Whites Get More Pain Meds Than Minorities, Study Says

Jan. 2, 2008 — -- Julie Posey, a 65-year-old retiree, said her arthritis caused her to live with debilitating, chronic pain for nine years before her primary-care physician prescribed her any pain medication stronger than Tylenol.

Posey, who developed arthritis in 1998, said she suffered with severe arthritis pain for several months until she was diagnosed with breast cancer in 1999.

After her diagnosis, Posey was offered narcotics to treat the pain associated with her cancer. But the narcotics did little to ameliorate the arthritis pain in her lower back, the swelling in her joints and the constant agony of simple activities such as walking.

Posey's breast cancer went into remission in 2004. But what should have been happy news also meant that she would no longer have the narcotics prescribed to her for breast cancer treatment.

Her arthritis pain became excruciating. She was forced to use a cane to walk and had to depend on her friends and family to help her with day-to-day chores.

"I've been seeing my [primary-care physician] every three months for the past nine years, and each time I was there he'd ask me why I'm walking with a cane, and I'd tell him it's because of the pain in my back, that the arthritis pain kept getting worse and Tylenol and physical therapy didn't help me," she said.

"But he wouldn't change my medication. I'd talk to other arthritis patients who were taking opioids, but all I could get was Tylenol, and I knew there had to be something better."

A number of factors may have contributed to Posey's doctor's decision not to prescribe her a more powerful painkiller. But a growing body of evidence suggests that one of the reasons she may not have received proper pain treatment is because Posey is black.

And the latest addition to this body of research shows that these discrepancies in care may be present not only in the family physician's office, but also in the emergency department.

A study released Tuesday reveals racial and ethnic minorities may be less likely to receive pain medication by emergency department doctors than white patients, despite the fact that opioid prescribing for patients making pain-related visits to the emergency department increased over the past 15 years.

Researchers at the University of California, San Francisco, analyzed data from 1993 to 2005 gathered through the National Hospital Ambulatory Medical Care Survey (NHAMCS) of U.S. emergency department visits.

After reviewing nearly 400,000 pain-related visits to emergency departments across the country, they found that emergency department physicians prescribed opioids — a class of pain drugs that have morphinelike effects — to 37 percent of patients in 2005, compared with 23 percent of patients in 1993.

But the researchers also found that striking disparities still exist in the quality of pain management between white and nonwhite patients, despite national initiatives to improve and standardize pain-related care.

"The good news is this study shows that opioid-prescribing rates increased over the past decade, and that appears to be partially in response to national quality improvement programs to improve pain treatment in U.S.," said lead study investigator Dr. Mark Pletcher, assistant adjunct professor of epidemiology and biostatistics at the University of California, San Francisco.

"But there appears to be this persistent gap in prescribing [of opioids] for whites and nonwhites, and the disparity is just as large now as it was a decade ago; it didn't shrink with the increase in prescribing opioids."

Specifically, over the 13-year survey period, the likelihood that a white patient complaining of pain would receive the pain medications from an emergency room doctors was 31 percent, while black and Hispanic patients only received the drugs 23 percent and 24 percent of the time, respectively.

In 2005, opioid-prescribing rates in the emergency department were 40 percent for white patients and 32 percent for all other patients.

Pam Kedziera, clinical director of the Pain and Palliative Care Center at Fox Chase Cancer Center in Philadelphia, Pa., says the findings underscore an inherent prejudice within the medical system.

"Nonwhites going to an ER are often labeled as drug seekers and their pain is ignored," Kedziera said. "Unfortunately, all nonwhites — even the affluent, educated, employed group— have reported that they are viewed differently than white [patients]."

"There is a bias in our health system to be more concerned with potential diversion problems than to be concerned about good pain management."

Although a standardized pain assessment tool is used by physicians in determining which patients should be prescribed pain medication, much of the pain-management decision-making remains subjective and therefore vulnerable to the influence of racial bias.

According to Ferdinando Mirarchi, medical director and director of operations of the department of emergency medicine at Hamot Medical Center in Erie, Pa., each patient visiting the emergency department with a complaint of pain is asked to rate their pain on a scale from zero to 10, with 10 being the worst pain.