Author: Naveed Saleh, MD, MS
Anesthesiology News
Regardless of race, patients with long bone fractures are prescribed opioids in the emergency department (ED). Opioid dosing, however, is lower for minority patients than it is for white patients.
In research presented at the American Pain Society 2019 Scientific Meeting (abstract 277), investigators analyzed differences in opioid prescribing and morphine milligram equivalent (MME) dosing in adults presenting to the ED with long bone fractures (e.g., radius, humerus and fibula).
In the study, 11,576 patients were identified as having been discharged from the ED between 2016 and 2017 for long bone fractures. These cases were mined from electronic health records representing 23 ED sites in the Sutter Health system in northern California. Furthermore, 336 physicians across the 23 sites were presented with eight versions of a long bone fracture case vignette that varied by race and sex. Respondents were asked about perceived patient pain level, perceived prior use of opioids by the patient, and prescribed medication and dose.
Average total MME units per opioid prescription varied widely by race. Specifically, white patients received 132.3 average total MME units, Hispanic patients received 122.6 average total MME units, black patients received 118.6 average total MME units, and Asian patients received 109.4 average total MME units. Of note, data from the cross-sectional physician surveys supported these findings.
Dr. Romanelli suggests that all races get opioid prescriptions for long bone fracture because of the nature of the injury. “Long bone fractures are definitively painful conditions,” he said. “You can confirm that patients have these injuries with an x-ray, which is not the case for other conditions like back or abdominal pain.” Of note, some studies have shown that minority patients are less likely to receive prescriptions for back pain, abdominal pain and other conditions that are harder to confirm with diagnostic tests and laboratory results.
Dr. Romanelli hypothesizes that the reason why minority patients receive lower opioid doses is likely unintentional. “Physicians may subconsciously believe that minority patients are more likely to misuse or abuse opiates, which may result in—as we observed—lower opioid dosing,” he said. “We can’t know this for sure from our data. Alternatively, minority patients may have just been more likely to report lower levels of pain, requiring lower opioid doses.” Of note, the researchers did not have access to self-reported pain levels by patients, which was a limitation of the study.
Dr. Romanelli doesn’t think that the observed differences in opioid dosing reflect discriminatory practices by the clinicians. “Discrimination is a term I wouldn’t use in this situation,” he said. “We believe prescribers are doing what they think is the best for their patients. We don’t believe that clinicians are intentionally denying patients drugs or intentionally prescribing them lower doses. They may not even know they’re doing it.”
The clinical effects of differences in dosing observed in this study are unknown because of the personalized nature of pain. “For some individuals, small differences in opioid potency may be really important,” Dr. Romanelli said. “Conversely, for other individuals large differences in opioid potency may not make very much of a difference.”
Dr. Romanelli has some ideas on how to combat racial disparities in opioid dosing. “Clinicians should be made aware of potential implicit biases that could influence their prescription practices.” He also suggests that “opioid prescribing could be standardized so default options could be set for injuries such as long bone fracture.”
Mihir M. Kamdar, MD, an associate director of the Division of Palliative Care and interventional pain physician at Massachusetts General Hospital, in Boston, is intrigued by the study findings. “Studies such as this one—exploring differences in opioid prescribing along race and ethnicity—are incredibly important for several reasons,” he said.
“First, this type of research identifies the possibility of inherent biases that lead minority groups to have their pain undertreated, which must be explored by the larger medical community. Simultaneously, groups that receive more opioids may be at greater risk for opioid complications, such as opioid use disorder. Hence, the potential implications of these prescribing differences merit investigation on several important levels.”