Experts: Vast Disparities in Opioid Prescribing Observed for Minority Communities in Past Decade

Allison Ju-Chen Hu, PhD

Allison Ju-Chen Hu, PhD, is a postdoctoral associate at Weill Cornell Medicine and coauthor of the study.

In an exclusive Q&A with Pharmacy Times®, investigators Allison Ju-Chen Hu, PhD, postdoctoral associate at Weill Cornell Medicine, and Yuhua Bao, PhD, health economist at Weill Cornell Medicine, explain the results of a landmark clinical trial finding that majority non-White, minoritized communities across various socioeconomic deprivation levels had significantly lower distribution rates of common opioids than majority White communities. Correspondingly, Hu and Bao found that there was substantially lower availability of commonly prescribed opioid analgesics in majority non-White communities than in majority White communities.¹

Yuhua Bao, PhD

Yuhua Bao, PhD, is a health economist at Weill Cornell Medicine and coauthor of the study.

These results offer major implications for policies that regulate opioid analgesic availability, which Hu, Bao, and their fellow investigators warn “warrant[s] careful consideration and potential adjustments.” Disparities in opioid dispensing across socioeconomic, racial, or ethnic lines raise major concerns regarding the accessibility of safe and effective pain management therapies for patients who can benefit from opioid therapy.¹

Hu and Bao discuss how pharmacists can advocate for reduced regulatory burdens, better allocations of opioid products, and exemptions for critical care patients while counseling patients on alternative solutions for pain management. Additionally, Hu and Bao seek to highlight how policies intended to curb opioid misuse may have unintentionally worsened access issues in marginalized communities by reinforcing existing shortages.

Pharmacy Times: What factors do you believe contributed most to the observed disparity in opioid prescriptions?

Hu and Bao: We found that racially and ethnically minoritized communities had lower per-capita availability of opioid analgesics over the decade since 2011. Studies on pharmacies in New York City and Michigan from the early 2000s have highlighted similar disparities and identified several contributing factors, including pharmacy perceptions of low demand for these medications in the communities, fears of illicit use and fraud, concerns about theft, and the administrative burden of additional paperwork required by the government for dispensing. We believe that these same factors likely contributed to the persistent disparities seen in our study.

Policies aimed at addressing unsafe opioid prescriptions in recent years may have inadvertently reinforced these disparities. Examples of policies include reductions in opioid production and distribution quotas, heightened regulatory oversight, and stricter scrutiny of pharmacy operations when dispensing these medications. It’s important to recognize that the intent behind these policies is to combat the opioid crisis, not to restrict access to appropriate care. However, when implemented without fully considering the diverse needs and resources of different communities, these policies could have disproportionately affected racially and ethnically minoritized communities and their pain management outcomes because people living in these communities face greater barriers to accessing pharmacies and non-pharmacological pain management options, such as physical therapy or chiropractic care.

Pharmacy Times: How can pharmacists address these observed barriers in their practice?

Hu and Bao: We need to recognize the significant administrative burden current policies place on pharmacists. For example, the DEA requires pharmacists to identify and address "red flags" that may indicate potential diversion or inappropriate prescriptions when dispensing opioid analgesics. Failure to address these red flags can result in penalties for violating controlled substance laws, such as losing registration for dispensing controlled substances. However, investigating these red flags requires time and additional communication with prescribers, which can delay the dispensing process. In particular, certain red flags—such as long travel distances or cash payments—can also disproportionately affect patients from racially and ethnically minoritized communities, who may have limited access to medications locally or lack insurance. These patients may be forced to travel long distances or pay out-of-pocket for medications, further discouraging pharmacists from filling prescriptions for them. Additionally, prior authorization requirements imposed by insurance companies add another layer of administrative burden, which may deter pharmacies from stocking opioid analgesics altogether.

Reducing the administrative burden on pharmacists should be a priority. To address these challenges, a collective effort from pharmacists, prescribers, insurance companies, and government agencies (especially the DEA) is needed. This could involve re-evaluating and adjusting the criteria for "red flags," improving communication, and allowing for exemptions from repeated prior authorizations when long-term opioid therapy is deemed clinically appropriate.

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Pharmacy Times: How might have well-intentioned policies to curb opioid misuse inadvertently led to worsened access disparities?

Hu and Bao: As we have noted, many of the policies aimed at curbing opioid misuse were not intended to restrict clinically appropriate use of opioid analgesics, and these policies have played a key role in addressing the opioid crisis. Our research aims to highlight the potential unintended consequences of these well-intentioned policies, offering insights and potential solutions to improve future policy design and implementation.

In the context of our study, we believe the current approach the DEA uses to determine opioid production and distribution quotas falls short in considering the different needs for opioid analgesics across communities. Specifically, the DEA’s approach primarily relies on historically dispensed volumes, which doesn’t capture the "unmet needs" in communities, such as unfilled prescriptions because opioids are not sufficiently stocked in the community. Moreover, this approach may unintentionally reinforce existing shortages, especially in areas where opioids are chronically understocked—an issue more likely to occur in racially and ethnically minoritized communities, as our findings suggest. Moving forward, we suggest that the DEA consider the disproportionate implications for racial and ethnic minoritized communities when developing procedures to adjust quotas.

Pharmacy Times: What are the potential short- and long-term consequences of delayed opioid treatment for minority patients, and how can health care providers, particularly pharmacists, proactively address these delays?

Hu and Bao: Delaying opioid treatment can have significant negative impacts on patients. In the short term, it may result in uncontrolled pain, reduced quality of life, and worsened mental health. Patients who lack timely access to pain management may also have increased adverse events such as ED visits or hospitalization. Over the long term, untreated or inadequately managed pain can develop into chronic pain conditions, pain-related disability, and decreased functionality. These conditions can limit a patient’s ability to work and perform daily activities.

Pharmacists can help address these delays in several ways. For example, they can work closely with prescribers to identify alternative approaches when opioids are not available. Pharmacists, by witnessing the chronic shortage of opioids in certain communities and how patient pain management needs are unmet, could provide strong advocacy for policy changes such as changes in DEA distribution quotas, discussed previously.

Pharmacy Times: What specific steps or advocacy efforts would you recommend for pharmacists to help reduce inequities in opioid access while maintaining responsible prescribing practices?

Hu and Bao: In addition to the strategies for reducing the administrative burden mentioned earlier, we believe pharmacists can advocate for system changes that support them at the point of dispensing and improve the availability of opioid analgesics in communities with historically low stock. These changes could include enabling easy access to the state Prescription Drug Monitoring Program and exemptions from prior authorization and opioid duration/dose limits for prescriptions for cancer pain, palliative care, or end-of-life care, automated with the pharmacy dispensing system.

REFERENCES

1. Hu JC, Chakraborty P, Zhang H, Portenoy R, Rosa WE, Zhang Y, Reid MC, Tamimi RM, Zhang F, Bruera E, Paice JA, and Bao Y. Distribution of Opioid Analgesics by Community Racial/Ethnic and Socioeconomic Profiles, 2011-2021. PAIN. In press. doi:10.1097/j.pain.0000000000003511