A Painful Reminder By Neal E. Flomenbaum, MD, Editor-in-Chief

The opening words of a widely reported January 2, 2008, JAMA study on trends in opioid-prescribing in emergency departments provided more of a sting than that day’s wind chill. “Inadequately treated pain is…a particular problem in emergency departments…[and]…racial and ethnic minority groups appear to be at particularly high risk of receiving inadequate treatment…” The bottom line is that although opioid-prescribing for patients making a pain-related visit to an emergency department in this country increased after national quality improvement initiatives in the 1990s, differences in opioid-prescribing by race or ethnicity have not diminished.

The JAMA study analyzed 156,729 pain-related emergency department visits over a 13-year period. Using the reason-for-visit codes and physician diagnostic codes from the National Hospital Ambulatory Medical Care Survey between 1993 and 2005, and any of up to six (eight since 2003) administered or prescribed medications, the authors found that an opioid analgesic was prescribed for 23% of pain-related visits in 1993 and 37% by 2005.  However, despite this positive trend in the overall use of pain meds, the disparity of less- frequent use of opioids to treat pain in blacks and Hispanics compared to  white patients did not appear to decrease over time. In the 13 years covered by the survey, white patients received opioids for pain 31% of the time, compared to 23% for blacks, 24% for Hispanics, and 28% for Asians and others.

Statistical variations for the different races and ethnic groups held for all types of pain studied, including pain resulting from long-bone fractures and nephrolithiasis. A particularly disturbing finding was that opioid-prescribing rates were very low among black and Hispanic children compared to white children.  Not as widely reported in the media was the finding that because non-opioid analgesics were prescribed more frequently for non-whites (32%) than whites (26%), overall prescribing rates for all analgesics among ethnic groups were about the same.

These findings are not new. Since the early 1990s, Knox Todd, MD, one of the foremost emergency medicine pain experts in the country, and others have been documenting this problem in a variety of settings and in all parts of the country. In 1993, Todd and his colleagues identified four factors by which ethnicity may influence pain management decisions: the patient’s pain perception, the patient’s ability to communicate the presence of pain, the physician’s skill in assessing pain intensity, and the physician’s selection and ordering of an analgesic to treat the pain—with pain assessment probably being most important. 

What is new is that the unsettling pattern of racial and ethnic disparities has not changed despite the pain initiatives of the past decade. So I asked Dr. Todd what we need to do to make these disparities disappear, and he suggested that ethnic identifiers be incorporated by both hospital quality improvement efforts and regional and national health plans to locate any inequalities. Knox believes that simply supplying feedback to emergency physicians may be an effective intervention. He further notes that emergency medicine is an inherently egalitarian specialty with a key role in promoting fairness and equal access to quality medical care.

Clearly there are issues here for ACEP, ABEM, AAEM, SAEM, and other national and regional organizations to address, as there are for individual hospitals and emergency departments. Ultimately, however, it is up to each and every one of us to practice pain-free and color-blind emergency medicine.

Emerg Med 40(2):8, 2008