Addressing Racial Disparities in Opioid Prescriptions: The Role of Pharmacists in Achieving Equity

Opioids are potent chemicals that bind to receptors in the brain and body to reduce the intensity of pain signals. Although these medications have been effective in managing moderate-to-severe pain, their highly addictive nature has caused significant concerns regarding overdose and fatalities. In 2023, approximately 123 million Americans were prescribed opioids, and 8.5 million Americans aged 12 and older reported misusing them. Alongside these issues, racial and ethnic disparities in opioid prescriptions and overdose mortality trends are particularly alarming, especially for Black Americans.^1,2

Image credit: Anastasiia | stock.adobe.com

The US opioid epidemic has occurred in 3 distinct waves. The first wave, beginning in 1979 and continuing through the late 1990s, was driven by the introduction of prescription opioids. The second wave, starting in 2010, was fueled by increased heroin use. The third and most fatal wave, beginning in 2013, has been marked by the proliferation of synthetic opioids such as illicitly manufactured fentanyl.³ By 2017, the opioid crisis was officially declared a national public health emergency.⁴

Historically, the opioid crisis has disproportionately affected low-income white communities, a departure from the usual pattern in which drug epidemics disproportionately affect communities of color. However, the COVID-19 pandemic has intensified racial and ethnic disparities in overdose-related deaths, with Black Americans experiencing higher rates of drug-related fatalities than white Americans for the first time since 1999.^5,6 These disparities in overdose rates have been mirrored in opioid prescription patterns, with Black patients consistently receiving fewer prescriptions for pain management than their white counterparts.⁷

The systemic inequities that underpin these trends underscore the urgency of addressing racial disparities in opioid prescriptions. Pharmacists, who play a crucial role at the intersection of prescribing and dispensing, are well-positioned to influence these disparities, either by perpetuating or mitigating them.

The persistence of racial disparities in opioid prescriptions reflects deep-seated biases within the health care system. Implicit bias, for example, leads many health care providers, including pharmacists, believing incorrectly that Black patients have a higher pain tolerance than white patients. As a result, Black patients are systematically undertreated for pain. Studies have shown that Black patients are less likely to receive opioids than white patients for similar pain complaints, a disparity that persists even when accounting for clinical factors.⁷

Pharmacists play a dual role in either perpetuating or addressing these disparities. On the one hand, they may reinforce biased prescribing patterns by uncritically following prescriber instructions or by relying on data from Prescription Drug Monitoring Programs (PDMPs). Although PDMPs are essential tools for preventing opioid misuse, they disproportionately flag Black and Hispanic patients as high-risk, often without clinical justification. Consequently, these patients face increased barriers to accessing necessary pain management.³

Compounding these challenges is the issue of pharmacy deserts—areas, particularly in low-income urban communities, where residents lack access to nearby pharmacies. Patients in these areas are not only deprived of medication but also miss out on critical pharmacist consultations, which could help bridge the gap in pain management outcomes between racial groups.⁸

Pharmacists have a unique opportunity to either exacerbate or alleviate disparities in opioid prescribing. The negative impacts of pharmacists’ actions often stem from strict adherence to prescribing guidelines and PDMP alerts without considering the broader context of a patient’s pain management needs. For instance, Black and Hispanic patients are 29% less likely to receive opioids than white patients for comparable levels of pain, a gap that pharmacists may reinforce if they fail to critically assess the appropriateness of prescriptions.⁹

However, pharmacists can also be agents of change. Through cultural competency training, pharmacists can become more aware of their implicit biases and develop strategies for providing equitable care. Research shows that pharmacists trained in cultural competency are more likely to offer balanced assessments of patients’ pain and ensure that all patients receive appropriate care, regardless of race.¹⁰ Collaborative practice agreements (CPAs) between pharmacists and physicians also offer a valuable tool for improving opioid prescribing practices in underserved communities. CPAs enable pharmacists to take a more active role in pain management, including recommending non-opioid alternatives and adjusting opioid dosages to meet the specific needs of minority patients.¹¹

In addition to their clinical role, pharmacists are well-positioned to act as patient advocates. By working closely with prescribers, pharmacists can help dismantle biased prescribing patterns and ensure that all patients have access to adequate pain management. Through advocacy, pharmacists can foster trust with patients, empower them to make informed decisions about their care, and ensure that systemic barriers do not prevent them from receiving the pain relief they need.

The pharmacy profession has made some progress in addressing racial disparities through education and community-based programs. Pharmacy schools across the US are increasingly incorporating curricula on health disparities and social determinants of health, equipping future pharmacists with the skills needed to identify and address biases in clinical practice. Research suggests that students trained in these areas are more likely to challenge prescriber biases and advocate for equitable care.¹²

Community programs also show promise in addressing disparities. These programs prioritize individualized care for minority populations and foster collaboration among pharmacists, physicians, and community organizations to improve access to pain management.³

Despite these advances, significant research gaps remain. Although there is extensive literature on physician prescribing practices, little attention has been paid to the specific role of pharmacists in either perpetuating or addressing opioid disparities. Future research should focus on how pharmacists can use PDMP data to balance safety with equity. Policymakers must also consider the unintended consequences of PDMPs on minority communities and adjust these programs to ensure that safety does not come at the expense of access to pain relief.

The persistence of racial disparities in opioid prescribing is a critical issue, but pharmacists have the tools and influence to address it. By prioritizing cultural competency, collaborative practice agreements, and patient advocacy, pharmacists can help ensure that all patients receive equitable care. The profession must also continue to advocate for policy changes and contribute to research that sheds light on the specific ways pharmacists can reduce disparities. Through these efforts, pharmacists can play a pivotal role in closing the racial gap in opioid prescribing and improving pain management outcomes for all patients.

REFERENCES

1. About Prescription Opioids. CDC. October 11, 2024. Accessed November 7, 2024. https://www.cdc.gov/overdose-prevention/about/prescription-opioids.html#cdcreference_3

2. Opioid Dispensing Rate Maps. CDC. May 7, 2024. Accessed November 7, 2024. https://www.cdc.gov/overdose-prevention/data-research/facts-stats/opioid-dispensing-rate-maps.html

3. Lippold KM, Jones CM, Olsen EO, Giroir BP. Racial/ethnic and age group differences in opioid and synthetic opioid-involved overdose deaths among adults aged ≥18 years in metropolitan areas – United States, 2015-2017. MMWR Morb Mortal Wkly Rep. 2019;68(43):976-973. doi:10.15585/mmwr.mm6843a3

4. Haffajee RL, Frank RG. Making the opioid public health emergency effective. JAMA Psychiatry. 2018;75(8):767-768. doi:10.1001/jamapsychiatry.2018.0611

5. Drake J, Chales C, Bourgeois JW, Daniel ES, Kwende M. Exploring the impact of the opioid epidemic in Black and Hispanic communities in the United States. Drug Sci, Pol, Law. 2020;6. doi:10.1177/2050324520940428

6. Friedman JR, Hansen H. Evaluation of increases in drug overdose mortality rates in the US by race and ethnicity before and during the COVID-19 pandemic. JAMA Psychiatry. 2022;79(4):379-381. doi:10.1001/jamapsychiatry.2022.0004

7. Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. 2008;299(1):70-78. doi:10.1001/jama.2007.64

8. Hoopsick RA, Homish GG, Leonard KE. Differences in opioid overdose mortality rates among middle-aged adults by race/ethnicity and sex, 1999-2018. Public Health Rep. 2021;136(2):192-200. doi:10.1177/0033354920968806

9. McLaughlin JM, Lambing A, Witkop ML, Anderson TL, Munn J, Tortella B. Racial differences in chronic pain and quality of life among adolescents and young adults with moderate or severe hemophilia. J Racial and Ethnic Health Disp. 2015;3:11-20. doi:10.1007/s40615-015-0107-x

10. Friedman J, Kim D, Schneberk T, et al. Assessment of racial/ethnic and income disparities in the prescription of opioids and other controlled medications in California. JAMA Intern Med. 2019;179(4):469-476. doi:10.1001/jamainternmed.2018.6721

11. Santoro TN, Santoro JD. Racial bias in the US opioid epidemic: a review of the history of systemic bias and implications for care. Cureus. 2018;10(12):e3733. doi:10.7759/cureus.3733

12. Understanding the Opioid Overdose Epidemic. CDC. April 5, 2024. Accessed November 7, 2024. https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html