Inequities Drive Different Experiences With Pain and Opioids
By Laura E. Brown | January 14, 2020
The devastating opioid epidemic in the U.S. is well-documented. In decades past, women were commonly prescribed opioids to cope with chronic pain conditions. Now medical experts question the effectiveness of opioid therapy for long-lasting pain, and fatal overdoses involving opioids have become a national crisis.
Where does that leave women and other groups with chronic pain? How can policymakers and prescribers facilitate the safe and effective alleviation of pain for all patients? Finding solutions will demand that we ask nuanced questions about the correlations between social factors, quality of care, and health outcomes that contribute to health disparities rooted in gender, race, and class.
Signs of Inequitable Care
Since 1999, the rate of drug overdose deaths involving opioids has increased almost six times. Prescription opioids were involved in 36 percent of the total 47,000 fatal overdoses in 2017. Although prescription opioids can be a healthy part of a comprehensive plan for pain management, there are many associated risks including misuse, diversion, and overdose. There is also evidence to suggest that the intensity of pain actually increases when patients use prescription opioids over the long term.
Social factors play a role in the proportion and likelihood of fatal overdose. In part, overdose deaths explain why mortality rates for every group but middle-aged whites have decreased over the past decade. In this case, the impact of health disparities is somewhat counterintuitive. Men make up over two-thirds of these deaths. Non-Hispanic whites make up 78 percent. What explains the comparatively low rates for women, Black, and Hispanic populations?
Among other possibilities, evidence suggests that pain is taken less seriously by clinicians for these groups. Ironically, this disparity in care has offered some protection from the risk of prescription opioid overdose. However, this does not mean that pain is being treated in other ways. In fact, it may be evidence that these groups are not receiving equitable care.
Social Factors Influence the Likelihood of Chronic Pain
It’s important to understand the social factors that drive diagnoses and subsequent treatment plans, including prescription opioids. Women are disproportionately diagnosed with chronic pain conditions, and this trend holds across the globe.
Women are disproportionately diagnosed with chronic pain conditions, and this trend holds across the globe.
Although some have argued that there may be purely “biological” reasons—for example, ideas about women’s pain tolerance, or lack thereof—these ideas continue to be up for debate.
What is more likely is that there are social causes that explain women’s experiences of chronic pain throughout the life course. All pain has physiological, psychological, and social causes. Some argue that the experience of pain is a manifestation of a combination of these causes.
From a societal level, pain is a complex public health issue, but it hasn’t always been viewed that way. It wasn’t until the advent of the Affordable Care Act that the federal government created the National Pain Strategy, which recognizes that pain is made up of distinct biological, psychological, emotional, and social elements. In addition, growing social and economic inequity in the U.S. arguably contribute to the national crisis of pain, which has important ramifications for policy efforts to address the opioid crisis.
Unclear Policies Create Potential for Unanticipated Harms
Although national agencies agree that opioid stewardship is necessary and that pain must be managed as a public health issue, federal policies on both fronts remain unclear. This sits in stark contrast to the public response to the crack cocaine crisis of the 1980s and 1990s, when policies were swiftly implemented to incarcerate rather than rehabilitate people who were swept up in the court system. The white-coded opioid crisis, by comparison, has received more public attention in the form of countless sympathetic think pieces, but less of a centralized government response.
The current lack of clarity at the policy level means that prescribers have a lot of power to make well-intentioned decisions with patients about opioids. But it also creates significant potential for unanticipated harm, including under-prescribing to women and people of color (for example, following a painful surgery) and over-prescribing to white men, which can precipitate substance use disorders.
The current lack of clarity at the policy level means that prescribers have a lot of power to make well-intentioned decisions with patients about opioids. But it also creates significant potential for unanticipated harm, including under-prescribing to women and people of color (for example, following a painful surgery).
So far, there have been relatively few consequences for pharmaceutical corporations. Although preliminary data suggest that over-prescribing has been curbed, opioid misuse and the problem of chronic pain persist, interacting with gender and racial biases in health care.
Crafting Effective Policies: Where Do We Go From Here?
Given persistent health disparities and social inequalities, U.S. policymakers must carefully consider how their responses to the opioid crisis may affect groups differently. Abruptly curtailing of the use of all prescription opioids would likely cause harm, particularly to people experiencing chronic pain. There are risks to eliminating treatment options without creating additional, effective options that are accessible and affordable.
Broadly, increased funding for social services, universal healthcare, and other policies that promote wellness throughout the lifespan will help people get well, stay well, and reduce the demand for opioids.
Broadly, increased funding for social services, universal healthcare, and other policies that promote wellness throughout the lifespan will help people get well, stay well, and reduce the demand for opioids. More specifically, increased funding to help meet mental health needs can make it easier for people to address the non-physiological elements of pain. But to remedy gender- and race-based health disparities, funding must be allocated equitably.
Rehabilitation services and medication assisted therapies like buprenorphine (Suboxone) can get people back to their daily routines and lives if they are coping with substance use disorder. State and local policies can mandate the use of prescription drug monitoring programs, follow-up conversations, co-prescription of Naloxone during an office visit, and in-office overdose prevention counseling. My own work on the Texas Prescription Monitoring Program addresses the role of trust in patient-provider interactions, and how clinicians can successfully initiate and facilitate difficult conversations about pain and opioids.
Although federal policy is not the sole solution for an issue as complex as the opioid epidemic, policymakers would do well to consider the role that sexism, racism, and other forms of prejudice, discrimination, and stigma play in pain and public health.