CORR Insights®: Are There Differences in Postoperative Opioid Prescribing Across Racial and Ethnic Groups? Assessment of an Academic Health System

Where Are We Now?

Racial disparities in opioid prescribing patterns in United States healthcare delivery systems have been well described for many years [10]. Numerous studies have demonstrated lower rates of opioid prescriptions for Black and Hispanic patients than for their White counterparts across several healthcare contexts, including the emergency department [13, 17], inpatient medicine [14], general surgery [8], and outpatient chronic pain management [15].

In this insightful and comprehensive analysis, O’Sullivan et al. [12] expanded on these results by investigating opioid prescribing patterns after elective orthopaedic surgery. Interestingly, they found no evidence of racial and ethnic differences in opioid prescription rates after eight commonly performed orthopaedic procedures. Moreover, no between-group differences in overall opioid milligram equivalent doses prescribed after surgery were observed, indicating that opioid prescriptions were given similarly, regardless of race and ethnicity.

These data by O’Sullivan et al. [12] demonstrating equal postoperative opioid prescriptions irrespective of race or ethnicity are especially encouraging given contrasting disparities documented in several other medical subspecialties; based on these discoveries, individual orthopaedic surgeons and their respective subspecialty departments should continue to define and enact standardized postoperative treatment protocols to help minimize racial and ethnic variation in postoperative orthopaedic care.

Where Do We Need to Go?

Many prior studies reporting disparities in opioid prescribing patterns have relied on retrospective data collected from large national databases [2, 4, 7, 11, 13, 15, 16]. In contrast to the current study [12], these analyses often used aggregated data from various hospitals across the United States, which may have represented disparities arising not only at the intra–health systems level (that is, in an individual healthcare system or hospital), but also at the inter–health systems level (between separate healthcare systems and hospitals) [11]. Although the ability to identify disparities and inherent biases in one healthcare system is a major strength of this study [12], additional studies using nationally representative data may further elucidate interhospital disparities that are influenced by differences in hospital geographic location, urbanicity, size, or teaching status [3]. These analyses might also help capture data from hospitals with differing levels of patient diversity or hospitals with more-conservative postoperative opioid prescribing patterns.

Even though this study found no differences in opioid prescription rates after surgery, disparities in opioid treatment can arise at several other points along the postoperative care pathway. More specifically, although Black and Hispanic patients may be prescribed the same amount of opioids as White patients, this does not translate to equal downstream access to these medications. For example, recent data show that patients living in predominately Black and Hispanic neighborhoods experience greater difficulty filling their prescriptions because they are disproportionately housed in areas with fewer pharmacies (“pharmacy deserts”) and higher rates of pharmacy closures [5]. Disparities in access to medication can also be perpetuated by differences in community distress and societal deprivation, which vary by race and ethnicity [4, 7, 9]. This is especially true in the United States, where income is unfortunately tied with race and Black and Hispanic individuals have lower levels of income despite similar educational attainment to White people. Data that capture these additional barriers to postoperative pain medications may be helpful to determine whether orthopaedic surgeons should consider alternative medication delivery systems for certain patients in need (such as prescribing medications to the hospital pharmacy or enrolling patients in automatic medication delivery programs). Additional studies predicting the likelihood a patient will fill an opioid prescription after surgery may also be helpful in quantifying the role of some of these complex societal forces.

How Do We Get There?

The results from this study [12] are certainly promising but should be interpreted with caution so as not to provide false reassurance that racial disparities in pain management after orthopaedic surgery do not exist in the United States. As we know, our profession is practiced in a society in which a number of racial and social inequalities persist and, in fact, there are some data to suggest that disparities in pain management are present in other orthopaedic care delivery systems nationwide [17]. Nonetheless, this study provides reason for optimism that our professional community is slowly making strides toward the shared goal of providing equal care for all patients regardless of race or ethnicity.

Moving forward, standardization of postoperative care pathways will continue to be critical in helping to minimize the effects of implicit bias and equalize care for our patients receiving opioids [6]. As a resident who has rotated with different attendings at several different hospitals, I have observed, and likely contributed to, the subtle variability in postoperative opioid prescribing patterns that exists not only between individual attendings in the same department, but also across hospital systems. To continue to reduce these variations in treatment, the orthopaedic surgery community should continue to pursue and enact evidence-based standardized postoperative pathways on both regional and national levels. The American Academy of Orthopaedic Surgery has already outlined recommendations to standardize postoperative pain management while also allowing room for individualized patient-centered care, and they should be commended for these efforts [1]. Nevertheless, further work by subspecialty department leaders and chairs is needed to ensure that these recommendations are implemented in clinical practice.

Disparities in healthcare can be two-sided, and although undertreatment of any particular group is harmful, so too is overtreatment. As the opioid epidemic persists and rates of opioid addiction continue to rise in the United States, this could not be truer. In fact, recent data suggest that reported racial disparities in pain management may have inadvertently protected Black and Hispanic patients from the relatively higher rates of postoperative opioid addiction and overdose exhibited among White patients [4]. This brings us to a final and important point: Standardization of care not only helps to reduce disparities for one racial or ethnic group (although its improved effects may be disproportionately felt by some), it also continues to push us all toward the shared goal of providing patients with equal care regardless of race, ethnicity, or varying sociodemographic factors.