Elderly Black and Hispanic patients with advanced cancer are less likely than white patients to receive opioid medications for pain relief in the last weeks of life, according to new research from the Dana-Farber Cancer Institute.
The research builds on more than 20 years of evidence showing racial disparities in pain management.
“It adds another layer of evidence showing just how pervasive racial bias is in medical care, even in places where you’d expect that not to be the case,” said Dr. Haider Warraich, a physician at Brigham and Women’s Hospital, Harvard Medical School and the VA Boston Healthcare System, who was not involved in the research.
The new study, published online today in the Journal of Clinical Oncology, is the largest to examine disparities in opioid access among patients with cancer in the country.
Researchers examined opioid prescription orders between 2007 and 2019 for 318,549 Medicare patients with terminal cancer over the age of 65 who were nearing the end of life.
They found that, compared to white patients, Black patients were 4.3 percent less likely to receive any opioid and 3.2 percent less likely to receive long-acting opioids near the end of life. Hispanic patients were 3.6 percent less likely to receive any opioids and 2.2 percent less likely to receive long-acting opioids.
When Black and Hispanic patients did receive opioids for pain management, they usually received lower doses in the last month of life than the average white patient, according to the findings. Black men faced the greatest inequities and were found to be the least likely demographic to be prescribed “reasonable doses,” according to Dr. Alexi Wright, a medical oncologist and Director of Gynecologic Oncology Outcomes Research at Dana-Farber Cancer Institute and a senior author of the study.
“Cancer pain is one of the few conditions where there’s broad consensus that opioids are the treatment of choice,” said Dr. Astha Singhal, an assistant professor at Boston University’s Henry M. Goldman School of Dental Medicine, who was not involved in the research. “Pain management is one of the prime goals in end-of-life cancer patients, so to see the disparities in this group is quite striking”
The study did find a steady decline in access to opioids for patients of all races and a rapid increase of urine drug screening during that time period. Black patients, however, were more likely than any other group to undergo urine drug screening when receiving opioid therapy.
“These patients are near the end of life,” said Dr. Andrea Enzinger, a medical oncologist and palliative care physician at Dana-Farber Cancer Institute and the study’s lead author. “Unless there is a known history of substance misuse or some other very strong indication, it’s difficult to imagine why this is an important part of their pain treatment.”
Increased restrictions on prescription opioids in the wake of a national opioid crisis have significantly decreased patient access to these drugs. Although the restrictions are aimed at curbing opioid abuse, researchers have noted that, in some instances, they have made it more difficult for terminal cancer patients to get the pain medication drugs they need.
Since the Centers for Disease Control and Prevention published its opioid guidelines in 2016, more than half of U.S. states have adopted legislation restricting opioid prescription and/or dispensation for acute pain citing 2016 CDC guidelines. Although these guidelines excluded patients with active cancer, they have been widely “misapplied...leading to significant opioid access issues for persons with chronic pain, including cancer,” according to Dr. Salimah Meghani, a professor of nursing at the University of Pennsylvania School of Nursing who researched race-based disparities in pain treatment.
“Obviously, a lot of these regulations are appropriate, because we want to stem the tide of the opioid crisis, but they’ve been a very blunt tool,” Enzinger said. “These aren’t just cancer patients, we’re looking at dying cancer patients.”
Findings from the new study suggest that doctors lack “trust” that their Black and Hispanic patients won’t misuse the medication, Warraich said. He said this is particularly inappropriate considering, during the course of the study, overdose deaths and addiction rates from opiates were statistically much higher amongst white individuals.
Previous studies have found that doctors who underprescribe pain medication to Black people hold false beliefs about biological differences between races. A 2016 survey of 222 white medical students and residents found that half believed Black people feel less pain than white people, a myth that dates back to the time of slavery.
The new study’s authors plan to continue researching racial disparities in the pain management of cancer patients to identify the main causes of these inequities and devise appropriate solutions.
“Our next step is to understand the drivers of this and see how much of this can be explained by individual physicians’ behaviors, clinics instituting drug screening policies or area level things such as pharmacy access,” Wright said. “To understand it, but importantly, to change it.”