Racial Disparities in Acute Pain Management Not Linked to Treatment Preference

Zachary F. Meisel, MD

Efforts to standardize opioid prescribing have shown Black patients are less likely than White patients to receive opioid medication for acute pain treated in the emergency department (ED).

Despite the racial disparities in pain management, questions remain on the factors associated with the disparities, with some experts theorizing statistical discrimination where clinicians make choices based on generalizations about a group, rather than a patient.

Investigators, led by Zachary F. Meisel, MD, MPH, Perelman School of Medicine, University of Pennsylvania, observed the disparities in acute pain management in black patients compared to white patients remained after clinicians were given additional patient-level data, which suggested a lack of patient information is not associated with disparities in opioid prescribing.

Study

The study addressed gaps in pain management through an examination of racial disparities in opioid prescribing through a secondary analysis of data from the Life Stories for Opioid Risk Reduction in the ED (Life STORRIED) randomized clinical trial.

Patients were enrolled between June 2017 - August 2019.

The team noted inclusion criteria compromise of presentation to the ED for uncomplicated ureteric colic or musculoskeletal back and/or neck pain, aged 18 - 70 years, and clinician intention to discharge patients ≥24 hours after enrollment.

Following randomization, patients were asked to complete a series of surveys including a demographic survey, pain management preference survey, and the Opioid Risk Tool (ORT) to assess risk of opioid misuse.

ORT has a score range of 0 - 26, with 0 -3 showing low risk, 4 - 7 moderate risk and ≥ 8 indicating high risk.

Investigators assessed the risk of opioid misuse using the ORT and collected self-report patient demographic data using a survey administered during the ED visit.

Main outcomes included a patient receipt of an opioid prescription at discharge from ED and concordance between patient preference for opioid-containing treatment and received treatment.

They defined concordant treatment if a participant who preferred opioids received a prescription at discharge or if a patient who did not prefer opioid did not receive a prescription at discharge.

Results

A total of 1302 participants were enrolled in the Life STORRIED clinical trial, with a total of 1012 patients having complete data on demographic characteristics and treatment preferences in the secondary analysis.

Of the total, 671 patients (66.3%) were assigned to the treatment arm, while 341 patients (33.7%) were assigned to the control arm.

Demographics showed 563 patients (55.6%) self-identified as female, with a mean age of 40.8 years. Further, a total of 455 patients (45.0%) identified as White, while 384 patients (37.9%) identified as Black.

Data show 377 patients (37.3%) had preference for opioids at ED discharge, 238 patients (23.6%) received a prescription for opioids at ED discharge, and 659 patients (65.2%) received treatment concordant with preference.

Investigators observed white patients were more likely to receive a prescription for opioids at ED discharge compared with Black patients (33.7% versus 12.2%, P <.001).

In addition, after controlling for demographic and clinical features, black patients had lower odds compared to White patients of receiving prescription for opioid medication at ED discharge (OR 0.42; 95% CI, 0.27 - 0.65).

The team noted when considering patients who preferred and did not prefer opioids, Black patients still had lower odds of discharge with prescription for opioids compared with White patients.

Data show this among those who preferred opioids (OR, 0.43; 95% CI, 0.24 - 0.77) and among those who did not prefer opioids (OR, 0.45; 95% CI, 0.23 - 0.89).

Conclusion

“These disparities were not eliminated by assessing and providing clinicians with patients’ treatment preferences and risk of opioid misuse,” investigators wrote. “Future research is warranted to further examine alternative factors associated with prescribing disparities.

The study, “Patient Preference and Risk Assessment in Opioid Prescribing Disparities A Secondary Analysis of a Randomized Clinical Trial,” was published online in JAMA Network Open.