Racial Gap in ER Opioid Use Still Persists

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As reported in the Journal of the American Medical Association for January 2, Dr. Mark J. Pletcher, from the University of California in San Francisco, and colleagues analyzed data from the National Hospital Ambulatory Medical Care Survey (1993-2005) to assess opioid-prescribing patterns for pain-related visits to ERs in the US.

Forty-two percent of the 374,891 ER visits examined were pain-related, the report indicates. During the study period, opioid use for such visits rose from 23 percent in 1993 to 37 percent in 2005.

Over all years, 31 percent of white patients with pain received an opioid compared with 23 percent of black, 24 percent of Hispanic, and 28 percent of Asian/other patients. In 2005, a racial gap was still apparent: 40 percent of whites with pain received these agents compared with only 32 percent of all other patients.

The racial gap identified was present for all types of pain studied and increased with pain severity. Even for the most severe types of pain, such as long-bone fractures, whites continued to receive opioids more often than patients of other racial groups.

The racial differences were also apparent in pediatric patients.

The investigators acknowledge that it is conceivable that the disparity represents overprescribing to white patients, but they think it a more plausible explanation is true undertreatment of pain in minority patients. This may not be a result of physician bias but could reflect expectations and assertiveness of the patients.

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[Editor’s Note: The full text of “Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments,” by Mark J. Pletcher, MD, MPH; Stefan G. Kertesz, MD, MSc; Michael A. Kohn, MD, MPP; Ralph Gonzales, MD, MSPH, as an HTML textcan be read here. or read or downloaded as a PDF here. A subscription is required. The abstract appears below.]

Context National quality improvement initiatives implemented in the late 1990s were followed by substantial increases in opioid prescribing in the United States, but it is unknown whether opioid prescribing for treatment of pain in the emergency department has increased and whether differences in opioid prescribing by race/ethnicity have decreased.

Objectives To determine whether opioid prescribing in emergency departments has increased, whether non-Hispanic white patients are more likely to receive an opioid than other racial/ethnic groups, and whether differential prescribing by race/ethnicity has diminished since 2000.

Design and Setting Pain-related visits to US emergency departments were identified using reason-for-visit and physician diagnosis codes from 13 years (1993-2005) of the National Hospital Ambulatory Medical Care Survey.

Main Outcome Measure Prescription of an opioid analgesic.

Results Pain-related visits accounted for 156 729 of 374 891 (42%) emergency department visits. Opioid prescribing for pain-related visits increased from 23% (95% confidence interval [CI], 21%-24%) in 1993 to 37% (95% CI, 34%-39%) in 2005 (P < .001 for trend), and this trend was more pronounced in 2001-2005 (P = .02). Over all years, white patients with pain were more likely to receive an opioid (31%) than black (23%), Hispanic (24%), or Asian/other patients (28%) (P < .001 for trend), and differences did not diminish over time (P = .44), with opioid prescribing rates of 40% for white patients and 32% for all other patients in 2005. Differential prescribing by race/ethnicity was evident for all types of pain visits, was more pronounced with increasing pain severity, and was detectable for long-bone fracture and nephrolithiasis as well as among children. Statistical adjustment for pain severity and other factors did not substantially attenuate these differences, with white patients remaining significantly more likely to receive an opioid prescription than black patients (adjusted odds ratio, 0.66; 95% CI, 0.62-0.70), Hispanic patients (0.67; 95% CI, 0.63-0.72), and Asian/other patients (0.79; 95% CI, 0.67-0.93). Conclusion Opioid prescribing for patients making a pain-related visit to the emergency department increased after national quality improvement initiatives in the late 1990s, but differences in opioid prescribing by race/ethnicity have not diminished.

Author Affiliations: Department of Epidemiology and Biostatistics (Drs Pletcher and Kohn) and Division of General Internal Medicine, Department of Medicine (Drs Pletcher and Gonzales), University of California, San Francisco; Division of Preventive Medicine, University of Alabama at Birmingham (Dr Kertesz); Deep South Center on Effectiveness, Veterans Affairs Medical Center, Birmingham, Alabama (Dr Kertesz); and Emergency Department, Mills-Peninsula Medical Center, Burlingame, California (Dr Kohn).