Racial Disparities Found in Children’s ER Access to Medications for Pain

Racial disparities exist in how children are treated for moderate and severe pain.

Several studies have documented racial inequality in pain treatment among hospitalized adults. However, according to findings from a receivent study (JAMA Pediatr Sep 14, 2015. doi:10.1001/​jamapediatrics.​2015.1915, black children are less likely to receive any pain medication for moderate pain or opioids for severe pain.

Using data from the National Hospital Ambulatory Medical Care Survey (www.cdc.gov/​nchs/​ahcd.htm) for 2003 to 2010, the cross-sectional study evaluated patients aged 21 years and younger who were diagnosed with appendicitis. The researchers calculated the frequency of administration of opioids and nonopioid drugs and then performed multivariable regression to examine racial differences.

Disparities in Adult Populations Mirrored in the Young

Of the nearly 1 million children diagnosed with appendicitis during the study period, about 57% received analgesia of some type. After adjusting for pain score and ethnicity, black patients with moderate pain were less likely to receive analgesia than white patients. About 21% of black patients received opioid analgesia, compared with 43% of white patients. Among those with severe pain, about 12% of black patients received opioid analgesia, compared with 34% of white patients.

“People know that these disparities exist in the care of adults, but the fact that they transcend to the care of children is surprising,” said Monika Goyal, MD, the lead author and assistant professor of pediatric and emergency medicine at George Washington University and Children’s National Health System, in Washington, D.C. “Now that we know these disparities exist, it’s time to develop interventions to achieve health equity.”

Dr. Goyal’s team plans to continue the research by documenting racial disparities related to other medical conditions and pain management scenarios. She previously published work in Academic Emergency Medicine (2012;19:604-607) about racial differences in testing for sexually transmitted infections in emergency departments.

“The ultimate goal is to eradicate these disparities and create an equitable health care system for every patient, where race and ethnicity are not factors,” she said. “Before we can do that, we need to understand why these disparities exist.”

A ‘Profound Trend’

Neil Schechter, MD, who directs the Chronic Pain Clinic at Boston Children’s Hospital and is associate professor of anesthesiology at Harvard Medical School, and Eric Fleegler, MD, MPH, a member of the sedation service, Boston Children’s Hospital, and assistant professor of pediatrics at Harvard Medical School, wrote an accompanying editorial about the findings, entitled “Pain and Prejudice” (JAMA Pediatr Sep 14, 2015. doi:10.1001/jamapediatrics.2015.2284 [Epub ahead of print]).

“The numbers leaped out at me from this study,” Dr. Fleegler said. “Early research around this type of pain disparity typically took place within an institution, yet this massive national study shows a pretty profound trend.”

The editorial opened with an historical perspective on the changing philosophies about pain management and how treatment has changed during the past 30 years, often swinging between extremes. Publications about undertreatment of pain appeared in the 1970s, marking a point when analgesia treatment and opioid use for operations, procedures and cancer-related pain became more common. During recent decades, however, fear about addiction and adverse effects created an opiophobia of sorts, even among doctors, Drs. Schechter and Fleegler wrote. Their editorial pinpoints studies that documented racial disparities in pain treatment in the early 1990s and the Institute of Medicine’s 2002 report entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” (www.nap.edu/​catalog/​10260.html).

The editorial concluded with suggestions for how hospitals and emergency departments can guard against racial disparities—mainly, personal awareness of unintentional biases and institutional protocols for analgesia in common procedures such as appendicitis.

“Institutions are typically resistant to change, and there is often a lack of uniformity in the way individual clinicians handle problems. One way to address this is to create protocols that are developed by and agreed on by every department,” Dr. Schechter said. “This process diminishes individual judgments, reduces the possibility of unconscious disparities and allows for an institutional benchmark.”

Combat Bias With Institutional Scrutiny

At Boston Children’s Hospital, Drs. Schechter and Fleegler serve on the Pain Executive Committee, which oversees pain management throughout the institution. The group has examined the pain scores of every child admitted during a two-year period (more than 1 million children) and found that most had little or no pain. Less than 1% had significant pain (score >7, with 10 points being the highest), and the group found that the children fell into three groups: those with chronic pain, sickle cell disease and neuromuscular/developmental disorders. The committee established algorithms and interventions to manage pain in these groups.

Dr. Fleeger also sits on the emergency department’s Pain Free Committee, which pulls together doctors, nurses and child life specialists each month to review emergency department data regarding pain management. They set goals based on institutional and national benchmarks for pain in children. They also look at individual patient charts to determine any trends in provider care or a particular medicine.

“A few years ago, we introduced the use of intranasal opioids for acute pain management. The use quickly increased and then plateaued, so we talked to nurses, doctors, patients and parents about why they decided not to use them as much,” he said. “The key is to gather data to better inform decisions at your institution and to better educate your clinicians and patients.”

In addition, Dr. Fleegler emphasized the importance of knowing why patients sometimes decline pain treatment based on concerns about addiction, overtreatment or historical events regarding race and medical abuse. At the end of the editorial, Dr. Fleeger discussed the concept of patient-centric pain management that asks patients whether they want to receive more medication to control their pain rather than use a traditional numeric pain score that is subjective.

“I often ask people whether they want pain medication, and if they decline, that is OK as long as they understand what they are saying no to,” he said. “We need to make sure they understand what it is we are or are not offering.”

Recent news coverage about racial disparities in several aspects of society—education, housing and law enforcement—make these articles particularly relevant in discussions among the medical community, Dr. Schechter said. Drs. Goyal, Fleegler and Schechter all said they received positive feedback from colleagues about the JAMA Pediatrics articles.

“It is important to recognize that medicine is practiced in a social context and the complicated decisions that we make on a daily basis are influenced by a number of factors, not all of them strictly biological,” Dr. Schechter said. “The findings in the Goyal paper may not have resulted strictly from racism, but it is important to constantly be aware of the influences that impact the care that we provide.”