Advertisement

Racial Differences in Prescription of Opioid Analgesics for Chronic Noncancer Pain in a National Sample of Veterans

Published:January 21, 2014DOI:https://doi.org/10.1016/j.jpain.2013.12.010

      Abstract

      The purpose of this study was to investigate possible racial differences in opioid prescriptions among primary care patients with chronic noncancer pain receiving care in the Veterans Affairs health care system. This was a retrospective cohort study of 99,903 veterans with diagnoses of low back, neck, or joint pain selected to participate in the Veterans Affairs Survey of the Healthcare Experiences of Patients in fiscal year 2006. The outcome was prescription of opioids in the year following the first pain diagnosis, obtained through electronic medical record data. Analyses incorporated fixed effects for race, most recent pain intensity rating, new or established primary care patient status, and an interaction between race and most recent pain intensity rating, together with random effects for health care facility and race within facility. The association between patient race and prescription of opioids was moderated by baseline level of pain intensity scores (assessed on a 0–10 scale) and patient age. Among patients under 65 years of age, blacks with moderate (4–6) or high (7–10) levels of pain were less likely to receive opioids than whites (P = .0025, P = .0011); however, there were no significant differences between black and white patients with low levels of pain intensity (1–3) and those with pain intensity ratings of 0 (no pain). Among patients 65 and older with pain intensity ratings of zero, blacks were more likely than whites to receive opioid prescriptions (P = .0087), but there were no significant racial differences in opioid prescriptions in those with low to high levels of pain.

      Perspective

      Among veterans under age 65 reporting moderate to high levels of chronic noncancer pain, blacks were less likely to be prescribed opioids than whites, even after controlling for clinical and system-level factors. Results underscore the challenges of eliminating racial differences in pain treatment, despite comprehensive systemwide improvement initiatives.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Allen K.D.
        • Oddone E.Z.
        • Coffman C.J.
        • Keefe F.J.
        • Lindquist J.H.
        • Bosworth H.B.
        Racial differences in osteoarthritis pain and function: Potential explanatory factors.
        Osteoarthritis Cartilage. 2010; 18: 160-167
        • Anderson K.O.
        • Green C.R.
        • Payne R.
        Racial and ethnic disparities in pain: Causes and consequences of unequal care.
        J Pain. 2009; 10: 1187-1204
        • Anderson K.O.
        • Richman S.P.
        • Hurley J.
        • Palos G.
        • Valero V.
        • Mendoza T.R.
        • Gning I.
        • Cleeland C.S.
        Cancer pain management among underserved minority outpatients: Perceived needs and barriers to optimal control.
        Cancer. 2002; 94: 2295-2304
        • Armstrong K.
        • Hughes-Halbert C.
        • Asch D.A.
        Patient preferences can be misleading as explanations for racial disparities in health care.
        Arch Intern Med. 2006; 166: 950-954
        • Avenanti A.
        • Sirigu A.
        • Aglioti S.M.
        Racial bias reduces empathic sensorimotor resonance with other-race pain.
        Curr Biol. 2010; 20: 1018-1022
        • Azevedo R.T.
        • Macaluso E.
        • Avenanti A.
        • Santangelo V.
        • Cazzato V.
        • Aglioti S.M.
        Their pain is not our pain: Brain and autonomic correlates of empathic resonance with the pain of same and different race individuals.
        Hum Brain Mapp. 2013; 34: 3168-3181
        • Becker W.C.
        • Starrels J.L.
        • Heo M.
        • Li X.
        • Weiner M.G.
        • Turner B.J.
        Racial differences in primary care opioid risk reduction strategies.
        Ann Family Med. 2011; 9: 219-225
        • Becker W.C.
        • Sullivan L.E.
        • Tetrault J.M.
        • Desai R.A.
        • Fiellin D.A.
        Non-medical use, abuse and dependence on prescription opioids among U.S. adults: Psychiatric, medical and substance use correlates.
        Drug Alcohol Depend. 2008; 94: 38-47
        • Bohnert A.S.
        • Valenstein M.
        • Bair M.J.
        • Ganoczy D.
        • McCarthy J.F.
        • Ilgen M.A.
        • Blow F.C.
        Association between opioid prescribing patterns and opioid overdose-related deaths.
        J Am Med Assoc. 2011; 305: 1315-1321
        • Bonham V.L.
        Race, ethnicity, and pain treatment: Striving to understand the causes and solutions to the disparities in pain treatment.
        J Law Med Ethics. 2001; 29: 52-68
        • Braden J.B.
        • Fan M.Y.
        • Edlund M.J.
        • Martin B.C.
        • DeVries A.
        • Sullivan M.D.
        Trends in use of opioids by noncancer pain type 2000-2005 among Arkansas Medicaid and HealthCore enrollees: Results from the TROUP study.
        J Pain. 2008; 9: 1026-1035
        • Braden J.B.
        • Russo J.
        • Fan M.Y.
        • Edlund M.J.
        • Martin B.C.
        • DeVries A.
        • Sullivan M.D.
        Emergency department visits among recipients of chronic opioid therapy.
        Arch Intern Med. 2010; 170: 1425-1432
        • Burgess D.J.
        • Grill J.
        • Noorbaloochi S.
        • Griffin J.M.
        • Ricards J.
        • van Ryn M.
        • Partin M.R.
        The effect of perceived racial discrimination on bodily pain among older African American men.
        Pain Med. 2009; 10: 1341-1352
        • Burgess D.J.
        • van Ryn M.
        • Crowley-Matoka M.
        • Malat J.
        Understanding the provider contribution to race/ethnicity disparities in pain treatment: Insights from dual process models of stereotyping.
        Pain Med. 2006; 7: 119-134
        • Burgess D.J.
        • van Ryn M.
        • Malat J.
        • Matoka M.
        Understanding the provider contribution to race/ethnicity disparities in pain treatment: Insights from social cognitive research on stereotyping.
        Pain Med. 2006; 7: 119-134
        • Cerda M.
        • Ransome Y.
        • Keyes K.M.
        • Koenen K.C.
        • Tracy M.
        • Tardiff K.J.
        • Vlahov D.
        • Galea S.
        Prescription opioid mortality trends in New York City, 1990-2006: Examining the emergence of an epidemic.
        Drug Alcohol Depend. 2013; 132: 53-62
        • Chibnall J.T.
        • Tait R.C.
        • Ross L.R.
        The effects of medical evidence and pain intensity on medical student judgments of chronic pain patients.
        J Behav Med. 1997; 20: 257-271
        • Cintron A.
        • Morrison R.S.
        Pain and ethnicity in the United States: A systematic review.
        J Palliat Med. 2006; 9: 1454-1473
        • Cleeland C.S.
        • Reyes-Gibby C.C.
        • Schall M.
        • Nolan K.
        • Paice J.
        • Rosenberg J.M.
        • Tollett J.H.
        • Kerns R.D.
        Rapid improvement in pain management: The Veterans Health Administration and the institute for healthcare improvement collaborative.
        Clin J Pain. 2003; 19: 298-305
        • Cooper L.A.
        • Roter D.L.
        • Carson K.A.
        • Beach M.C.
        • Sabin J.A.
        • Greenwald A.G.
        • Inui T.S.
        The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care.
        Am J Public Health. 2012; 102: 979-987
        • Craine M.
        • Kerns R.D.
        Pain management improvement strategies in the Veterans Health Administration.
        APS Bull. 2003; 135: 1-9
        • Drwecki B.B.
        • Moore C.F.
        • Ward S.E.
        • Prkachin K.M.
        Reducing racial disparities in pain treatment: The role of empathy and perspective-taking.
        Pain. 2011; 152: 1001-1006
        • Edwards R.R.
        The association of perceived discrimination with low back pain.
        J Behav Med. 2008; 31: 379-389
        • Elixhauser A.
        • Steiner C.
        • Harris D.R.
        • Coffey R.M.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Forgiarini M.
        • Gallucci M.
        • Maravita A.
        Racism and the empathy for pain on our skin.
        Front Psychol. 2011; 2: 108
        • Green C.R.
        • Anderson K.O.
        • Baker T.A.
        • Campbell L.C.
        • Decker S.
        • Fillingim R.B.
        • Kalauokalani D.A.
        • Lasch K.E.
        • Myers C.
        • Tait R.C.
        • Todd K.H.
        • Vallerand A.H.
        The unequal burden of pain: Confronting racial and ethnic disparities in pain.
        Pain Med. 2003; 4: 277-294
        • Green C.R.
        • Baker T.A.
        • Ndao-Brumblay S.K.
        Patient attitudes regarding healthcare utilization and referral: A descriptive comparison in African- and Caucasian Americans with chronic pain.
        J Natl Med Assoc. 2004; 96: 31-42
        • Green T.C.
        • Black R.
        • Serrano J.M.G.
        • Budman S.H.
        • Butler S.F.
        Typologies of prescription opioid use in a large sample of adults assessed for substance abuse treatment.
        PLoS One. 2011; 6: e27244
        • Hausmann L.R.
        • Gao S.
        • Lee E.S.
        • Kwoh C.K.
        Racial disparities in the monitoring of patients on chronic opioid therapy.
        Pain. 2013; 154: 46-52
        • Ives T.J.
        • Chelminski P.R.
        • Hammett-Stabler C.A.
        • Malone R.M.
        • Perhac J.S.
        • Potisek N.M.
        • Shilliday B.B.
        • DeWalt D.A.
        • Pignone M.P.
        Predictors of opioid misuse in patients with chronic pain: A prospective cohort study.
        BMC Health Serv Res. 2006; 6: 46
        • Kaseweter K.A.
        • Drwecki B.B.
        • Prkachin K.M.
        Racial differences in pain treatment and empathy in a Canadian sample.
        Pain Res Manag. 2012; 17: 381-384
      1. Kerns RD: Improving Pain Management in the VA. Chatham, NJ, Federal Practitioner, 2001 Supplement, pp 18-22.

        • Kerns R.D.
        • Philip E.J.
        • Lee A.W.
        • Rosenberger P.H.
        Implementation of the Veterans Health Administration National Pain Management Strategy.
        Transl Behav Med. 2011; 1: 635-643
        • Kressin N.R.
        • Chang B.H.
        • Hendricks A.
        • Kazis L.E.
        Agreement between administrative data and patients' self-reports of race/ethnicity.
        Am J Public Health. 2003; 93: 1734-1739
        • McCaffery M.
        • Beebe A.
        Pain: Clinical Manual for Nursing Practice.
        V.V. Mosby Company, Baltimore1993
        • McCracken L.M.
        • Matthews A.K.
        • Tang T.S.
        • Cuba S.L.
        A comparison of blacks and whites seeking treatment for chronic pain.
        Clin J Pain. 2001; 17: 249-255
        • Meghani S.H.
        • Byun E.
        • Gallagher R.M.
        Time to take stock: A meta-analysis and systematic review of analgesic treatment disparities for pain in the United States.
        Pain Med. 2012; 13: 150-174
        • Meghani S.H.
        • Cho E.
        Self-reported pain and utilization of pain treatment between minorities and nonminorities in the United States.
        Public Health Nurs. 2009; 26: 307-316
        • Meghani S.H.
        • Polomano R.C.
        • Tait R.C.
        • Vallerand A.H.
        • Anderson K.O.
        • Gallagher R.M.
        Advancing a national agenda to eliminate disparities in pain care: Directions for health policy, education, practice, and research.
        Pain Med. 2012; 13: 5-28
        • Morasco B.J.
        • Duckart J.P.
        • Carr T.P.
        • Deyo R.A.
        • Dobscha S.K.
        Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain.
        Pain. 2010; 151: 625-632
        • Paulozzi L.J.
        Prescription drug overdoses: A review.
        J Saf Res. 2012; 43: 283-289
        • Paulozzi L.J.
        • Budnitz D.S.
        • Xi Y.
        Increasing deaths from opioid analgesics in the United States.
        Pharmacoepidemiol Drug Saf. 2006; 15: 618-627
        • Paulozzi L.J.
        • Kilbourne E.M.
        • Shah N.G.
        • Nolte K.B.
        • Desai H.A.
        • Landen M.G.
        • Harvey W.
        • Loring L.D.
        A history of being prescribed controlled substances and risk of drug overdose death.
        Pain Med. 2012; 13: 87-95
        • Petersen L.A.
        • Byrne M.M.
        • Daw C.N.
        • Hasche J.
        • Reis B.
        • Pietz K.
        Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans.
        Health Serv Res. 2010; 45: 762-791
        • Portenoy R.K.
        • Ugarte C.
        • Fuller I.
        • Haas G.
        Population-based survey of pain in the United States: Differences among white, African American, and Hispanic subjects.
        J Pain. 2004; 5: 317-328
      2. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. National Acadeies Press, Washington, DC2011
        • Reyes-Gibby C.C.
        • Aday L.A.
        • Todd K.H.
        • Cleeland C.S.
        • Anderson K.O.
        Pain in aging community-dwelling adults in the United States: Non-Hispanic whites, non-Hispanic blacks, and Hispanics.
        J Pain. 2007; 8: 75-84
        • Rosen A.K.
        • Gardner J.
        • Montez M.
        • Loveland S.
        • Hendricks A.
        Dual-system use: Are there implications for risk adjustment and quality assessment?.
        Am J Med Qual. 2005; 20: 182-194
        • Ruehlman L.S.
        • Karoly P.
        • Newton C.
        Comparing the experiential and psychosocial dimensions of chronic pain in African Americans and Caucasians: Findings from a national community sample.
        Pain Med. 2005; 6: 49-60
        • Seal K.H.
        • Shi Y.
        • Cohen G.
        • Cohen B.E.
        • Maguen S.
        • Krebs E.E.
        • Neylan T.C.
        Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan.
        J Am Med Assoc. 2012; 307: 940-947
        • Shavers V.L.
        • Bakos A.
        • Sheppard V.B.
        Race, ethnicity, and pain among the U.S. adult population.
        J Health Care Poor Underserved. 2010; 21: 177-220
        • Smedley B.
        • Stith A.
        • Nelson A.
        Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
        National Academies Press, Washington, DC2003
        • Sohn M.W.
        • Zhang H.
        • Arnold N.
        • Stroupe K.
        • Taylor B.C.
        • Wilt T.J.
        • Hynes D.M.
        Transition to the new race/ethnicity data collection standards in the Department of Veterans Affairs.
        Popul Health Metr. 2006; 4: 7
        • Staton L.J.
        • Panda M.
        • Chen I.
        • Genao I.
        • Kurz J.
        • Pasanen M.
        • Mechaber A.J.
        • Menon M.
        • O'Rorke J.
        • Wood J.
        • Rosenberg E.
        • Faeslis C.
        • Carey T.
        • Calleson D.
        • Cykert S.
        When race matters: Disagreement in pain perception between patients and their physicians in primary care.
        J Natl Med Assoc. 2007; 99: 532-538
        • Tait R.C.
        • Chibnall J.T.
        Physician judgments of chronic pain patients.
        Soc Sci Med. 1997; 45: 1199-1205
        • Tait R.C.
        • Chibnall J.T.
        • Kalauokalani D.
        Provider judgments of patients in pain: Seeking symptom certainty.
        Pain Med. 2009; 10: 11-34
        • Trawalter S.
        • Hoffman K.M.
        • Waytz A.
        Racial bias in perceptions of others' pain.
        PLoS One. 2012; 7: e48546
        • van Ryn M.
        • Burgess D.J.
        • Dovidio J.F.
        • Fu S.S.
        • Griffin J.
        • Malat J.
        • Phelan S.
        • Saha S.
        The impact of racism on clinician cognition, behavior, and clinical decision making.
        Du Bois Rev. 2011; 8: 199-218
        • Varkey A.B.
        • Manwell L.B.
        • Williams E.S.
        • Ibrahim S.A.
        • Brown R.L.
        • Bobula J.A.
        • Horner-Ibler B.A.
        • Schwartz M.D.
        • Konrad T.R.
        • Wiltshire J.C.
        • Linzer M.
        Separate and unequal: Clinics where minority and nonminority patients receive primary care.
        Arch Intern Med. 2009; 169: 243-250
        • Weiss S.C.
        • Emanuel L.L.
        • Fairclough D.L.
        • Emanuel E.J.
        Understanding the experience of pain in terminally ill patients.
        Lancet. 2001; 357: 1311-1315