Use of opioid medications for pain in ERs on the rise, but racial differences in use still exist

Jan 2 2008

In the last 15 years, use of opioid medications to treat patients with pain-related emergency department visits has improved although white patients were more likely to receive opioids than patients of a different race/ethnicity, according to a study in the January 2 issue of JAMA: The Journal of the American Medical Association.

In the 1990s, national attention focused on increasing awareness of the problem of inadequately treated pain. Also, racial and ethnic minority groups appeared to be at higher risk of receiving inadequate treatment for pain in the emergency department, according to background information in the article. National quality improvement initiatives were implemented in the late 1990s, followed by substantial increases in opioid (narcotic agents used for pain relief) prescribing in the United States, but it is unknown whether opioid prescribing for treatment of pain in the emergency department has increased and whether differences in opioid prescribing by race/ethnicity have decreased.

Mark J. Pletcher, M.D., M.P.H., of the University of California, San Francisco, and colleagues examined whether opioid prescribing is increasing in U.S. emergency departments for patients presenting with pain and whether non-Hispanic white patients are more likely to receive an opioid than other racial/ethnic groups. Pain-related visits to U.S. emergency departments were identified using reason-for-visit and physician diagnosis codes from thirteen years (1993-2005) of The National Hospital Ambulatory Medical Care Survey.

During the survey years, pain-related visits accounted for 156,729 of 374,891 (42 percent) emergency department visits. An opioid analgesic was prescribed at 29 percent of pain-related visits. This proportion increased during the study period, from 23 percent in 1993 to 37 percent in 2005. Despite this time trend, the researchers found no evidence that the difference in opioid prescribing by race/ethnicity diminished over time. Averaged over the 13 survey years, opioid prescribing was more likely for pain-related visits made by whites (31 percent) than by blacks (23 percent), Hispanics (24 percent), or Asians/others (28 percent), and there was no evidence of an interaction between the time trend and race/ethnicity during the study period. In 2005, opioid prescribing rates were 40 percent in whites and 32 percent in all others.

Differential opioid prescribing was consistently present across different types of pain, across different levels of pain severity, for visits in which pain was the first or second/third reason for visit, and for two specific painful diagnoses, long-bone fracture and kidney stones. Differences in prescribing between whites and nonwhites were larger as pain severity increased and were particularly pronounced for patients with back pain (48 percent vs. 36 percent, respectively), headache (35 percent vs. 24 percent), abdominal pain (32 percent vs. 22 percent), and other pain (40 percent vs. 28 percent). Blacks were prescribed opioids at lower rates than any other race/ethnicity group for almost every type of pain visit.

Statistical adjustment for pain severity and other factors did not substantially change these differences. Compared with white patients, black patients were 34 percent less likely to receive an opioid prescription; Hispanic patients, 33 percent less likely; and Asian/other patients, 21 percent less likely.

“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.

http://jama.ama-assn.org/