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Racism and Bias in Our Healthcare System Evidenced by The Opioid Crisis

Delaney Strange, BA ’21 Nursing with Health, Humanities, and Society Minor

HHS Competencies: Social and Structural Proficiency; Narrative and Historical Perspective

At least 130 people die every day from opioid related drug overdoses (HHS.GOV).  The opioid crisis is an urgent public health issue in the United States that requires active reform in order to improve treatment and access and advance our understanding of pain and addiction. Opioids are powerful tools for pain relief and comfort in hospitalized patients with acute pain.  The safe use of opioids for pain management is important to prevent addiction, but also to improve pain outcomes of patients undergoing surgeries and procedures. Recent studies have shown that Black Americans are less likely to be prescribed opioids and subsequently have worse pain management outcomes. When Black Americans are not prescribed opioids, they can still access these drugs on the streets or by other means in cheaper, more accessible and even more dangerous forms.    Along with undertreated pain and counter-intuitively high opioid-related death rates, Black Americans also face structural barriers that limit their access to treatment. Between worse pain management outcomes, and inferior access to treatment, the American healthcare system in a time of an urgent opioid crisis is failing the Black community.

Pain is an extremely subjective experience, making it difficult to treat and diagnose.  It is important for healthcare providers to assess pain from an objective and unbiased standpoint. However, extremely difficult because there is no universal scale for pain due to its subjective nature. In addition, cultural norms, societal expectations and self-image can affect a patient’s expression of pain, increasing the complexity of pain assessment. Unintentional favoritism or societal stereotypes can easily sway a doctor’s judgements on a patient’s condition based on the doctor’s own background, beliefs and ideologies.  How seriously a patient’s pain is taken can indicate how impartially the doctor views the patient. It is the responsibility for the doctor to view their patients from an unbiased standpoint to provide the best care and treatment outcomes.  However, discrepancies between the pain of Black patients and white patient’s is still seen in our health institutions today.

A recent study published in epidemiology found that doctors are statistically less likely to prescribe narcotics if a patient is Black (Mosley & Hagan 2020).  From one perspective, this could be seen as a good thing: The New York Times estimated that “14,000 Black Americans would have died from the opioid crisis had they been prescribed the drugs at the same rate as their counterparts.” (Mosley & Hagen 2020) On the other hand, this evidence is a result of a negative, stereotypical addict narrative, affecting the health outcomes of Black Americans. Dr. Andrew Kolodny, director of opioid policy research at Brandeis University, concluded that doctors are more hesitant to prescribe opioids to Black Americans due to a preconceived assumption that a certain minority is more prone to addiction, and an underlying tendency to be less sensitive to a Black patient’s pain. Racism is still unproductive even if it has a potentially preventative effect.

After healthcare providers started more frequently prescribing opioids in the late 1990s, the United States saw many kinds of people becoming addicted, including white, upper-class majority populations.  This shifted the traditional idea that addicts are low income people of minorities.  However, this Mosley & Hagan study on opioid prescription to Black Americans, shows how even after historical changes in society’s idea of what a “typical addict,” looks like, stubborn and innate bias can still remain, shaping the unintentional stereotypes doctors treat their patients with. Despite small change and reform, this innate racial bias is still an issue within the healthcare system.

Doctors under-prescribing narcotics to Black patients is also counterproductive towards efforts to minimize over-prescription of opioids.  If certain physicians think that some people are more susceptible to addiction and should not be prescribed opioids as easily, than this is a fundamental flaw in the understanding of addiction in the health system. Substance use disorder is a universal disease to which no population has total immunity to.  A level of genetic predisposition to addiction can be true, however, there is no concrete evidence that this predisposition is racially linked. Based on this assumption, doctors need to see all populations as equal when it comes to addiction in order to adequately treat SUD and prescribe opioids with caution.

Although some physicians seem to have an underlying idea that Black Americans are predisposed to opioid addiction, in 2018 the rate of opioid overdose deaths was actually greater in whites than in Blacks (SAMHSA). In addition to a greater risk for addiction, Black Americans also have statistically worse access to treatment. Social determinants associated with the black population, such as stigma, negative representation, intergenerational substance abuse, and lack of culturally respectful care, often serve as barriers to treatment and prevention. “Studies found Caucasians were 35 times more likely to visit hospitals for buprenorphine compared to African-American counterparts” (Murray 2019).  The stereotypes and misrepresentations that lead doctors to under-prescribe opioids to Black Americans, also make Black Americans less likely to seek out help. The negative connotations associated with people of color and addiction can be discouraging for Black Americans when seeking out treatment. This problem is detrimental when combined with the socioeconomic obstacles that people from Black communities are more likely to face when in need of treatment.

  Another key obstacle in access to opioid overdose prevention and recovery is the fear of legal consequences.  Only 10% of people with a substance use disorder seek treatment.  This percentage is inflated within the Black community due to a historical mistrust of the health and justice system.  Addiction must be recognized as a disease to be treated not a crime to be incarcerated for in order to see adequate outcomes in minority communities. Despite the numbers of opioid misuse being almost equal in Black and white communities, public health awareness campaigns are still targeted towards white communities and workforces to assist people with addiction are still not culturally relevant and diversely representative. If we have been culturally trained to see Black Americans as more likely to abuse opioids, but our treatment programs target white populations, reform is most definitely necessary.

Structural racism, unintentional biases, and unproductive narratives surrounding addiction have led to racial disparities within the Opioid crisis. This racial inequality seen is reflective and significant to underlying issues of bias throughout our healthcare system. In order to improve, Americans must take unintentional racist stigma seriously and work to reform the ideologies that shape our healthcare system.  The first step in this process is acknowledging that there is a discrepancy.  Just as Black pain should not be undermined, barriers to treatment in Black communities and Black addiction stereotyping also should not be undermined.

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