RESEARCH ANALYSIS | Gender and Racial Disparities in Pain Perception, Opioid Prescribing, and OUD Treatment

Gender and Racial Disparities in Pain Perception, Opioid Prescribing, and OUD Treatment

Gopika Pillai, BS

Drexel University College of Medicine

SUMMARY POINTS

• Women are both overexposed to prescription opioids and underserved in adequate pain evaluation.

• Black, Hispanic, and other minority patients receive fewer analgesics and opioids for similar pain compared to White patients.

• Rising OUD mortality among racial/ethnic minority groups is linked to lower prescribing rates for analgesics and limited MOUD access.

ANALYSIS

Background

Chronic pain in the United States is becoming increasingly common, with one in five Americans experiencing chronic pain (1). Untreated pain may evolve into chronic suffering, medication dependency, and increased healthcare costs. Effective pain management is, therefore, a vital and challenging aspect of healthcare due to limitations in the current objective pain measurement tools. Healthcare providers need to assess patients’ subjective pain reports using their clinical judgment, making them vulnerable to different kinds of biases (2).

Several studies show that laypeople and often clinicians tend to judge females’ pain as less intense than that of males (1, 2). These perceptions, combined with the increased prevalence of chronic pain conditions and more frequent healthcare engagement among women, place them at an increased risk of long-term opioid use (3). On the other hand, men are more likely to engage in nonmedical opioid use (NMOU) during their first treatment involving medication for opioid use disorder (MOUD) (4).

While opioids are commonly prescribed for pain, recent trends point to increases in opioid misuse. Between 1999 and 2017, opioid-related deaths increased more sharply for women (503%) than for men (404%), despite men having more overall deaths (5). This reflects the issue of opioid use disorder (OUD), defined as chronic opioid use leading to clinically significant distress or impairment, often requiring both MOUD and psychosocial support (6, 7). Since 2015, however, illicitly manufactured fentanyl accounts for the third wave of mortality in the opioid crisis, much more than prescription opioids (8).

OUD-related mortality from recent data shows significant race-based differences as well, with pronounced increases in deaths since 2019 among Native American, Black, and Hispanic populations (9). Additionally, black patients' pain also tends to be underestimated and undertreated compared to white patients, highlighting racial disparities in pain management (10).

These pain management disparities reflect broad patterns of inequality in pain and addiction treatment. Thus, this analysis explores how gender and race influence pain perception, opioid prescribing practices, and access to OUD treatment.

Findings

One of the major findings in a study conducted by Guzikevits et al. was that women are more likely to report pain than men, but less likely to receive opioid analgesics, have their pain documented appropriately, or be treated promptly in emergency departments. They found that this correlated with medical providers’ gender–pain exaggeration bias, where women were perceived as overreporting symptoms (2).

However, several studies found that women are paradoxically more likely to receive prescription opioids in comparison to men under chronic settings, especially preoperatively. Women were also more likely to remain on opioids long-term after ACL reconstruction and total joint arthroplasty (3, 5, 11). In contrast, men are often prescribed higher doses at discharge (5).

In addition to gender-based differences, notable race-based differences were also found. Black and Hispanic patients are significantly less likely to receive opioids for similar pain levels as compared to white patients (1, 10). A retrospective study performed in 2000 indicated that 57% of black patients received analgesics compared to 74% of white patients in an emergency setting for extremity fractures (12). Even when opioid receipt rates were similar, black patients received 36% lower average annual opioid dosage than white patients (10, 13). Another study also found that medical trainees who endorsed myths regarding biological differences in pain sensitivity between black and white individuals attributed higher pain levels and corresponding treatment to white patients for the same symptoms (10).

OUD-related mortality has been rising recently among black and minority patients, despite lower opioid prescription rates (9). Minorities were less likely to receive a referral for treatment by a medical professional, receive MOUD, or complete treatment episodes (14). Additionally, buprenorphine, which is considered to have a safer risk profile, is more often prescribed to white and high-income patients, while methadone is more common in lower-income, minority neighborhoods, demonstrating disparities in MOUD access (15).

Regarding gender differences for receiving OUD treatment, Marsh et al. showed in a cross-sectional study that women faced longer delays than men in entering treatment than men but tended to stay on longer after starting. Minority women, including those identifying as African American or Latina, were more likely to have shorter treatment regimens and limited access to only methadone compared to white men, potentially due to disproportionate patterns of homelessness, mental illness, substance use severity, as well as structural racism and implicit biases (16)

Additionally, in a study by Torres, minority patients were less likely to be offered opioids directly and often initiated the request themselves in comparison to white patients. Discourse analysis showed that physicians exercise more caution and scrutiny in prescribing opioids to racial/ethnic minority patients, even when they reported severe pain, compared to the more relaxed prescribing practices and increased patient autonomy with White patients (17).

Discussion

Race and gender significantly influence access to both pain and MOUD, especially for women and racial/ethnic minorities. The previous findings have shown that women are often overprescribed opioids yet underserved in proper pain evaluation. Black, Hispanic, and other racial/ethnic minority patients are frequently undertreated for pain, which may be contributing to the rise in OUD-related mortality. 

One possible explanation for this discrepancy between low opioid prescribing and high mortality among racial and ethnic minorities could be the increased awareness of the opioid crisis among healthcare providers, which leads to overly cautious opioid prescribing practices and inequities in pain management. These restrictions may push some individuals towards illicit opioid use in an effort to achieve pain control, contributing to the increase in OUD-related mortality.

Future research should explore solutions and policies to expand MOUD access to a larger and more diverse range of populations, including non-binary gender identities and underrepresented racial/ethnic groups. Additionally, studying how to balance standardized pain assessment tools with individualized patient care could help reduce provider biases. Ultimately, incorporating more inclusive and equitable practices in therapies for pain and substance use can lead to significant progress in addressing the opioid crisis.

REFERENCES

1.         Hirani S, Benkli B, Odonkor CA, et al. Racial Disparities in Opioid Prescribing in the United States from 2011 to 2021: A Systematic Review and Meta-Analysis. J Pain Res. 2024;17:3639-3649. Published 2024 Nov 7. doi:10.2147/JPR.S477128

2.         Guzikevits M, Gordon-Hecker T, Rekhtman D, et al. Sex bias in pain management decisions. Proc Natl Acad Sci U S A. 2024;121(33):e2401331121. doi:10.1073/pnas.2401331121

3.         Meade PJ, Matzko CN, Stamm MA, Mulcahey MK. Females Are More Likely Than Males to Fill an Opioid Prescription in the Year After Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil. 2023;5(4):100758. Published 2023 Jul 8. doi:10.1016/j.asmr.2023.100758

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5.         Soffin EM, Wilson LA, Liu J, Poeran J, Memtsoudis SG. Association between sex and perioperative opioid prescribing for total joint arthroplasty: a retrospective population-based study. Br J Anaesth. 2021;126(6):1217-1225. doi:10.1016/j.bja.2020.12.046

6.         Dydyk AM, Jain NK, Gupta M. Opioid Use Disorder: Evaluation and Management. In: StatPearls. Treasure Island (FL): StatPearls Publishing; January 17, 2024.

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8.         NIDA. Drug Overdose Deaths: Facts and Figures . National Institute on Drug Abuse website. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates. August 21, 2024

9.         Congressional Budget Office. The Opioid Crisis and Recent Federal Policy Responses | Congressional Budget Office. www.cbo.gov. Published September, 2022.

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12.      Todd KH, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11–16. doi: 10.1016/s0196-0644(00)70099-0.

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16.      Marsh JC, Amaro H, Kong Y, Khachikian T, Guerrero E. Gender disparities in access and retention in outpatient methadone treatment for opioid use disorder in low-income urban communities. J Subst Abuse Treat. 2021;127:108399. doi:10.1016/j.jsat.2021.108399

17.      Torres PJ. Race and gender disparities in pain treatment and opioid prescribing. Soc Sci Med. 2025;374:118011. doi:10.1016/j.socscimed.2025.118011