Minorities Less Likely to Get Powerful Painkillers in ER
WEDNESDAY Jan. 2, 2008 -- If you arrive in an emergency room in significant pain, you are less likely to be prescribed a narcotic to ease that pain if you are not white, new research shows.
The reasons for the disparity aren't clear, but there's no doubt that minorities don't get effective pain treatment in the ER as often as whites do, said study author Dr. Mark Pletcher, an assistant professor of epidemiology and biostatistics at the University of California, San Francisco. "There's no difference in the pain severity or types of pain that people are presenting with, but the difference is there consistently."
To come to this conclusion, Pletcher and his colleagues examined reports from a national survey about visits to emergency rooms between 1993 and 2005. Pain-related visits made up 156,729, or 42 percent, of 374,891 visits tracked by the survey.
The findings are reported in the Jan. 2 issue of the Journal of the American Medical Association.
Researchers did find that doctors have started prescribing powerful painkillers -- including morphine, codeine, oxycodone and Vicodin -- more often in recent years. Thirty-seven percent of pain-related cases were treated with narcotics in 2005, a jump from 23 percent in 1993.
The overall use of opioid drugs may have grown because, as the study noted, doctors began paying more attention to poorly treated pain during the 1990s.
But that increased attention appears to have been tempered by the race of the patient. White patients received opioid drugs 31 percent of the time, compared to lower rates among blacks (23 percent), Hispanic (24 percent), and other groups such as Asians (28 percent).
In 2005, whites received the drugs 40 percent of the time, while all others got them 32 percent of the time.
While there are concerns about addiction to opioids, it's appropriate to prescribe them for significant pain, Pletcher said. Still, they're only prescribed about two-thirds of the time for kidney stones and half the time for serious broken bones, he said, when those numbers should be at least 90 percent.
Patients may be hesitant about treating pain aggressively because of concern about abuse of opiates, he said. Also, patients have to go through a lot of procedures to get a prescription.
"They have to come in and say they have pain, and convince a nurse and doctor that they have pain that requires an opioid. It has to be prescribed and administered," Pletcher said. "There's enough barriers that it doesn't happen as consistently as it should."
Why would doctors be less likely to prescribe the drugs to minorities? The study doesn't answer that question, but Pletcher said there are a number of potential explanations.
"There could well be an element of pure racial bias," he said. "But it's probably more subtle and insidious than that. The interaction that occurs between a patient and a physician is complex in terms of interpersonal communications, and minority patients may be less empowered to complain and to demand good pain control. They may be less willing to show weakness by asking for a pain medication."
In addition, "there may be poorer communication in general and language barriers," he said. "A lot of things can get in the way of ideal care."
Another expert voiced similar concerns.
Dr. Thomas Fisher Jr., assistant professor of emergency medicine at the University of Chicago, said a variety of factors could explain the disparity.
For one, minority patients might be less likely to demand painkillers because of their history of "negative interactions" with authority, he said. "They may not feel comfortable voicing their needs, and they may not be able to given a language barrier or issues of culture," he added.
And doctors may make assumptions about minority groups and the likelihood that they'll abuse drugs, he said. "These things probably feed one another," Fisher said.
The American College of Emergency Physicians (ACEP), however, said in a statement released Wednesday afternoon that a study presented at the group's recent annual meeting found that most patients who come to the ER with pain are satisfied with the care they receive.
"Our research showed that people with chronic pain who come to the emergency department seeking relief generally get that relief and fairly quickly," study author Dr. Knox Todd, director of the Pain and Emergency Medicine Institute at Beth Israel Medical Center in New York City, said in a statement.
"The good new is that all physicians, including emergency physicians, are continuing to improve their pain management practices," Todd said. "The less-good news is that many physicians continue to under-treat pain in their patients."
Posted: January 2008
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