Pain Medication Usage In Black and White Patients: Biased treatment or Addiction Epidemic?

Recently, the Washington Post and other media outlets ran a story about a research study at the University of Virginia with the headline “The disturbing reason some African American patients may be undertreated for pain”.  The study at issue involved asking a group of approximately 200 white medical students a series of true-false questions about biological differences between white and black people and measuring how many times the students answered incorrectly.  The researchers then presented the medical students with a treatment scenario and found that the students who answered the true-false questions incorrectly (which they termed “endorsing the false beliefs”) were more likely to make inappropriate treatment recommendations.  The researchers suggest that this is evidence that it is due to bias that prior studies have shown that black patients are less likely to receive pain medication than white patients.

I haven’t been able to locate the actual published study, so I haven’t been able to look at the actual data from the study. However, the snippets of data that are contained in the news reports were very interesting to me.  The data clearly showed that while some medical students did incorrectly answer some of the questions, the number of incorrect answers decreased dramatically as they moved from 1st year medical students to becoming residents.  For example, as 1st year students, 29 percent incorrectly responded to the statement that “Black people’s blood coagulates more quickly than white’s”.  Yet, by the time they were 3rd year students only 3 percent answered that question incorrectly.

Patient and PhysicianThe researchers noted that the subjects who responded incorrectly to the questions were more likely to select inappropriate treatment options to proposed scenarios and then concluded that this was due to bias that explains the existing differences in pain treatment between black and white patients. I think it could just as easily be due to the fact that the subjects who answered incorrectly were more likely to be early in their medical education, so it makes sense that they might select the incorrect treatment choice.  It is important to understand that 1st year medical students have little to no clinical training and legally cannot even prescribe a Tylenol to a patient.

I have no doubt that racism exists in healthcare, nor do I dispute for a moment that we should do all we can to identify and remedy racially discriminatory practices in our healthcare system.  However, I think we also need to be cautious about concluding that differences in healthcare treatments and outcomes are necessarily the product or racial discrimination.  It is very possible that black patients receive less pain medication than white patients due to racial bias in the minds of healthcare providers, but this study didn’t prove that. In fact, other than demonstrating that medical students got fewer answers wrong as they progressed in their education, it didn’t really prove anything useful.

I think we have to consider that it’s very possible that factors other than racial bias are at play when it comes to the issue of the differences between pain medication use in Black and White patients.  I may well be that Black patients are being appropriately medicated while White patients are more inclined to be drug seeking and as a result receive more medication. That something very significant is happening in the White American population with regard to opiate use is evident from data in other research.  For example, the CDC recently reported that “The rate of past-year heroin use among non-Hispanic whites increased 114.3% from 1.4 per 1,000 in 2002–2004 to 3.0 per 1,000 in 2011–2013.”  There is a well-established link between prescription drug abuse and heroin use where many addicts start with prescription pain medication and then move onto heroin use when they are unable to obtain legal access to or afford opiate drugs.

I also think that it’s also important to examine whether cultural factors exist that may inhibit black patients from requesting pain medication and if that possible inhibition results in under treatment of pain for Black patients.

I think we have to be very cautious to conclude that differences in medical treatment or outcome are the result of bias rather than another factor.  For too long many healthcare treatments and theories have lacked the requisite scientific validation.  Granted, identifying and calling-out racism gives one the moral high ground, but it may not always be the truth, and in healthcare it is scientific truth that saves lives and preserves health.

For example, life expectancy data collected by the Kaiser Family Foundation shows that white Americans have a life expectancy of 78.9 years whereas black Americans have a shorter life expectancy of 74.6 years. It is very tempting to conclude that this is solely because white Americans hold greater political and economic power and as a result black patients get inferior care.  However, this doesn’t hold up when you look at the data for life expectancy across all ethnic groups.  According to the data, white Americans have a shorter life expectancy than Latinos (82.8 years) and Asian- Americans (86.5 years) and are only slightly ahead of Native Americans (76.9 years).  Neither Latinos nor Asian-Americans currently have greater political or economic power in the United States than do white Americans.  Race may be a factor, but that doesn’t mean racism or bias is the driving force behind the differences.

I think it’s also important to remember, before we declare black pain undertreated, that we recognize that the current practices regarding the use of pain medication in American healthcare is an anomaly worldwide. Consider that the New York Times reported that American “Patients here consumed 99 percent of the world’s hydrocodone, the opioid in Vicodin. They also consumed 80 percent of the world’s oxycodone, present in Percocet and OxyContin, and 65 percent of the world’s hydromorphone, the key ingredient in Dilaudid, in 2010.” According to the National Institute on Drug Abuse, the number of deaths in the United States due to prescription pain relievers has quadrupled since 1999.

Given these numbers, I have to question whether the data on the use of pain medication isn’t coming from the under treatment of black pain, but is more indicative of a larger epidemic of prescription pain medication abuse in white American patients.  Consider another article from the Washington Post that examined other research which reported that “Non-Hispanic white Americans take prescription drugs at roughly twice the rate of Mexican Americans. Researchers offered no clear explanation but said the disparity “was not entirely attributable” to differences in insurance status.”

This may not be better healthcare for white Americans, but indications of a serious untreated healthcare problem.  I won’t pretend that I have all the answers to the many questions and challenges we face as we seek to create a healthcare system to provide appropriate care to all Americans.  However, I do know that we have examine the issues very closely and seek truth above all else.