The Effect of Cognitive Load and Patient Race on Physicians' Decisions to Prescribe Opioids for Chronic Low Back Pain: A Randomized Trial

Authors

  • Diana J. Burgess PhD,

    Corresponding author
    1. Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota, USA
    2. Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
    • Reprint requests to: Diana J. Burgess, PhD, Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, MN 55417, USA. Tel: (612) 467-1591; Fax: (612) 727 5699; E-mail: diana.burgess@va.gov.

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  • Sean Phelan MPH, PhD,

    1. Department of Family Medicine and Community Health and Division of Epidemiology, University of Minnesota, Minneapolis, Minnesota, USA
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  • Michael Workman PhD,

    1. Nathan M. Bisk College of Business, Florida Institute of Technology, Melbourne, Florida, USA
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  • Emily Hagel MS,

    1. Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota, USA
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  • David B. Nelson PhD,

    1. Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota, USA
    2. Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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  • Steven S. Fu MSCE, MD,

    1. Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota, USA
    2. Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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  • Rachel Widome PhD,

    1. Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota, USA
    2. Division of Epidemiology, University of Minnesota, Minneapolis, Minnesota, USA
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  • Michelle van Ryn MPH, PhD

    1. Department of Family Medicine and Community Health and Division of Epidemiology, University of Minnesota, Minneapolis, Minnesota, USA
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  • Disclosures
  • Funding: This project was supported by grant from VA Health Services Research & Development: PPO 09–247 (Burgess) and a locally initiated project grant from the Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center.
  • Disclaimers: The views expressed in this article are those of the authors and do not necessarily represent the position or policy of the Department of Veterans Affairs.

Abstract

Objective

To test the hypothesis that racial biases in opioid prescribing would be more likely under high levels of cognitive load, defined as the amount of mental activity imposed on working memory, which may come from environmental factors such as stressful conditions, chaotic workplace, staffing insufficiency, and competing demands, one's own psychological or physiological state, as well as from demands inherent in the task at hand.

Design

Two (patient race: White vs Black) by two (cognitive load: low vs high) between-subjects factorial design.

Setting and Participants

Ninety-eight primary care physicians from the Veterans Affairs Healthcare System.

Methods

Web-based experimental study. Physicians were randomly assigned to read vignettes about either a Black or White patient, under low vs high cognitive load, and to indicate their likelihood of prescribing opioids. High cognitive load was induced by having physicians perform a concurrent task under time pressure.

Results

There was a three-way interaction between patient race, cognitive load, and physician gender on prescribing decisions (P = 0.034). Hypotheses were partially confirmed. Male physicians were less likely to prescribe opioids for Black than White patients under high cognitive load (12.5% vs 30.0%) and were more likely to prescribe opioids for Black than White patients under low cognitive load (30.8% vs 10.5%). By contrast, female physicians were more likely to prescribe opioids for Black than White patients in both conditions, with greater racial differences under high (39.1% vs 15.8%) vs low cognitive load (28.6% vs 21.7%).

Conclusions

Physician gender affected the way in which patient race and cognitive load influenced decisions to prescribe opioids for chronic pain. Future research is needed to further explore the potential effects of physician gender on racial biases in pain treatment, and the effects of physician cognitive load on pain treatment.

Ancillary