New Study Reveals: Minorities Less Likely to Receive Narcotics for Pain in the ER

Posted by Pam Spaulding, Pandagon at 2:05 PM on January 2, 2008.

A few of you wrote me about the results of this study funded by the U.S. Department of Health and Human Services on the disparity in the pain management in the ER based on ethnicity. It's appalling.

The study, which analyzed treatments for more than 150,000 pain-related visits to U.S. hospitals between 1993 and 2005, found 23 percent of blacks and 24 percent of Hispanics received opioids compared with 31 percent of whites. Twenty-eight percent of Asians and other groups received opioids.

- Differences in prescribing between whites and non-whites were greater among people with the worst pain. Among patients in severe pain, opioids were prescribed to 52 percent of whites, 42 percent of Hispanics and 39 percent of blacks.

- Blacks were prescribed opioids at lower rates than other groups for almost every type of pain-related emergency department visit, including back pain (33 percent for blacks versus 48 percent for whites), headache (22 percent versus 35 percent) and abdominal pain (20 percent versus 32 percent).

- Opioids were prescribed less often for blacks than whites for kidney stones (56 percent to 72 percent) and long bone fractures (45 percent to 52 percent).

- Non-opioid pain relievers, such as acetaminophen (sold as Tylenol), were prescribed more for non-whites (36 percent) than whites (26 percent).

This study is particularly timely since I've 1) been to the ER recently and 2) had gall bladder surgery last week. Both resulted in my receiving morphine while inpatient and pain-relieving opioid drugs for use at home. While I can't say that I experienced biased care and withholding of these medications because of my race, I have no doubt that implicit bias plays a role in denial of adequate medical pain management in many cases. I was simply fortunate.

I highly recommend Blender JulieWaters' diary on this, Medical care and racism: this is your war on drugs, which I noticed while working on this post. It gets to the heart of the third rail discussions that you all simply love to comment about -- not.

This is about having a discussion about the spectrum of racism and bias, not accusing people of running around in a Klan Night Rider hood. People often head straight for the defensive zone there to make sure everyone knows they aren't "racist," when in fact this study proves that implicit bias has direct impact on minority health and well being. It's there, and it's dangerous.

When talking about racism, it's easy to reduce it to the simplistic: to assume that everyone's racist to some degree and that while whites can act racist towards blacks, sometimes blacks are racist against whites as well. So let's get that out of the way first, by distinguishing between "small r" racism, which is personal racism: "I don't think I'd ever want to date a black man." "I lock my doors in that neighborhood." While problematic, occasional personal individual racism is not nearly as damaging as large-scale ("big R") institutional Racism, which is just intensely dangerous and is implemented nearly universally to the detriment of non-whites.

And it's not a matter of whites shouldering all the blame for holding those biases. See after the jump.

That doesn't leave anyone off the hook for providing inadequate health care, but this is a perfect example of misguided, misinformed attitudes affecting the health and welfare of individuals in dire pain based on preconceived notions about their ethnicity. This is a call for all of us to be honest about implicit bias.

"It's time to move past describing disparities and work on narrowing them," said Dr. Thomas L. Fisher, an emergency room doctor at the University of Chicago Medical Center who was not involved in the study. Fisher, who is black, said he is not immune to letting subconscious assumptions inappropriately influence his work as a doctor. "If anybody argues they have no social biases that sway clinical practice, they have not been thoughtful about the issue or they're not being honest with themselves," he said.

The study doesn't go into motivation for withholding adequate pain management, but one can assume some doctors believe blacks are more prone to abuse opioids, even though this flies in the face of the facts -- blacks are the groupleast likely to abuse them.

While it's possible some doctors and nurses are doing this consciously, most do so because of the biases they hold based on the legacy of racism that permeates our culture. These medical professionals simply don't even think about whether they care for one group of patients differently than another. That doesn't make them evil, it merely means better ways to make health care providers more self-aware and diligent in doling out medical services based on the ailment, not the recipient's skin tone.

If you've ever been to the ER with kidney stones or a gall bladder attack, being denied adequate medication based on the biases of a health care provider is a sad commentary on our culture. Tossing someone non-opioid pain relievers on their way out of the ER, such as acetaminophen, simply won't cut it for either of the above woes.

I'm sure that differences in patient self-advocacy for requesting pain medication, also noted in the study press release, has some impact. It would be interesting to see statistics on how often minorities request additional pain medication or are aware that they should declare pain levels to the health care provider. I know I am always asked to rate my pain on a scale of 1-10. As I noted in an earlier post, my "10" is kidney stone pain, so I have a frame of reference.

If you want to examine your own implicit biases on race, gender, orientation, and all sorts of matters (and maybe you don't want to stomach it), you can try several out at Harvard's Project Implicit.

Tagged as: race, racism, narcotics, health industry, medical care

Pam Spaulding blogs at Pam's House Blend.