Blacks, Hispanics Less Likely To Get Strong Pain Drugs In Emergency Rooms

The study examined treatments for more than 150,000 pain-related visits to U.S. hospitals between 1993 and 2005. It found that 31 percent of whites received opioid drugs compared with only 23 percent of blacks and 24 percent of Hispanics. About 28 percent of Asians received the drugs.

In contrast, non-opioid pain relievers, such as acetaminophen and ibuprofen were prescribed much more often to non-whites (36 percent) than to whites (26 percent).

"Studies in the 1990s showed a disturbing racial or ethnic disparity in the use of these potent pain relievers, but we had hoped that the recent national efforts at improving pain management in emergency departments would shrink this disparity," said Mark Pletcher, MD, a UCSF assistant professor of epidemiology and biostatistics and lead author of the study. "Unfortunately, this is not the case."

Opioids are narcotic drugs used to treat patients with moderate to severe pain. Their use in emergency rooms increased overall from 23 to 37 percent between 1993 and 2005. National quality improvement guidelines on pain control in 2001 called for increased monitoring of pain status and stressed the need for adequate pain control. Since then, the hospital use of opioids has further increased. The new study is the first to assess national opioid prescribing patterns in the emergency room setting since implementation of the guidelines.

Among the findings:

• Blacks were prescribed opioids at lower rates than other groups for almost every type of pain-related emergency department visit, including back pain, headache, and abdominal pain.
• Differences in prescribing were greatest for people with the worst pain. About 52 percent of whites in severe pain received opioids, compared with 42 percent of Hispanics and 39 percent of blacks.
• Prescribing rates were particularly low for:

1. Black and Hispanic children
2. Blacks in county and state hospitals
3. Asians and other insured by Medicare
4. All non-white patients in the Northeast

There is no evidence that non-whites have less severe or different types of pain when they arrive in the emergency department," Pletcher said. "We think our data indicate that opioids are being underprescribed to minority emergency department patients, especially black and Hispanic patients."

"Our results suggest that new strategies are needed to understand and improve the quality and equity of management of acute pain in the United States. Future initiatives should continue to monitor pain management quality indicators and processes of care that may contribute to inadequate care, to educate physicians about the importance of adequate pain control, and to promote cultural competence within individual physicians. It is likely, however, that eliminating disparities in pain control will also require nonphysician interventions such as patient-targeted self-efficacy education, nurse-initiated pain-treatment protocols, and other system-level changes to facilitate equitable, systematic, and consistent alleviation of pain in emergency department patients," the authors write.

The study was not designed to determine the causes of these ethnic disparities in care, and they are likely to complex, Pletcher said. The authors call for ongoing education of physicians and nursing staff on treatment of pain, and promotion of cultural awareness. They also call for more education of patients to advocate for their own pain control.

The paper suggests that changes in systems for pain management in the emergency department may be required, such as use of protocols allowing nurses to initiate pain control measures.

The study draws on data compiled by the National Hospital Ambulatory Medical Care Survey conducted by the Census Bureau. The researchers analyzed nearly 375,000 emergency room visits over 13 years. About 42 percent of these visits were for pain.

Journal reference: JAMA. 2008;299(1):70-78.

Co-authors on the study are Michael Kohn, MD, assistant clinical professor of epidemiology and biostatistics, and professor Ralph Gonzales, MD, professor of medicine, both at UCSF; and Stefan Kertesz, MD, professor of preventive medicine at the University of Alabama.

The study was funded by the Agency for Healthcare Research and Quality of the National Institute on Drug Abuse.