How Racial Bias May Have Saved 14,000 Black Lives

Really interesting study on one of the rare positive impacts of implicit bias and discrimination:

When the opioid crisis began to escalate some 20 years ago, many African-Americans had a layer of protection against it.

But that protection didn’t come from the effectiveness of the American medical system. Instead, researchers believe, it came from racial stereotypes embedded within that system.

As unlikely as it may seem, these negative stereotypes appear to have shielded many African-Americans from fatal prescription opioid overdoses. This is not a new finding. But for the first time an analysis has put a number behind it, projecting that around 14,000 black Americans would have died had their mortality rates related to prescription opioids been equivalent to that of white Americans.

Starting in the 1990s, new prescription opioids were marketed more aggressively in white rural areas, where pain drug prescriptions were already high. African-Americans received fewer opioid prescriptions, some researchers think, because doctors believed, contrary to fact, that black people 1) were more likely to become addicted to the drugs 2) would be more likely to sell the drugs and 3) had a higher pain threshold than white people because they were biologically different.

A fourth possibility is that some white doctors were more empathetic to the pain of people who were like them, and less empathetic to those who weren’t. Some of this bias “can be unconscious,” said Dr. Andrew Kolodny, a director of opioid policy research at Brandeis University.

This accidental benefit for African-Americans is far outweighed by the long history of harm they have endured from inferior health care, including infamous episodes like the Tuskegee study. And it doesn’t remedy the way damaging stereotypes continue to influence aspects of medical practice today. “The reason to study this further is twofold,” Dr. Kolodny said. “It’s easy to imagine the harm that could come to blacks in the future, and we need to know what went wrong with whites, and how they were left exposed” to overprescribing.

The prescription-opioid-related mortality rates of black and white Americans were relatively similar two decades ago, but researchers found that by 2010, the rate was two times higher for whites than for African-Americans.

Because African-Americans were less likely to receive those prescriptions, they were less likely to become addicted (though they were more likely to endure unnecessary and excruciating pain for illnesses like cancer).

The researchers, Monica Alexander, a statistician with the University of Toronto; Mathew Kiang, an epidemiologist at Stanford; and Magali Barbieri, a demographer at the University of California, Berkeley; published their study in the journal Epidemiology.

With additional analysis at The Upshot’s request, Mr. Kiang calculated that had the African-American population’s mortality rates caused by prescription opioids been equivalent to those of whites, black Americans would have experienced 14,124 additional deaths from 1999 to 2017.

It’s a counterfactual analysis that relies on some large assumptions. Among other things, the projection assumes that the public health and medical response to the epidemic would have remained the same even if the African-American mortality rate had been higher. And it doesn’t take into consideration any potential changes in overdoses from heroin and fentanyl had African-Americans had greater access to prescription opioids. Still, Mr. Kiang found the results “fairly remarkable in at least two ways.”

“First, it’s a good example of how more medical care is not necessarily a good thing,” he said. “Second, it’s an extremely rare case where racial biases actually protected the population being discriminated against.”

A crackdown in recent years has reduced opioid prescribing over all, “and the racial/ethnic gap in opioid prescribing has narrowed,” said Mr. Kiang, but he said it was unclear whether the gap had closed entirely.

In recent years, drug overdoses have risen sharply among black Americans, particularly among older heroin users in places where fentanyl has become widespread. One reason that the death rates from heroin and fentanyl have converged between black and white people may be simple: Heroin and fentanyl are readily available outside the health system, so they’re less affected by bias within it.

The public response to drug epidemics also tends to diverge along racial lines. During the crack epidemic, there was a greater emphasis on punishment and incarceration. With the opioid crisis primarily affecting white people, there has been more emphasis on empathy and rehabilitation. (This same disparity was seen in crack versus powder cocaine.) Race played an obvious role in the policy response, Dr. Kolodny said: “From ‘Arrest our way out of it’ to, ‘It’s a disease.’”

Analysis Finds Geographic Overlap In Opioid Use And Trump Support In 2016

Interesting correlation with nuanced explanation and analysis:

The fact that rural, economically disadvantaged parts of the country broke heavily for the Republican candidate in the 2016 election is well known. But Medicare data indicate that voters in areas that went for Trump weren’t just hurting economically — many of them were receiving prescriptions for opioid painkillers.

The findings were published Friday in the medical journal JAMA Network Open.Researchers found a geographic relationship between support for Trump and prescriptions for opioid painkillers.

It’s easy to see similarities between the places hardest hit by the opioid epidemic and a map of Trump strongholds. “When we look at the two maps, there was a clear overlap between counties that had high opioid use … and the vote for Donald Trump,” says Dr. James S. Goodwin, chair of geriatrics at the University of Texas Medical Branch in Galveston and the study’s lead author. “There were blogs from various people saying there was this overlap. But we had national data.”

Goodwin and his team looked at data from Census Bureau, the 2016 election and Medicare Part D, a prescription drug program that serves the elderly and disabled.

To estimate the prevalence of opioid use by county, the researchers used the percentage of enrollees who had received prescriptions for a three-month or longer supply of opioids. Goodwin says that prescription opioid use is strongly correlated with illicit opioid use, which can be hard to quantify.

“There are very inexact ways of measuring illegal opioid use,” Goodwin says. “All we can really measure with precision is legal opioid use.”

Goodwin’s team examined how a variety of factors could have influenced each county’s rate of chronic opioid prescriptions. After correcting for demographic variables such as age and race, Goodwin found that support for Trump in the 2016 election closely tracked opioid prescriptions.

In counties with higher-than-average rates of chronic opioid prescriptions, 60 percent of the voters went for Trump. In the counties with lower-than-average rates, only 39 percent voted for Trump.

A lot of this disparity could be chalked up to social factors and economic woes. Rural, economically-depressed counties went strongly for Trump in the 2016 election. These are the same places where opioid use is prevalent. As a result, opioid use and support for Trump might not be directly related, but rather two symptoms of the same problem – a lack of economic opportunity.

To test this theory, Goodwin included other county-level factors in the analysis. These included factors such as unemployment rate, median income, how rural they are, education level, and religious service attendance, among others.

These socioeconomic variables accounted for about two-thirds of the link between voter support for Trump and opioid rates, the paper’s authors write. However, socioeconomic factors didn’t explain all of the correlation seen in the study.

“It very well may be that if you’re in a county that is dissolving because of opioids, you’re looking around and you’re seeing ruin. That can lead to a sense of despair,” Goodwin says. “You want something different. You want radical change.”

For voters in communities hit hard by the opioid epidemic, the unconventional Trump candidacy may have been the change people were looking for, Goodwin says.

Dr. Nancy E. Morden, associate professor at the Dartmouth Institute for Health Policy and Clinical Practice, agrees. “People who reach for an opioid might also reach for … near-term fixes,” she says. “I think that Donald Trump’s campaign was a promise for near-term relief.”

Goodwin’s study has limitations and can’t establish that opioid use was a definitive factor in how people voted.

“With that kind of study design, you have to be cautious in terms of drawing any causal conclusions,” cautions Elene Kennedy-Hendricks, an assistant scientist in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. “The directionality is complicated.”

Goodwin acknowledges that the study has shortcomings.

“We were not implying causality, that the Trump vote caused opioids or that opioids caused the Trump vote,” he cautions. “We’re talking about associations.”

Still, the study serves as an interesting example highlighting the links between economic opportunity, social issues and political behavior.

“The types of discussions around what drove the ’16 election, and the forces that were behind that, should also be included when people are talking about the opioid epidemic,” Goodwin says.

Source: Analysis Finds Geographic Overlap In Opioid Use And Trump Support In 2016