White Patients More Likely To Receive Opioids In Emergency Department, USA

White patients in emergency department visits are more likely to receive opioids, powerful painkillers, than patients who are not white, according to an article in the Journal of the American Medical Association (JAMA). This is despite the fact that the use of opioids to treat pain-related emergency department visits has improved over the last 15 years.

During the 1990s there was a national focus on the problem of inadequately treated pain, the authors explain. Patients from ethnic/racial minority groups were less likely to receive adequate pain treamtnet in the emergency department. Consequently, nationwide quality improvement initiates were put into practice at the end of the 1990s.

Mark J. Pletcher, M.D., M.P.H., University of California, San Francisco, and team wanted to find out whether opioid prescribing had increased in American emergency departments for patients who were in pain. They also wanted to see what the likelihood is of a non-Hispanic white patient receiving an opioid compared to patients from other racial/ethnic groups. Pain-related visits to U.S. emergency departments were identified using reason-for-visit and physician diagnosis codes from 13 years (1993-2005) of The National Hospital Ambulatory Medical Care Survey.

The researchers found that 42% of emergency department visits were pain-related, a total of 156,729 out of 374,891. In 29% of pain-related visits an opioid analgesic was prescribed – the percentage grew from 23% in 1993 to 37% in 2005. However, the researchers found no evidence that the difference in opioid prescribing by race/ethnicity fell over time.

Over the 13 survey years, the researchers found that

— 31% of whites received an opioid prescription for pain related visits
— 23% of blacks received an opioid prescription for pain related visits
— 24% of Hispanics received an opioid prescription for pain related visits
— 28% of Asians and other ethnic/racial groups received an opioid prescription for pain related visits

The differences in opioid prescribing were present, consistently, across different kinds of pain, pain severities, for visits in which pain was the first/second/third reason for the visit, as well as two specific painful diagnoses – long-bone fracture and kidney stones. In fact, as pain severity increased the difference in opioid prescribing between whites and non-whites was larger. For example

— 48% of whites got an opioid prescription for back pain
— 36% of non-whites got an opioid prescription for back pain

— 35% of whites got an opioid prescription for headache
— 24% of non-whites got an opioid prescription for headache

— 32% of whites got an opioid prescription for abdominal pain
— 22% of non-whites got an opioid prescription for abdominal pain

— 40% of whites got an opioid prescription for other pain
— 28% of non-whites got an opioid prescription for other pain

Even after making statistical adjustments for pain severity, and some other factors, the differentials still remained.

Compared to a white patient,

— a black patient is 34% less likely to get an opioid prescription
— a Hispanic patient is 33% less likely to get an opioid prescription
— an Asian/other patient is 21% less likely to get an opioid prescription

The researchers write “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.”

“Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments”
Mark J. Pletcher, MD, MPH; Stefan G. Kertesz, MD, MSc; Michael A. Kohn, MD, MPP; Ralph Gonzales, MD, MSPH
JAMA. 2008;299(1):70-78.
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