality rates from cancer — they are less
likely to get screened, their cancers are more likely to grow before being
detected, and survival rates once diagnosed are often shorter.”
Bridget J. Goosby, who
studies racial disparities at the University of Texas and was not involved in
Friedman’s work, called it “a tragic and appalling irony” that African
Americans have been “protected by the assumption that they cannot be believed
when reporting their pain.”
But she cautioned that not far down the road, the same
inequities that afforded this brief advantage are likely to work against the
interests of people of color. As governments and medical groups crack down on
opioid prescribing, African Americans will find it harder to convince doctors
to prescribe needed pain relief, despite their often greater need. Meanwhile,
she added, cheaper, more dangerous street drugs are already flooding their
communities as the flow of prescription opioids is shut down.
“Does this exacerbate the already poor quality of treatment
they receive?” Goosby said. “That’s a risk here.”
Melissa
Healy is a health and science reporter with the Los Angeles Times writing from
the Washington, D.C., area. She covers prescription drugs, obesity, nutrition
and exercise, and neuroscience, mental health and human behavior. She's been at
The Times for more than 30 years, and has covered national security,
environment, domestic social policy, Congress and the White House. As a baby
boomer, she keenly follows trends in midlife weight gain, memory loss and the
health benefits of red wine.
http://www.latimes.com/science/sciencenow/la-sci-sn-opioids-whites-doctors-20190211-story.html?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202019-02-12%20Healthcare%20Dive%20%5Bissue:19378%5D&utm_term=Healthcare%20Dive
No comments:
Post a Comment