NR 307A Week 3 Pain Treatment Disparity Analysis Example

"He's Just Here for the Pills": Testing a Belief About Pain Medication Against National Emergency Department Data

Student Name

College of Nursing, Chamberlain University

NR 307A: Advancing Equity, Inclusion, and Diversity in Healthcare

Instructor Name

Month Day, Year

"He's Just Here for the Pills": Testing a Belief About Pain Medication Against National Emergency Department Data

The Claim

On the emergency department where I float two shifts a month, one sentence comes up more often than any other when a patient asks for more pain medicine: "He's just here for the pills." I have heard it said about patients of every background, but when I tried to recall the last ten times, most of them were about Black or Hispanic men in their twenties to forties with back pain or abdominal pain. I do not have a count of those ten times, only my memory, and memory is the kind of evidence this assignment is meant to replace.

Stated as a testable claim, the belief goes something like this: Black and Hispanic patients who come to the emergency department with pain are more likely than white patients to be seeking opioids they do not need, and so they receive, or should receive, opioids less readily. If the first half were true, we would expect to see it in national data as a pattern of higher opioid use or prescribing among these groups. If it is not true, the data should show something else.

What Would Settle It

Before searching, I decided that three kinds of figures would speak to the claim. First, national rates of opioid prescribing at emergency department visits for pain, by race and ethnicity. Second, whether any difference holds for conditions where pain is objectively confirmed, such as a broken bone or a kidney stone, compared with conditions where the clinician depends on the patient's report, such as back pain. Third, a pooled estimate across studies, so that one survey does not decide the question. I limited the sources to national survey data and peer-reviewed studies, since I cannot verify anything from my employer's internal system in a classroom paper.

What the Figures Show

Pletcher et al. (2008) analyzed 13 years of the National Hospital Ambulatory Medical Care Survey, covering pain-related emergency department visits from 1993 to 2005. Across all years, white patients with pain received an opioid at 31% of visits, compared with 23% for Black patients and 24% for Hispanic patients. The gap did not narrow over time; in 2005, the figures were 40% for white patients and 32% for all other patients. The difference was larger for more severe pain and appeared even for long-bone fractures and kidney stones.

Singhal et al. (2016) used the same national survey for 2007 to 2011, focusing on adults aged 18 to 65, and asked the question behind the claim more directly. They compared conditions often associated with drug-seeking, which they listed as toothache, back pain and abdominal pain, with conditions where pain is objectively confirmed, long-bone fractures and kidney stones. After adjustment, Black patients were less likely than white patients to be prescribed an opioid at discharge for back pain and abdominal pain, with adjusted odds ratios between 0.56 and 0.67. They found no significant difference for toothache, fractures or kidney stones.

Lee et al. (2019) pooled 14 studies of acute pain in US emergency departments. Black patients were less likely than white patients to receive any pain medicine for acute pain, with an odds ratio of 0.60. For Hispanic patients the odds ratio was 0.75, but the confidence interval included no difference, so that estimate is less certain.

Table 1

Pain Medication in US Emergency Departments by Race and Ethnicity

Note. ED = emergency department. Figures are taken from the published abstracts and reports of each study. Odds ratios below 1.00 mean the group was less likely than white patients to receive the medication.

The Part That Did Not Match

Not every figure pointed the same way. Guedj et al. (2021) studied 8,347 children with limb fractures at one pediatric emergency department from 2011 to 2015. Black and Hispanic children were less likely than white children to receive an opioid, with adjusted odds ratios of 0.61 and 0.66, but they were more likely to receive some pain medicine of any kind, with adjusted odds ratios of 1.63 and 1.43. In that setting, the difference was not whether pain was treated but how. This complicates a simple story in which minority patients are always undertreated, and it points toward the choice of drug as the place where decisions differ. It does not support the claim either: nothing in it suggests that minority children were seeking medication they did not need.

What the Figures Say About the Claim

The claim assumed that Black and Hispanic patients are more likely to be seeking opioids. The national data do not measure motives, so they cannot prove or disprove what any one patient intends. What they do show is the opposite of what the claim would predict in practice: across two decades of national survey data and a pooled analysis, Black patients, and to a lesser and less certain degree Hispanic patients, received opioids or any pain medicine less often than white patients with similar complaints. Most tellingly, Singhal et al. (2016) found the gap specifically in the conditions where clinicians rely on the patient's report, and not where pain is confirmed by an X-ray or a scan. That is the pattern one would expect if clinicians' judgments about who is believable, rather than patients' behavior, were driving the difference.

Hoffman et al. (2016) offer one explanation for how such judgments form. In a study of white medical students and residents, about half endorsed at least one false belief about biological differences between Black and white people, such as thicker skin, and those who did rated a Black patient's pain as lower and made less accurate treatment recommendations. The claim I started with, "he's just here for the pills," is a judgment about believability made at the bedside, and the figures suggest it is applied unevenly.

From the Patients to the Arrangements

The most important turn in this analysis is that the figures describe what was done to patients, not what the patients are. A lower rate of opioid prescribing for Black patients with back pain is a fact about prescribing, and prescribing is shaped by arrangements: whether pain is reassessed with the same scale for everyone, whether a clinician's note must record the reason when a requested analgesic is withheld, and whether a unit ever reviews its own prescribing by race and ethnicity. None of those arrangements currently exists in a formal way on the unit where I float.

One small change follows from this. The emergency department already requires a pain score at triage and after each intervention. Adding a required field to the pain reassessment, "If requested medication is not given, reason," would give the department a record that could later be reviewed by patient group. It would not prove anyone's intent, but it would make the reasons visible and comparable, which is what the figures above were built from.

Limitations

The national survey data are older than I would like, and the pooled analysis relies on studies of varying quality. Race and ethnicity in these data are recorded by hospital staff, not always by the patients themselves. None of these sources describes my own unit. They can tell me what the claim would have to overcome, not what happens on any particular shift.

References

Guedj, R., Marini, M., Kossowsky, J., Berde, C. B., Kimia, A. A., & Fleegler, E. W. (2021). Racial and ethnic disparities in pain management of children with limb fractures or suspected appendicitis: A retrospective cross-sectional study. Frontiers in Pediatrics, 9, Article 652854. https://doi.org/10.3389/fped.2021.652854

Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296-4301. https://doi.org/10.1073/pnas.1516047113

Lee, P., Le Saux, M., Siegel, R., Goyal, M., Chen, C., Ma, Y., & Meltzer, A. C. (2019). Racial and ethnic disparities in the management of acute pain in US emergency departments: Meta-analysis and systematic review. American Journal of Emergency Medicine, 37(9), 1770-1777. https://doi.org/10.1016/j.ajem.2019.06.014

Pletcher, M. J., Kertesz, S. G., Kohn, M. A., & Gonzales, R. (2008). Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA, 299(1), 70-78. https://doi.org/10.1001/jama.2007.64

Singhal, A., Tien, Y.-Y., & Hsia, R. Y. (2016). Racial-ethnic disparities in opioid prescriptions at emergency department visits for conditions commonly associated with prescription drug abuse. PLOS ONE, 11(8), Article e0159224. https://doi.org/10.1371/journal.pone.0159224