By Will Boggs MD
NEW YORK (Reuters Health) - Of all racial/ethnic groups in the U.S., low-income whites are more likely to receive opioid prescriptions and to die from overdoses, three studies suggest.
"We propose that the prescription drug crisis should be thought of as a 'double-sided' epidemic, in which systematic racism within the healthcare system has led to increased addiction and overdoses among low-income white areas, but also insufficient treatment among nonwhite communities," Joseph Friedman from David Geffen School of Medicine, UCLA, Los Angeles, California told Reuters Health by email.
"These disparities may have ironically shielded communities of color from the brunt of the opioid epidemic," he said. "Nevertheless, they also represent a lack of access to adequate treatment for pain and psychiatric conditions."
Recognizing that an opioid prescription is a key risk factor for long-term use, Friedman and colleagues evaluated the race/ethnicity-income gradient in exposure to opioids by the California healthcare system, using the percentage of individuals who received at least one prescription for an opioid each year as the metric of exposure of the population to opioids by the healthcare system.
Each year from 2011 through 2015, 23.6% of all individuals in California aged 15 years or older received a prescription for an opioid medication, according to the February 11th JAMA Internal Medicine online report.
The mean annual prevalence of opioid prescriptions was highest among individuals in the highest proportion-white/lowest-income quintile (44.2%) and lowest in the lowest proportion-white/highest-income quintile (16.1%).
Overdose deaths in California during this period were also highly concentrated in the lower-income and mostly white areas, with 9.6 opioid overdose deaths each year per 100,000 people in the highest proportion-white/lowest-income quintile versus 1.3 in the lowest proportion-white/highest-income quintile.
Benzodiazepine rates varied strongly across lines of race/ethnicity (much higher rates among white than nonwhite communities) but showed little variation by income status. Stimulant prescriptions, on the other hand, were highly concentrated among higher proportion-white/higher-income communities.
"Discussions of race are remarkably absent from mainstream medical and political discussions of the opioid epidemic," Friedman said. "We highlight systematic and profound racial disparities in the prescription of controlled substances, showing that race must be considered as a key dimension in discussion of controlled substances in the United States."
Dr. Mathew Kiang from Stanford University School of Medicine's Center for Population Health Sciences, Palo Alto, California, told Reuters Health, "Opioids are an important part of the physicians' toolbox. They're a powerful method of controlling a patient's pain level; however, they are also potentially dangerous to a small set of recipients. While this is an ecological study, as the authors note, and thus cannot determine if those who received opioid prescriptions were also those who subsequently overdosed on heroin, it still serves as a reminder that this powerful tool must be used carefully."
"I think this highlights a growing body of work that continues to put the opioid epidemic in the context of socioeconomic factors," he said in an email interview. "Race/ethnicity and income are important social determinants of health and our policies to address the epidemic thus far have largely ignored them. We need to take into account the social and economic context of the epidemic in order to understand what is driving a subset of the population to using opioids for non-medical purposes."
Dr. Barry Meisenberg, Chair of Medicine and Medical Director of the DeCesaris Cancer Institute at the Anne Arundel Medical Center, Annapolis, Maryland, where multilevel interventions proved successful at reducing opioid overprescribing, told Reuters Health by email, "The results showing differential prescribing by micro regions for all three drug classes are profound and raise additional questions. We don't know if these results are explained by prescriber bias, differences in access, or increased patient demand in affluent areas or all three. Certain symptoms such as anxiety, pain and distraction may have different interpretations and meaning in different cultural subgroups creating different interest in receiving certain medications."
"This study adds to the body of evidence that clinician prescribing patterns are important drivers of long-term opioid dependence and overdose," he said. "Clinicians must understand that their prescriptions can affect the health of entire communities. We have an individual and group responsibility to be cautious in our use of all of these medications."
In the second study, Bennett Allen and colleagues from the New York City Department of Health and Mental Hygiene, Queens, New York examined 2017 New York City data on overdose deaths to determine patterns related to age, race, and drug type.
Among 1487 overdose deaths, 37.0% were among whites, 28.0% among blacks, 31.0% among Latinos, and 4.0% among other or undefined racial/ethnic groups.
Among younger persons (aged 15-34 years), heroin and/or fentanyl overdose deaths per 100,000 New Yorkers were higher among whites (22.2) than among blacks (5.8) or Latinos (9.7).
Among older persons (aged 55-84 years), however, these death rates were higher among blacks (25.4) than among whites (9.4). Older blacks also had significantly higher cocaine overdose death rates (25.4) than did whites (5.1) or Latinos (11.8).
These findings "highlight the need for heterogeneous approaches to treatment and the equitable allocation of treatment and health care resources to reach diverse populations at risk of overdose," the researchers conclude.
In the third study, Dr. Gery P. Guy and colleagues from Centers for Disease Control and Prevention, Atlanta, Georgia examined opioid prescribing at national and county levels using data from the IQVIA Xponent database.
From 2015 to 2017, the amount of opioids prescribed decreased 20.1% (from 641.4 to 512.6 morphine milligrams equivalents (MME) per capita), opioid prescribing rates decreased 16.9% (from 70.7 to 58.7 per 100 persons), high-dose prescribing decreased 25.3% (from 6.7 to 5.0 prescriptions of 90 or more MME per day per 100 persons), and the average daily MME per prescription decreased 6.0% (from 48.1 to 45.2 MME).
Overall prescribing rates varied 4.6-fold and high-dose prescribing rates varied 7.1-fold between the highest and lowest prescribing counties.
About three-quarters of counties experienced annual reductions in the amount of opioids prescribed (74.7%) averaging around 10%, compared with 3.6% annual reductions in 49.6% of counties from 2010 to 2015. The amount of opioids prescribed, however, remained nearly triple the amount prescribed in 1999.
"Physicians stand out as natural leaders to help solve the crises because of the depth of their knowledge, immediacy of their contact with patients, and relatively high level of respect their profession enjoys," write US Surgeon General Dr. Jerome M. Adams and Assistant Secretary for Health Dr. Brett P. Giroir, US Public Health Service, Washington, DC in a related invited commentary. "We thereby call on our nation's doctors to embrace their roles in the clinic and beyond to help educate communities, bring together stakeholders, and be part of the cultural change to support people living free from addiction."
"Although health care professionals have many ways to respond to the opioid crisis, we must also acknowledge that the problem cannot be solved by medical interventions alone," they note. "Stopping the epidemic requires a public health approach that recognizes substance misuse and addiction are the result of interrelated individual, environmental, and societal factors, requiring diverse stakeholder cooperation to prevent, mitigate, and reverse."
Dr. Guy and Dr. Adams did not respond to a request for comments.
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JAMA Intern Med 2019.