Black patients offered lower pain relief doses in 90% of primary care

• The reality experienced by far too many Black people in the United States is that they receive less help with managing pain from healthcare professionals than white patients do.
• Although this racial inequality has been consistently demonstrated, the sources behind these differences have not been identified.
• A new study compared prescription of pain medications among Black and white patients in the U.S. across and within individual health systems, and unraveled these differences.

The U.S. medical system provides less pain relief to Black patients than white patients, and this has been the case for decades. More Black patients are served by lower quality healthcare systems, and over the years, researchers have hypothesized that this is the cause of pain relief inequity.

A new study from researchers at Dartmouth College in Hanover, New Hampshire, however, suggests the problem lies elsewhere.

The study finds that Black and white patients receive the same number of pain relief prescriptions, but that doctors routinely prescribe significantly lower doses for Black patients.

“Our findings likely reflect systematic racial bias throughout the course of care leading to pain medicine receipt,” says the study’s lead author, Nancy Morden. Dr. Morden adds, “We hope our system-level reporting will prompt dialogue and commitment to deep exploration of this inequity — its causes, consequences, and tireless testing of potential remedies.”

The new study is published in the New England Journal of Medicine.

Dr. Tiffany Green, who was not among the authors of the new research, told Medical News Today that the study aligns with separate research regarding patients who had undergone a cesarean birth.

Dr. Green, of the departments of population health sciences and obstetrics & gynecology at the University of Wisconsin-Madison, is senior author of a study that was presented at the 2020 Society for Maternal Fetal Medicine Conference.

Dr. Green and her team found that, “Black patients reported higher average levels of pain compared to white patients, but still received similar amounts of pain medication.” Controlling for reported pain scores, explained Dr. Green, they received less pain medication than their white counterparts. This was also true of Asian patients.

310 health systems analyzed

The researchers analyzed pain medication prescriptions from 310 health systems that provide primary care to Black and white patients.

They found that, overall, Black and white patients were equally likely to be given prescriptions for pain relief. The difference was in the dosages prescribed.

In 90% of the healthcare systems monitored in the study, white patients received higher doses on an annual basis than Black patients.

In most of these systems, the difference in prescription strength was 15% or greater.

The factors behind the disparity

“The ‘why’ is the million-dollar question,” said Dr. Green.

“I think,” she continued, “many clinicians would like to believe that they are egalitarian and objective, but the data suggest that they hold the same kinds of anti-Black biases as people in the general population.”

Dr. Vickie M. Mays, who was not involved in the study, spoke with Medical News Today. While not minimizing the role of personal racial bias, Dr. Mays, of UCLA’s psychology department in the College of Life Sciences, recalled that research several years ago revealed how profoundly historical biases have influenced what people think they know.

In that study, people were asked to complete a questionnaire testing their knowledge of medical facts about Black people and white people, some of which related to pain. “People were just ignorant,” Dr. Mays said. “It was stunning the kinds of knowledge that they lacked.”

The authors of the new Dartmouth study suggest discredited stereotypes may also be standing in the way of effective pain relief for Black patients.

Dr. Green reported, “One study found that medical trainees who believed false stereotypes about Black patients (e.g., that they were biologically different from white patients) provided more inaccurate pain assessments and did a poorer job making treatment recommendations.”

“It’s interesting because I teach a course on health disparities,” said Dr. Mays. “I have physicians in my course, nurses in my course, I have regular students in my courses, and I teach a very specific way because I don’t want people to walk away with stereotypes.”

If a caregiver has been taught the value of being more thoughtful in their interactions with patients, Dr. Mays asserted, “you have a better sense of an intervention solution.”

Dr. Mays also noted another possible stumbling block. Lowered expectations may mean that Black patients “don’t rate their health as being as bad as it actually is,” particularly compared with other people they know. White patients, on the other hand, may “feel they have a right, and demand to get treatment because they’re used to it.”

Therefore, said Dr. Mays, “It really is two things: The ability to present [the way something hurts], and the ability [of the physician] to hear based on the way it’s presented.”

This ties into the study’s suggestion that “patient-physician racial discordance” may also be a factor, with its ”potential for lower levels of empathy, trust, physician perception of patient’s pain, and effective communication.”

Doing better

Senior author Ellen Meara, Ph.D., suggests that this inequity persists due to the decentralized nature of the U.S. medical system.

Dr. Meara says:

“A decade of national data on racial inequity in prescription opioid receipt has done little to narrow known racial gaps in the receipt of pain medicine because no one person or entity is tasked with alleviating inequality in pain medicine receipt or healthcare for the nation.”

Dr. Meara hopes that system-level studies such as this one provide support for healthcare experts working within their own systems to remedy the problem:

“Healthcare leaders, in contrast, routinely hold their providers and their organizations accountable for the care delivered to their patients, and leaders have been vocal in prioritizing equity. They need data to do so.”

In addition, the authors of the study call for physicians and health system administrators to explore the drivers of pain relief inequity, and more seriously begin to address them so that the color of one’s skin does not stand in the way of receiving relief from pain.

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