Racial-Ethnic Disparities in Opioid Prescribing During ED Visits for Pain

There are significant racial-ethnic disparities regarding how opioids are prescribed for pain relief in the emergency department (ED), with non-Hispanic blacks being less likely to receive opioid prescription at discharge during ED visits for back pain and abdominal pain—but not for toothache, fractures, and kidney stones—compared with non-Hispanic whites. The findings, by Astha Singhal, DMD, PhD, of the Boston University School of Dental Medicine, and colleagues, were published in PLOS ONE.

Although inadequately treated pain in the ED is a major national concern, the abuse of prescription opioids is the fastest-growing drug problem in the nation, and has overtaken use of cocaine and heroin combined as a cause of death. In an attempt to confront opioid abuse and reduce prescribing of opioids to drug abusers, guidelines have been developed for physicians to determine whether a patient is a drug abuser. But it is often impossible for physicians, especially those in the ED, to definitively make the judgment as to whether a patient is a drug abuser when they come to the ED with pain-related complaints.

Thus ED physicians must rely on cues, possibly without being conscious of them, to quickly determine whether or not to prescribe opioids. Singhal and colleagues hypothesized that there was differential prescribing of opioids by race-ethnicity, which could lead to a widening of existing health disparities and may have implications for the disproportionate burden of opioid abuse among whites.

Unlike previous studies, this one differentiates between whether opioids were administered in the ED or prescribed at discharge. The distinction was used by the researchers to further elucidate the role of race and ethnicity for 2 reasons: 1) nonwhite race is one of the largest predictors of provider mistrust, and prescribing opioids at discharge requires a high level of provider-patient trust; and 2) while prescribing opioids contributes to the prescription opioid epidemic, one-time administration of opioid in the ED does so minimally.

The study categorized patients into non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other categories. The investigators also categorized patients by pain severity and patients’ condition into non-definitive (such as back pain or abdominal pain, which typically have no visible clinical or diagnostic presentations) and definitive (pain-related conditions such as long-bone fracture and kidney stones that have objective clinical presentations and can be confirmed with simple diagnostic tools). The latter distinction was created to see if racial-ethnic disparities would be present in opioid prescribing for non-definitive conditions that have been associated with drug-seeking behavior, but not for definitive conditions.

Investigators used 2007-2011 data from the National Hospital Ambulatory Medical Care Survey, which is based on a national sample of visits to the ED, outpatient departments, and ambulatory surgical centers that is made available by the CDC. The study analyzed all ED visits made by adults aged 18 to 65 years. After adjusting for other covariates, the investigators found that non-Hispanic black patients were less likely to receive opioid prescriptions at ED discharge during visits for back pain and abdominal pain, but not for toothache, fractures, and kidney stones, compared with non-Hispanic whites.

“Our study shows that there are significant racial-ethnic disparities in opioid prescription and administration in ED visits for non-definitive conditions,” they concluded. “These disparities may reflect inherent biases that health care providers hold unknowingly, leading to differential treatment of patients based on their race.”

The authors say their findings have important implications for medical provider education, suggesting that sensitization exercises be included to enable them to consciously avoid these biases from defining their practice behavior.