Doctors are more than twice as likely to drug test black patients who take prescription opioids compared to their white counterparts, according to a new Yale University study of veteran health data released on Aug. 20.
This indicates a lack of clear guidance around drug testing for patients on long-term opioids therapy and contributes to evidence of broader racial disparities in how chronic pain patients who are prescribed opioids are treated, according to the study’s lead author Julie R. Gaither.
Gaither, an instructor and epidemiologist at the Yale School of Medicine told HuffPost that the mere magnitude of the findings and past research suggests that racial bias played a role in these disparities.
“We think that physicians are relying on subjective measures and that they’re vulnerable to implicit bias, falling back on ingrained stereotypes that black patients are more at risk and that they may be more likely to be engaging in illicit drug use,” she said.
Researchers analyzed the electronic health records of more than 15,000 patients who received long-term opioid therapy through the U.S. Department of Veterans Affairs between 2000 and 2010 to see if there were any disparities in illicit drug testing.
While only 20 percent of patients received a drug urine test, the study found black patients were more than twice as likely to be tested for drug use compared to white patients.
Though white people are dying more frequently from an opioid-related overdose, black patients who tested positive for marijuana were two times more likely than white patients to have their opioid treatment discontinued. Among patients who tested positive for cocaine, black patients were three times more likely to have opioid treatment discontinued.
We think that physicians are relying on subjective measures and that they’re vulnerable to implicit bias. Dr. Julie R. Gaither, lead author of the study.
Yale researchers referenced multiple past studies when discussing possible racial bias in their paper, including an April 2014 study that found black patients with moderate or high chronic noncancer pain in the VA health care system were less likely to receive opioid treatment than whites. A 2016 study from researchers at the University of Virginia also found that many white medical students believed inaccurate or “fantastical” beliefs about black patients’ tolerance for pain.
Dr. Diana Burgess, a social psychologist and a principal investigator at the VA, was the lead author on that study and told HuffPost the Yale team’s findings aren’t surprising.
“It seems completely consistent with the research on disparities in pain management,” Burgess said, adding that her own study reflected these differences and she agrees that physicians fall back on racial stereotypes when making some of these decisions.
Still, her team did not rule out the possibility that black patients were simply less likely to want to take opioids for pain. Some studies on pain management among cancer and terminally-ill patients suggest black patients have more concerns about possible addiction to opioids than other populations.
A Universal Approach
The Centers for Disease Control and Prevention (CDC) recommends physicians give patients a drug urine test before starting opioid therapy for chronic pain and at least once annually throughout treatment. The testing is meant to monitor for drug use that may contribute to an overdose.
Gaither said part of the reason these racial disparities exist in treatment is because federal guidelines are more like suggestions than mandates. She thinks physicians need explicit direction when it comes to illicit drug testing and how to respond if a patient tests positive.
“There’s no real clear guidance on what the clinician should do if the patient tests positive [for illicit drugs], so the physician is left relying on their judgment, which as we know is prompt to error,” Gaither said. “We found that, regardless of race, 90 percent of patients who tested positive for one of these illicit substances continued to refill their opioid prescription, which is troubling.”
“That’s why we recommend that clinicians follow the recommendations from the CDC and take a universal approach to not only testing but responding to illicit drug use,” she added.
But Burgess suggests looking beyond opioid therapy, particularly in light of the serious risks that come with opioid use. Instead, she hopes more research is done around possible racial disparities in other forms of pain treatment.
″[For example,] are black people also less likely to get physical therapy or other types of non-drug therapies?” she said. “I think that’s a really important area because we don’t want being prescribed opioids to be the final word in quality of treatment.”