African American Patients Screened More Frequently for Opioid Abuse

Black patients treated with opioids for pain are more likely to be required to attend regular office visits and receive restricted early refills.

Black patients treated with opioids for pain are more likely to be required to attend regular office visits and receive restricted early refills than white patients.

Despite evidence that white patients are more likely to abuse or misuse prescription opioid medications, studies have shown that physicians “are less likely to prescribe opioid analgesics to treat pain in black compared with white patients, even after adjusting for severity of illness and other clinically relevant factors.” The authors of a study published in the May/June issue of Annals of Family Medicine sought to account for these racial differences in opioid prescribing habits by assessing three opioid risk reduction strategies (urine drug testing, scheduling regular office visits, and restricted early refills of opioid medications) used by primary care physicians treating a mixed cohort of black and white patients with chronic noncancer pain.

Eligible patients for this retrospective study (conducted in eight primary care practices affiliated with the University of Pennsylvania Health System in Philadelphia, PA) met the following criteria:

  • At least three primary care practice visits that “demonstrated longitudinal care”
  • Received an ICD-9-CM diagnosis of musculoskeletal or neuropathic pain
  • Prescribed three or more monthly prescriptions for opioids by a primary care physician during a six-month period

Prescription opioids considered in this study included oral, transdermal, and intranasal opioid analgesics; intravenous and intramuscular formulations were excluded, as was tramadol. For ths study, urine drug testing was defined as “at least 1 completed urine drug test during the period of opioid treatment.” A “regular office visit” was defined as a primary care visit during a six-month opioid treatment period or a visit that occurred “30 days before or after an increase in an opioid dose or prescription of a new opioid.” Restricted early refills were defined as “existence of fewer than 2 occasions on which the patient received an opioid prescription more than 7 days before the previous prescription should have been completed if taken as directed.”

More than 1,600 patients met the inclusion criteria, nearly two-thirds of whom (62.1%) were black. Analysis of data showed that 8.0% of patients received urine drug testing, nearly half (49.8%) had regular office visits, and more than three-fourths (76.6%) had restricted early refills. However, the authors reported that black patients “were more likely to receive each opioid risk reduction strategy when compared with white patients.” In the study, black patients were more likely to be diagnosed with a substance use and/or tobacco use problem.

After adjusting for “sets of patient, clinical, and health care variables,” black patients had “significantly higher odds than their white counterparts of receiving regular office visits (odds ratio = 1.51; 95% confidence interval, 1.06—2.14) and restricted early refills (odds ratio = 1.55; 95% confidence interval, 1.03–2.32), but not urine drug testing (odds ratio = 1.41; 95% confidence interval, 0.78–2.54).”

In their discussion of these results, the authors wrote that the data “indicate physicians are more cautious about initiating opioid therapy in black patients and, once the medication is started, monitor black patients more closely than whites.” They also noted that overall use of the three opioid risk reduction strategies was low across the cohort; roughly 10% of black patients received urine drug testing, compared with only 4% of white patients. Only half of all patients undergoing opioid treatment for pain received regular office visits. Nearly 25% of patients were prescribed multiple early refills of their medications.

The authors offered several reasons for the increased frequency of office visits for black patients in this study (a phenomenon contrasted by other studies showing black patients are far less likely to use primary care services than white patients). They noted that the increase may be accounted for by the fact that black patients in this study had more medical comorbidities than their white counterparts and were more likely to have Medicaid insurance. Undertreatment of pain and/or physician concern about the need to monitor black patients for misuse may also have been contributing factors.

These results may indicate the existence of what the authors term “reverse disparity,” in that in this study it was the minority group that was the recipient of care that was “more consistent with expert recommendations and guidelines,” whereas physicians may have been “inappropriately lax in monitoring white patients,” resulting in “lower quality of care in regard to these monitoring outcomes.” The authors speculated that “lack of physician training, time, and other practice resources” and the “dearth of evidence demonstrating the effectiveness of risk reduction strategies in improving misuse outcomes” may have contributed to the low rate of risk reduction strategy implementation by the physicians in this study.

The authors concluded that their findings indicate that “real-world clinical practice” may often fall short of the ideal of the "universal precautions approach to risk reduction for patients prescribed opioids for chronic noncancer pain.” The fact that this shortcoming may in part be racially based “should stimulate clinical and educational initiatives to ensure all patients are appropriately monitored.” They recommended further study to determine whether “systems-based approaches with standardized monitoring strategies ameliorate these differences and improve overall monitoring rates.”