The Situationist

The Racial Situation of Pain Relief

Posted by The Situationist Staff on January 9, 2008

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Feeling pain? If you go to the ER in hope of relief, you’re chances of finding it are significantly greater if you’re white. That is the conclusion of recent study co-authored by Dr. Mark Pletcher, an assistant professor of epidemiology and biostatistics at the University of California, San Francisco.

The findings are reported in the Jan. 2 issue of the Journal of the American Medical Association.

Below we’ve excerpted and mashed up several stories about the article, including one piece by Reuters, another by the Associated Press, and a third by U.S. News & World Report.

* * *

An analysis of more than 150,000 emergency room visits over 13 years [found that] [p]rescribing narcotics for pain in emergency rooms rose [generally over that time period], from 23 percent of those complaining of pain in 1993 to 37 percent in 2005.

The increase coincided with changing attitudes among doctors who now regard pain management as a key to healing. Doctors in accredited hospitals must ask patients about pain, just as they monitor vital signs such as temperature and pulse.

[The study, however, also] found differences in prescribing by race in both urban and rural hospitals, in all U.S. regions and for every type of pain.

Emergency room doctors are prescribing strong narcotics more often to patients who complain of pain, but minorities are less likely to get them than whites . . . .

[The] study found 31 percent of whites in pain received opioid drugs — a broad class of narcotic painkillers dispensed only by prescription — compared to 23 percent of blacks and 24 percent of Hispanics.

In contrast, 36 percent of minority patients received less-potent, non-opioid pain relievers such as acetaminophen and ibuprofen during emergency room visits, compared to 26 percent of white patients.

Even for the severe pain of kidney stones, minorities were prescribed narcotics such as oxycodone and morphine less frequently than whites.

[According to Dr. Plether,] “[t]here’s no difference in the pain severity or types of pain that people are presenting with, but the difference is there consistently.” The reasons for the disparity aren’t clear.

“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,” Pletcher . . . said in a statement.

“Unfortunately, this is not the case,” he said.

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.”

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.”

The study’s authors [also] said doctors may be less likely to see signs of painkiller abuse in white patients, or they may be undertreating pain in minoritypain-relief-quotation.jpg patients.

Whites — who are more likely to have health insurance — may also be overprescribed the drugs, it said.

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.

“It’s time to move past describing disparities and work on narrowing them,” said Dr. . . Fisher . . . .

Fisher, who is black, said he is not immune to letting subconscious assumptions inappropriately influence his work as a doctor.

“If anybody argues they have no social biases that sway clinical practice, they have not been thoughtful about the issue or they’re not being honest with themselves,” he said.

* * *

For related Situationist posts discussing the situation of medical care . . . . “Infant Death Rates in Mississippi,” “The Situation of Racial Health Disparities,” “Unlevel Playing Fields: From Baseball Diamonds to Emergency Rooms,” and “The Physical Pains of Discrimination.”

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