Painkillers Understocked in Minority Areas, Study Says

By Marc Kaufman
Washington Post Staff Writer
Friday, October 14, 2005

Pharmacies in black neighborhoods are much less likely to carry sufficient supplies of popular opioid painkillers than those in white neighborhoods, a new study has found, leading researchers to conclude that minorities are routinely undertreated for chronic pain.

The study found that the disparity between what is available to patients in majority-black neighborhoods compared with majority-white areas had little to do with income levels, as pharmacies in wealthy black neighborhoods were no more likely to carry the prescription painkillers than those in poorer black neighborhoods. In wealthy white neighborhoods, however, pharmacies were far more likely to carry sufficient stock than in poor white communities.

"The pharmacies in minority areas generally say they stock limited amounts of pain medication because the demand is not there," said Carmen R. Green, an associate professor at the University of Michigan Medical School, who led the research.

"But the low-demand barrier does not ring true for me," she said. "We know that minorities are more at risk of suffering chronic pain, and maybe they don't come to local pharmacies because they've come to expect they won't carry the medicines they need."

Green and other researchers said that the new study, published this week in the Journal of Pain, is consistent with earlier studies showing that doctors were less likely to prescribe opioid painkillers to minorities than to whites.

"I'm shocked by these results," said Ashish K. Jha, an expert in health care disparities at the Harvard School of Public Health.

"There is no plausible explanation that makes sense," he said. "It's hard to know what gets us there, but if pharmacies are stocking [narcotic painkillers] at substantially lower levels for black people, what is clear is that there's no good clinical reason for it."

The study found that one possible non-clinical explanation for the lower availability is concern about illicit use, and the potential consequences for the dispenser.

The head of the Washington D.C. Pharmaceutical Association and one Capitol Hill pharmacist agreed with that assessment. Association President Herbert Kwash said many pharmacists in the District are reluctant to carry controlled drugs because of concerns that they will be robbed and their customers endangered. For those reasons, said pharmacist Michael Kim of Grubbs Pharmacy on East Capitol Street, some druggists no longer carry prescription narcotics and have signs in their front windows indicating that.

Pain diagnoses are notoriously difficult to make -- whether from an accident, from chronic arthritis or back pain, or from cancer -- because there is no objective way to measure suffering.

Research during the 1990s led many pain doctors to conclude that prescription narcotics such as OxyContin, Dilaudid and Percocet could be used at higher strength without a high risk of addiction. But the Drug Enforcement Administration became increasingly concerned about the diversion of these prescription narcotics, which agency officials argued became overprescribed and widely abused.

That view led the DEA and local authorities to prosecute scores of doctors and pharmacists for alleged improper and illegal prescribing, and a number are serving lengthy jail terms. Two high-profile cases involved local practitioners -- pain doctor William E. Hurwitz of McLean and pharmacist Emmanuel Thad Ereme, who operated Hremt Pharmacy in District Heights. Both men said they were just trying to help patients in pain, but juries concluded they were involved in criminal conspiracies to distribute prescription narcotics.

Susan Winkler, vice president for policy for the American Pharmaceutical Association, which represents pharmacists, said concern over DEA "heavy-handedness" could play a role in the limited availability of controlled pain drugs in some minority-neighborhood pharmacies.

Although the abuse of painkillers has reportedly been most widespread in rural white areas, she said pharmacists everywhere have become increasingly concerned about the risks of selling the controlled drugs. Patient demand determines which drugs a pharmacy stocks, Winkler said, but the paperwork and DEA oversight associated with the narcotic painkillers are also factors.

"For every violation, there is a substantial fine," she said. "And an investigation of a pharmacist's practice, like for a physician, can send a real chill throughout the health care practitioner community. . . . With the controlled drugs, the pharmacist now has to determine whether a prescription is legally valid and clinically appropriate, and that's a heavy burden."

Green's study, which surveyed 188 Michigan pharmacies, found stark differences in how well drugstores were stocked with opioid painkillers. In Zip codes predominantly inhabited by whites, 87 percent of pharmacies were deemed to have sufficient supplies; 54 percent met that standard in predominantly minority Zip codes.

The research also found a substantial difference between large chain stores and independents. Although 91 percent of independents were found to be well supplied with the painkillers, only 59 percent of chain stores met the criteria.

Valerie Stork, spokeswoman for the National Association of Chain Drug Stores, said that although the DEA does track and monitor the sale of controlled drugs, the agency does not directly mandate how much of a medication a pharmacy should carry.

"It is up to each individual pharmacy to decide the quantity of controlled substances to stock," she said.

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