Racism and Sexism
Besides over-exuberant enforcement of the CSA, racism and sexism also contribute to withholding opioid medications, oligoanalgesia, and opioid pseudoaddiction. Unfortunately, racism and sexism thrive in pain treatment. Physicians' treatment choices account for much of the racial disparity in healthcare. Physicians under-treat African-Americans, other minorities, and female patients for pain, compared to whites and especially white males. Among minority groups, untreated pain is highly prevalent.
African-Americans have a documented reduced tolerance to pain in this population. In one pain patient study, African-American males were found to be most likely to perceive discrimination. Reasons that African-Americans and minorities are under-treated for pain include cultural and racial biases that minorities are more frequently either addicted to or will become addicted to opioid medications. For example, the film industry has featured African-Americans as drug abusers. The war on drugs has disproportionately targeted African-Americans, showing evidence of a bias of African-Americans as drug abusers.
Besides being stereotyped as drug addicts, African-Americans and Hispanics have substantial difficulty filling their opioid prescriptions at their local pharmacies, because the pharmacies serving minority communities are much less likely to carry opioid medications. Many pharmacies that do not stock an adequate supply of opioid medications can order the medications within seventy-two hours; however, that seems to be an unacceptably long wait for someone in severe pain. Some pharmacies also decline to order opioid medications when requested by patients, perhaps because they do not want to attract opioid-using clients. Pharmacists' self-reported reasons for not stocking opioid medications include perceived low demand, fear of drug theft from the pharmacy, problems with health insurance reimbursement, and difficulty in compliance with CSA regulations.
Because three African-Americans for every one white individual live under the poverty line, the effect of socioeconomic status cannot be separated from race. Poorer individuals are less likely to have received medical care for pain. African-Americans, therefore, while more likely to suffer from disabling pain, have difficulty accessing the healthcare system. Likewise, lower income Hispanics also are underserved in pain management. Besides socioeconomic factors, Hispanics with chronic pain also tend to have difficulties with the English language and cultural differences from the American mainstream that may impact access to care.
In addition to finding difficulties in obtaining opioid medications, African-Americans also are hampered in their war on pain by opiophobia. Opiophobia thrives in the African-American community because of the stigma of drug abuse, arising from the war on drugs' targeting of African-Americans. African-Americans' poorer access to the healthcare system also leads to decreased access to accurate information about the benefits of opioid treatment for chronic pain.
Physicians also under-treat women's pain more often than men's pain. Women are taken less seriously when they report pain. There are several reasons women are under-treated despite documented lower pain thresholds, lower pain tolerance, and a higher propensity to develop chronic pain. Women are deemed to be able to cope better with pain despite societal notions that men are unwilling to complain or express pain. Additionally, women are more likely to have their pain attributed to psychogenesis. Finally, women are more likely than men to have their pain discounted if they are more physically attractive.
The former head of the National Institutes of Health, Bernadine Healy, describes the indifference in the treatment of women by healthcare providers until women prove themselves as worthy of medical intervention, as the Yentl syndrome. Because of the Yentl syndrome, women receive fewer medical interventions as compared to men, until they prove themselves as ill as men, at which point the gender difference disappears. For example, healthcare providers do not take a woman's chest pain as seriously as a man's chest pain, but if a woman actually has a documented heart attack, then she is treated more equally with men. Similar to the Yentl syndrome, women suffer from pain for longer time periods than men prior to being referred to a pain clinic. Both racism and sexism directly lead to opioid pseudoaddiction in the discriminated-against groups, because of inadequately treated pain in these patients who are seen as either likely to overstate their symptoms or more likely to become drug addicted.