Dartmouth-led Study Explores Race Inequality in Opioid Prescribing Among U.S. Health Systems

A new Dartmouth-led study published this month in the New England Journal of Medicine sheds light on the role U.S. health systems play concerning racial inequality in prescription pain medicine receipt.

For more than a decade, research has demonstrated that in the U.S. Black patients do not receive as much prescription pain medicine as white patients. But the sources of those differences haven’t been well-understood.

To this end, the researchers examined racial differences in prescription pain medicine receipt among patients of 310 health systems that provide primary care services to a substantial number of both Black and white patients.

They found that while Black and white patients were equally likely to receive prescription pain medicine, the doses differed substantially. In 90 percent of the systems studied, white patients, on average, received higher annual doses than Black patients (the difference was 15 percent or more in most systems).

Past research on other health services (such as heart procedures) has demonstrated that Black and white patients receive different quality or intensity of healthcare because they often receive care from different health systems (Black patients more often are served by lower-quality health systems).

This new study reveals that such “sorting” to different health systems (where doctors may have different prescribing practices) does not explain most of the racial differences in prescription pain medicine receipt. The difference instead stems almost entirely from Black and white patients receiving different pain medicine doses, even when treated by the same health system and team of clinicians.

“Our findings likely reflect systematic racial bias throughout the course of care leading to pain medicine receipt,” explains Nancy Morden, MD, MPH, a research consultant at Dartmouth and formerly a physician-researcher at Dartmouth-Hitchcock Health and the Geisel School of Medicine at Dartmouth, who served as lead author on the study. “We hope our system-level reporting will prompt dialogue and commitment to deep exploration of this inequity—it’s causes, consequences, and tireless testing of potential remedies.”

Interpreting their findings, the authors make clear that they cannot know if or how these differences affect patient outcomes, as both opioid underuse and overuse can cause harm. They emphasize, however, that skin color should not influence pain treatment receipt.

“A decade of national data on racial inequity in prescription opioid receipt has done little to narrow known racial gaps in the receipt of pain medicine, because no one person or entity is tasked with alleviating inequality in pain medicine receipt or healthcare for the nation,” notes senior author Ellen Meara, PhD, an adjunct professor of The Dartmouth Institute for Health Policy and Clinical Practice at Geisel.

“Healthcare leaders, in contrast, routinely hold their providers and their organizations accountable for the care delivered to their patients, and leaders have been vocal in prioritizing equity. They need data to do so.”

The researchers hope system-level reporting of race differences in pain medicine receipt will prompt doctors and administrators to reflect on the cause of these differences and develop efforts aimed at ensuring skin color does not influence pain management.

This study was supported by the Agency for Healthcare Research and Quality, as part of the Comparative Health System Performance Initiative, and by the National Institutes of Health – National Institute on Aging-funded Center on Causes and Consequences of Health Care Efficiency. The study team also included Dartmouth researcher Deanna Chyn and former Dartmouth researcher Andrew Wood.

The Dartmouth Institute for Health Policy and Clinical Practice is a world leader in studying and advancing models for disruptive change in healthcare delivery. The work of Dartmouth Institute faculty and researchers includes developing the concept of shared decision-making between patients and healthcare professionals, creating the model for Accountable Care Organizations (ACOs), and introducing the game-changing concept that more healthcare is not necessarily better care.