In another troubling finding on persistent racial disparities in medicine, a new study from researchers at the Dana-Farber Cancer Institute found that 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 their lives.
Published online Tuesday in the Journal of Clinical Oncology, the study is the largest to examine disparities in opioid access among patients with cancer in the United States. It found that not only were Black and Hispanic cancer patients less likely to receive those medications, but also that, when they did, they received lower doses in the last month of their lives on average than white patients.
Moreover, Black patients were much more likely to be screened for potential substance abuse in what experts say is a misapplication of federal guidelines aimed at addressing the opioid crisis.
“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 Dana-Farber 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 and a senior author of the study.
The study found a steady decline in access to opioids for patients of all races and a rapid increase in drug screening during the study period. Experts say those are unintended consequences of guidelines published by the Centers for Disease Control and Prevention in 2016 that require doctors to use urine drug tests before starting patients on opioids for chronic pain. According to the new study, Black cancer patients were more likely than any other group to undergo this type of screening.
“These patients are near the end of life,” said Dr. Andrea Enzinger, a medical oncologist and palliative care physician at Dana-Farber 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.”
Since the CDC published its opioid guidelines, more than half of the states have adopted legislation restricting opioid prescription or dispensation for acute pain. Although the guidelines exclude patients with active cancer, they have been widely “misapplied . . . leading to significant opioid access issues for persons with chronic pain, including cancer,” wrote Dr. Salimah Meghani, a professor of nursing at the University of Pennsylvania School of Nursing who researches race-based disparities in pain treatment, in an e-mail.
“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 that is particularly inappropriate considering, during the course of the study, overdose deaths and addiction rates from opiates were statistically much higher among white individuals.
The Dana-Farber research builds on more than 20 years of data 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.
Previous studies have found that doctors who under-prescribe pain medication to Black people often hold false beliefs about biological differences between races that date back to the era of slavery. A 2016 survey of 222 white medical students and residents found that half believed Black people feel less pain than white people. The practitioners who endorsed those beliefs rated Black patients’ pain lower than that of white people and made less accurate treatment recommendations.
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.”