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Underprescription in a Time of Excess

Santiago, Christine, MPH

doi: 10.1097/ACM.0000000000002485
Letters to the Editor

Fourth-year medical student, Harvard Medical School, Boston, Massachusetts;

Disclosures: None reported.

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To the Editor:

Ethnic minorities in the United States are routinely underprescribed opioids for pain management. Numerous studies show that physicians’ implicit biases are contributing to the disparities.1 Underprescription is pervasive, and no physician specialty is spared. Disparities in the emergency department, inpatient services, and primary care settings have been identified. One of the strongest predictors of whether a patient will receive pain medication is race. As opioids are the most efficacious medication for controlling severe pain, many people of color are left to suffer with no relief. Nationally, physicians are increasingly held responsible for the opioid epidemic and are tightening their prescription practices. As this crackdown spreads, I fear that tighter regulation will further exacerbate the racial differences in pain management.

Physicians are the primary gatekeepers of opioid medication prescription, and interventions that target them are the most likely to improve pain management in communities of color. Studies show that doctors who believe that minorities are more likely to misuse or sell drugs, or biologically have a higher pain tolerance than Caucasians, are less likely to prescribe appropriate doses of opioids in treating severe pain.2 Misinformation about racial differences in pain can be addressed in medical schools, and training should be provided on the appropriate use and distribution of opioids. By targeting these false ideologies and biases, it may be possible to reverse attitudes that contribute to racial disparities in pain management.

Underprescription of opioids to ethnic minorities is an enormous problem that is bound to get worse before it gets better. Ironically, doctors’ hesitancy to prescribe opioids to minorities may have prevented the opioid outbreak from hitting these communities.3 Therefore, efforts to increase good practices for pain management in communities of colors need to be conscious not to create a second-wave opioid epidemic in their wake.

As the highly addictive potential of opioids is currently exceedingly evident, teaching physicians to prevent overprescription to Caucasian groups while balancing underprescription to minority groups may be challenging. However, a balance must be struck; otherwise, many communities of color will continue to suffer in silence.

Christine Santiago, MPH

Fourth-year medical student, Harvard Medical School, Boston, Massachusetts;

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1. Dickason RM, Chauhan V, Mor A, et al. Racial differences in opiate administration for pain relief at an academic emergency department. West J Emerg Med. 2015;16:372–380.
2. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296–4301.
3. Ballesteros C. Racism might have spared black and latino communities from new opioid epidemic, drug abuse expert says. December 5, 2017. Newsweek. Accessed September 27, 2018.
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