Pain and prejudice: Exploring the racist origins of US drug policy and its impact on the modern opioid epidemic

Over the past decade, America has found itself in a pivotal moment of self-reflection, answering a call to reflect upon our national history, and reckon with the grave impact that systemic racism, societal inequity, stigma, and bias have all had in shaping the foundation of our modern lives. As pharmacists, we are entrusted by the public to devote our professional lives to the service of all humankind; it is, therefore, our duty to heed this call for action and work to develop a more equitable and just future. To accomplish this, we not only need to self-reflect upon our history of inequity but also seek to understand and learn from it. This will require a willingness to have difficult conversations and recognize the lingering effects that stigma and bias continue to have on our patients. Albeit difficult, this process of reflection and understanding will allow us to develop key strategies that address the impact that stigma and inequity have on our patients. As we reflect on the negative impact that stigma and inequity have on our patients across every facet of health care, we find one area deserving particular attention: pain management. In a recent survey, 15% of cancer patients reported that they felt awkward discussing pain with their providers; another 20% reported that they use less opioid medication than they need in order to avoid appearing “drug seeking. ” Opioids, and all other controlled substances for that matter, carry a stigma within the medical community, a stigma that continues to serve as a barrier and actively prevents patients from receiving appropriate medical care. The consequences of this stigma are vast, and unfortunately, they extend far beyond the realm of uncontrolled pain. The FDA has recently reported a pattern in which chronic pain patients, who are (as one would expect) physically dependent on their long-term opioid treatment, are having their prescription opioids abruptly stopped. This rapid discontinuation has been associated with increased pain, severe withdrawal symptoms, and even patient suicide. This is occurring across the United States, even within patients who show no signs of an opioid use disorder. This opioid stigma, however, does not solely impact pain patients, it has had devastating effects among patients with substance use disorder, especially opioid use disorder. Currently, only one in five patients who has been diagnosed with opioid use disorder receives first-line treatment with buprenorphine. The prevalence of appropriate treatment is even lower among African American and Hispanic populations, and also fails to account for the large number of patients with opioid use disorder who never receive an official diagnosis. Our lack of treatment utilization has consequences; despite our increased attention on opioid prescribing, overdose rates have continued to rise. As it stands, opioid overdoses are more prevalent than ever before, yet at the same time, pain patients have continued to report sub-par care, and the public need for effective opioid use disorder treatment far exceeds availability. If pharmacists are going to fulfill our oath, it is imperative that we reflect upon how we arrived at this point, seek to understand our history with opioids, learn from our mistakes, and use this newfound knowledge to develop equitable solutions and key strategies to improve the quality of care for all.