Prescription opioid overdoses killed almost 19,000 people in the United States in 2014. The terrible toll is traceable in large part to excessive prescribing by physicians and dentists. No less an authority than the Centers for Disease Control and Prevention has recently issued guidelines urging health care practitioners to be much more cautious about passing out what the CDC called “dangerous” medications, whose brand names include Vicodin and OxyContin.
So how come the New York Times has chosen this moment to announce, on its prestigious front page no less, that some Americans might not be getting their fair share of opioids?
Well, it’s complicated. The specific issue in the Times story (headlined “Minorities Seeking Pain Relief Are Shortchanged in Treatment”) was this: African American patients are significantly less likely to be prescribed opioids to treat pain than whites are, and this disparity persists even when the numbers are adjusted for other socio-economic variables such as income. This is not exactly news, but a finding of numerous studies going back years. (The Times also alluded to racial disparities in non-drug pain treatments, but the focus was on opioid prescribing.)
To be sure, the racial disparity is smallest in patients who report pain due to “definitive” causes, such as a bone fracture, as opposed to more subjective “non-definitive” causes, such as self-reported back or abdominal pain, which drug-seeking patients often invoke to elicit prescriptions. A brand-new study led by Astha Singhal of Boston University’s dental school found that non-Hispanic blacks and non-Hispanic whites who came to emergency rooms complaining of fractures, toothaches or kidney stones — “definitive” conditions a doctor could see — were equally likely to be sent home with a prescription for opioids. Racial disparities emerged, however, with respect to “non-definitive” conditions. In those cases, African Americans were 33 percent less likely than whites to get an opioid, the study found.
In other words, doctors, the vast majority of whom are white, are far more likely to provide opioids to whites than blacks in situations where suspicion of patient drug-seeking is greatest. It’s no great leap of racial paranoia to attribute this to bias or prejudice.
Whether it’s a front-page crisis or not is less clear. The opioid addiction epidemic, unlike previous drug-abuse waves in recent American history, spread not through illicit channels but perfectly legal ones. Indeed, the whole medical system, from the pharmaceutical industry to the family practitioner on Main Street, geared up to distribute these once sparingly issued pills in response to a purported epidemic of under-treated pain. Given that whites are far better connected to the medical system than blacks are — whites are “significantly” more likely to have insurance for example — it would have been surprising if there weren’t racial disparities in access to these prescription-only medicines.
And yet this makes the opioid epidemic the rare social catastrophe that has hit whites far harder than blacks. The Times story wrestles with this paradox, or “silver lining argument,” as the story calls it, but seems to conclude that the racial disparity is what really matters. Money quote: “We may agree that opioids can be harmful and that fewer of them may be a good thing,” an Indiana University professor told the paper. “But we should not ignore that black and white patients are getting treated differently.”
Fair enough. No one should be denied standard treatment because of race; and that applies to opioids if they are or were standard care for pain. But what if the real story here is that the standard of care itself was deeply misguided?
Andrew Kolodny, a psychiatrist long active in the effort to end opioid over-prescribing, argues that doctors’ racially skewed perceptions may not be causing inappropriately limited prescribing to blacks, but rather “aggressive inappropriate prescribing to whites.”
Indeed, maybe Americans of all races were, and still are, massively over-prescribed opioids. That’s one possibility the Times article did not entertain — but it could be true. Even if African Americans were 33 percent less likely than whites to get an opioid for back pain, that still means 67 blacks received opioids for every 100 whites. That’s a lot of heavy, addictive medication being handed out to salve highly subjective complaints. Thus, it’s not quite true that the opioid crisis has by-passed the black community. In fact, prescription opioid deaths quintupled among blacks in New York state between 2003 and 2012, according to the state department of public health. The rate of death among whites actually grew slightly slower in that period, though the absolute number of white deaths was higher.
By the Times piece’s implicit logic, whole countries are victims of disparate underprescription of opioids. The U.S. consumes far more opioids than the rest of the world does, even when you adjust for national wealth and income. For example, Americans take 195 milligrams of hydrocodone, the active ingredient in Vicodin and OxyContin, per capita annually, whereas the figure in Germany is 28 milligrams per capita. Is that because Germans suffer one-seventh as much pain as Americans do? Or because their health-care system is seven times more sensible?