Racial Differences in Opiate Administration for Pain Relief at an Academic Emergency Department

Abstract

IntroductionThe decision to treat pain in the emergency department (ED) is a complex, idiosyncratic process. Prior studies have shown that EDs undertreat pain. Several studies demonstrate an association between analgesia administration and race. This is the first Midwest single institution study to address the question of race and analgesia, in addition to examining the effects of both patient and physician characteristics on race-based disparities in analgesia administration.MethodsThis was a retrospective chart review of patients presenting to an urban academic ED with an isolated diagnosis of back pain, migraine, or long bone fracture (LBF) from January 1, 2007 to December 31, 2011. Demographic and medication administration information was collected from patient charts by trained data collectors blinded to the hypothesis of the study. The primary outcome was the proportion of African-Americans who received analgesia and opiates, as compared to Caucasians, using Pearson’s chi-squared test. We developed a multiple logistic regression model to identify which physician and patient characteristics correlated with increased opiate administration.ResultsOf the 2,461 patients meeting inclusion criteria, 57% were African-American and 30% Caucasian (n=2136). There was no statistically significant racial difference in the administration of any analgesia (back pain: 86% vs. 86%, p=0.81; migraine: 83% vs. 73%, p=0.09; LBF: 94% vs. 90%, p=0.17), or in opiate administration for migraine or LBF. African-Americans who presented with back pain were less likely to receive an opiate than Caucasians (50% vs. 72%, p<0.001). Secondary outcomes showed that higher acuity, older age, physician training in emergency medicine, and male physicians were positively associated with opiate administration. Neither race nor gender patient-physician congruency correlated with opiate administration.ConclusionNo race-based disparity in overall analgesia administration was noted for all three conditions: LBF, migraine, and back pain at this institution. A race-based disparity in the likelihood of receiving opiate analgesia for back pain was observed in this ED. The etiology of this is likely multifactorial, but understanding physician and patient characteristics of institutions may help to decrease the disparity by raising awareness of practice patterns and can provide the basis for quality improvement projects.

National audit of the quality of pain relief provided in emergency departments in Aotearoa, New Zealand: The PRiZED 1 Study

“…Some previous studies found evidence of ethnic bias in the provision of pain relief in the ED while others have not. 16,20,21 Rural location of ED has been shown to be associated with delays to analgesia, 7,15 although this was not the case in our study. Many barriers to treating pain in the ED have been identified 4,17,22 including ED crowding 23,24 and whether this is the case in New Zealand is the subject of ongoing research.…”

Optimal pain management for patients with cancer in the modern era

“…Providers are more likely to underestimate pain in Total pain Pain is not just physical but is also mental, psychological, emotional, spiritual-is the basis for the concept of "total pain" as coined by Cicely Saunders in the 1960s Clark 1999 42 Pain Management for Patients With Cancer minorities-two-thirds of Hispanic patients and nearly 75% of African American patients have a level of pain that is underestimated by their providers. 48 African American patients are less likely than whites to be administered or prescribed opioids 45,49 and, even when opioids are prescribed, many patients still report severe, undertreated pain. 48 Although these discrepancies remain present across all socioeconomic strata, opioids are generally prescribed more frequently to patients of higher socioeconomic status compared with those of lower socioeconomic status.…”

Methodologic limitations of prescription opioid safety research and recommendations for improving the evidence base

“…Some studies cited in the CDC guidelines included data from the 1980s and 1990s, 18 For example, some studies included skin cancer patients but excluded patients with other types of cancer. 22,23,27,31 Previous studies have shown that White race is associated with a higher incidence of skin cancer, 54 pain, 55 receiving opioids, 56,57 and experiencing overdose. 36 Therefore, selective inclusion of skin cancers (or selective exclusion of other cancers) could lead to selection bias, threatening both internal and external validity.…”