Undertreating Pain During the Opioid Epidemic

The term “opioid epidemic” describes the sharp increase in opioid prescriptions, abuse, and mortality throughout the United States since the late 1990s. Data from the Centers for Disease Control and Prevention (CDC) show that the number of prescriptions for opioids nearly quadrupled from 2000 to 2015, while the number of deaths from prescription opioids like oxycodone, hydrocodone, and methadone more than quadrupled. The CDC reports similar trends in the rate of fatal heroin-related overdoses, which nearly quadrupled between 2002 and 2013. It’s hard to imagine that serious pain could possibly go undertreated in this period of opioid proliferation, but research shows a concurrent trend of undertreating pain. A closer look reveals that women and racial/ethnic minorities are denied pain relief in numbers that far outpace their white male counterparts.

A 2008 study shows that women wait, on average, 65 minutes to be treated for their pain in the ER, whereas men wait an average of 49 minutes. This study also shows that, in addition to waiting longer to receive pain medication, women are less likely to receive any pain medication whatsoever, including opiates, than men. This difference in prescription trends persists when gender-specific diagnoses are excluded and after controlling for age, race, triage class, and pain score. Could it be that women experience pain differently than men? A paper published in The Journal of Law, Medicine & Ethics argues that the experience of and response to pain does indeed differ between men and women, but that it’s nearly impossible to determine whether these differences are rooted in biological, psychological, or social origins.

Racial bias also results in disparities in pain management treatment. Study after study demonstrate that African-American patients are not only less likely to be prescribed opioids than white patients, but they are also less likely to receive any pain medication for moderate pain even after controlling for clinical and system-level factors. This racial bias even applies to children, as evidenced in one study documenting racial disparities in management of pain resulting from appendicitis. One study found that a physician’s opinion of whether patients exaggerated their experience of pain was associated with the patient’s ethnic background, and that the physician’s beliefs negatively impacted the achievement of pain relief for the patient.

While undertreating pain is a genuine public health problem for women and racial/ethnic minorities, it may also serve as a protective factor when it comes to avoiding the brunt of the opioid epidemic. The CDC reports that non-Hispanic white men between the ages of 18 and 25 are at the highest risk of heroin addiction overall. Looking at data from 2013 as an example, the number of heroin-related deaths was nearly 4  times higher for men than for women, and non-Hispanic white persons aged 18 to 44 showed the highest heroin-related mortality rate of all demographics.

So what are physicians to do? How can they strike the perfect balance between avoiding the overprescription of medications fueling the opioid epidemic and ensuring high-quality of care for patients in genuine need of pain relief? I think the answer is that the burden of effectively treating pain can’t fall solely on physicians’ shoulders. It’s just not realistic to expect physicians to accurately assess a patient’s physical experience of pain, evaluate risk factors that increase vulnerability for drug abuse, gauge protective factors reducing the risk of addiction, and become familiar with nonpharmacologic interventions to manage both the physical and psychological elements of pain. While physicians have an ethical and moral obligation to correct the systemic undertreatment of pain for women and racial/ethnic minorities, the healthcare industry as a whole must evolve to support physicians and patients in achieving safe, effective, and holistic pain management.

Jessie Toporek is a medical writer in Fingerpaint’s Scottsdale office. She’s worked for a nonprofit in Nepal, federal agencies in the United States, a small start-up in Australia, and multinational pharmaceutical and medical device companies. She is the reigning Ugly Sweater Contest winner for Fingerpaint’s 2016 holiday party, and doesn’t shy away from reminding coworkers that she believes this to be a significant personal and professional victory.