Racial discrimination in medical care settings and opioid pain reliever misuse in a U.S. cohort: 1992 to 2015

Autoři: Samuel L. Swift aff001;  M. Maria Glymour aff002;  Tali Elfassy aff003;  Cora Lewis aff004;  Catarina I. Kiefe aff005;  Stephen Sidney aff006;  Sebastian Calonico aff007;  Daniel Feaster aff008;  Zinzi Bailey aff009;  Adina Zeki Al Hazzouri aff010
Působiště autorů: Center for Health Equity in Kidney Disease, University of New Mexico School of Medicine, Albuquerque, NM, United States of America aff001;  Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States of America aff002;  Division of Epidemiology, Department of Public Health Sciences, University of Miami, Miami, FL, United States of America aff003;  Division of Preventative Medicine, Department of Medicine, University of Alabama, Tuscaloosa, AL, United States of America aff004;  Department of Quantitative Health Sciences, University of Massachusetts Medical School, Boston, MA, United States of America aff005;  Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America aff006;  Department of Health Policy and Management, Columbia University, New York, NY, United States of America aff007;  Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami, FL, United States of America aff008;  Jay Weiss Institute for Health Equity, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, United States of America aff009;  Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States of America aff010
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0226490



In the United States whites are more likely to misuse opioid pain relievers (OPRs) than blacks, and blacks are less likely to be prescribed OPRs than whites. Our objective is to determine whether racial discrimination in medical settings is protective for blacks against OPR misuse, thus mediating the black-white disparities in OPR misuse.


We used data from 3528 black and white adults in the Coronary Artery Risk Development in Young Adults (CARDIA) study, an ongoing multi-site cohort. We employ causal mediation methods, with race (black vs white) as the exposure, lifetime discrimination in medical settings prior to year 2000 as the mediator, and OPR misuse after 2000 as the outcome.


We found black participants were more likely to report discrimination in a medical setting (20.3% vs 0.9%) and less likely to report OPR misuse (5.8% vs 8.0%, OR = 0.71, 95% CI = 0.55, 0.93, adjusted for covariates). Our mediation models suggest that when everyone is not discriminated against, the disparity is wider with black persons having even lower odds of reporting OPR misuse (OR = 0.63, 95% CI = 0.45, 0.89) compared to their white counterparts, suggesting racial discrimination in medical settings is a risk factor for OPR misuse rather than protective.


These results suggest that racial discrimination in a medical setting is a risk factor for OPR misuse rather than being protective, and thus could not explain the seen black-white disparity in OPR misuse.

Klíčová slova:

Cardiology – Death rates – Epidemiology – Heroin – Medical education – Opioids – Racial discrimination – Social discrimination


1. Centers for Disease Control and Prevention NCfHS. Underlying Cause of Death 1999–2016 on CDC WONDER Online Database, released December, 2017.

2. Kolodny A, Courtwright DT, Hwang CS, Kreiner P, Eadie JL, Clark TW, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annual review of public health. 2015;36:559–74. doi: 10.1146/annurev-publhealth-031914-122957 25581144

3. Rudd RA. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR Morbidity and mortality weekly report. 2016;65.

4. (NIDA) NIoDA. Misuse of Prescription Drugs. August 1st, 2016:[Available from: https://www.drugabuse.gov/publications/research-reports/misuse-prescription-drugs

5. Unick GJ, Ciccarone D. US regional and demographic differences in prescription opioid and heroin-related overdose hospitalizations. International Journal of Drug Policy. 2017;46:112–9. doi: 10.1016/j.drugpo.2017.06.003 28688539

6. Alexander MJ, Kiang MV, Barbieri M. Trends in Black and White opioid mortality in the United States, 1979–2015. Epidemiology (Cambridge, Mass). 2018;29(5):707.

7. Mossey JM. Defining racial and ethnic disparities in pain management. Clinical Orthopaedics and Related Research®. 2011;469(7):1859–70.

8. Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in us emergency departments. JAMA. 2008;299(1):70–8. doi: 10.1001/jama.2007.64 18167408

9. Mouton CP, Carter-Nolan PL, Makambi KH, Taylor TR, Palmer JR, Rosenberg L, et al. Impact of perceived racial discrimination on health screening in black women. Journal of health care for the poor and underserved. 2010;21(1):287. doi: 10.1353/hpu.0.0273 20173270

10. Hausmann LR, Jeong K, Bost JE, Ibrahim SA. Perceived discrimination in health care and use of preventive health services. Journal of general internal medicine. 2008;23(10):1679–84. doi: 10.1007/s11606-008-0730-x 18649109

11. Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, et al. The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization. New England Journal of Medicine. 1999;340(8):618–26. doi: 10.1056/NEJM199902253400806 10029647.

12. Krieger N, Chen JT, Waterman PD. Decline in US Breast Cancer Rates After the Women’s Health Initiative: Socioeconomic and Racial/Ethnic Differentials. Am J Public Health. 2010;100(S1):S132–9. doi: 10.2105/ajph.2009.181628 20147667; PubMed Central PMCID: PMC2837433.

13. Friedman GD, Cutter GR, Donahue RP, Hughes GH, Hulley SB, Jacobs DR, et al. CARDIA: study design, recruitment, and some characteristics of the examined subjects. Journal of clinical epidemiology. 1988;41(11):1105–16. doi: 10.1016/0895-4356(88)90080-7 3204420

14. Krieger N, Smith K, Naishadham D, Hartman C, Barbeau EM. Experiences of discrimination: validity and reliability of a self-report measure for population health research on racism and health. Social science & medicine. 2005;61(7):1576–96.

15. Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Applied psychological measurement. 1977;1(3):385–401.

16. Valeri L, VanderWeele TJ. Mediation analysis allowing for exposure–mediator interactions and causal interpretation: Theoretical assumptions and implementation with SAS and SPSS macros. Psychological methods. 2013;18(2):137. doi: 10.1037/a0031034 23379553

17. VanderWeele TJ, Vansteelandt S. Odds Ratios for Mediation Analysis for a Dichotomous Outcome. American Journal of Epidemiology. 2010;172(12):1339–48. doi: 10.1093/aje/kwq332 21036955; PubMed Central PMCID: PMC2998205.

18. Nandi A, Glymour MM, Kawachi I, VanderWeele TJ. Using marginal structural models to estimate the direct effect of adverse childhood social conditions on onset of heart disease, diabetes, and stroke. Epidemiology (Cambridge, Mass). 2012;23(2):223.

19. Inc. SI. SAS Software version 9.4, 2002–2012. Cary, NC.

20. Lyapustina T, Castillo R, Omaki E, Shields W, McDonald E, Rothman R, et al. The contribution of the emergency department to opioid pain reliever misuse and diversion: a critical review. Pain practice. 2017;17(8):1097–104. doi: 10.1111/papr.12568 28226416

21. Shiels MS, Freedman ND, Thomas D, de Gonzalez Berrington A. Trends in US drug overdose deaths in non-Hispanic black, Hispanic, and non-Hispanic white persons, 2000–2015. Annals of internal medicine. 2018;168(6):453–5. doi: 10.7326/M17-1812 29204603

22. Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. Journal of the National Medical Association. 2002;94(8):666. 12152921

23. Mustillo S, Krieger N, Gunderson EP, Sidney S, McCreath H, Kiefe CI. Self-reported experiences of racial discrimination and Black–White differences in preterm and low-birthweight deliveries: the CARDIA Study. American Journal of Public Health. 2004;94(12):2125–31. doi: 10.2105/ajph.94.12.2125 15569964

24. Cunningham TJ, Berkman LF, Kawachi I, Jacobs DR, Seeman TE, Kiefe CI, et al. Changes in waist circumference and body mass index in the US CARDIA cohort: fixed-effects associations with self-reported experiences of racial/ethnic discrimination. Journal of biosocial science. 2013;45(2):267–78. doi: 10.1017/S0021932012000429 22856616

25. Womack VY, Ning H, Lewis CE, Loucks EB, Puterman E, Reis J, et al. Relationship between perceived discrimination and sedentary behavior in adults. American journal of health behavior. 2014;38(5):641–9. doi: 10.5993/AJHB.38.5.1 24933133

26. Borrell LN, Jacobs DR Jr, Williams DR, Pletcher MJ, Houston TK, Kiefe CI. Self-reported racial discrimination and substance use in the Coronary Artery Risk Development in Adults Study. American Journal of Epidemiology. 2007;166(9):1068–79. doi: 10.1093/aje/kwm180 17698506

27. McLaughlin KA, Hatzenbuehler ML, Keyes KM. Responses to Discrimination and Psychiatric Disorders Among Black, Hispanic, Female, and Lesbian, Gay, and Bisexual Individuals. American Journal of Public Health. 2010;100(8):1477–84. doi: 10.2105/AJPH.2009.181586 20558791

28. Clark TT, Salas-Wright CP, Vaughn MG, Whitfield KE. Everyday discrimination and mood and substance use disorders: a latent profile analysis with African Americans and Caribbean Blacks. Addictive behaviors. 2015;40:119–25. doi: 10.1016/j.addbeh.2014.08.006 25254321

29. McCabe SE, Bostwick WB, Hughes TL, West BT, Boyd CJ. The Relationship Between Discrimination and Substance Use Disorders Among Lesbian, Gay, and Bisexual Adults in the United States. American Journal of Public Health. 2010;100(10):1946–52. doi: 10.2105/AJPH.2009.163147 20075317

30. Chavez LJ, Ornelas IJ, Lyles CR, Williams EC. Racial/ethnic workplace discrimination: association with tobacco and alcohol use. American journal of preventive medicine. 2015;48(1):42–9. doi: 10.1016/j.amepre.2014.08.013 25441232

31. Landrine H, Klonoff EA. The schedule of racist events: A measure of racial discrimination and a study of its negative physical and mental health consequences. Journal of Black Psychology. 1996;22(2):144–68.

32. Martin JK, Tuch SA, Roman PM. Problem drinking patterns among African Americans: the impacts of reports of discrimination, perceptions of prejudice, and" risky" coping strategies. Journal of health and social behavior. 2003:408–25. 14582316

33. Pascoe EA, Smart Richman L. Perceived discrimination and health: a meta-analytic review. Psychological bulletin. 2009;135(4):531. doi: 10.1037/a0016059 19586161

34. James K, Jordan A. The opioid crisis in Black communities. The Journal of Law, Medicine & Ethics. 2018;46(2):404–21.

35. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proceedings of the National Academy of Sciences. 2015;112(49):15078–83.

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2019 Číslo 12
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