Study: Whites more likely to get narcotics in ER

[ttac]

http://www.cnn.com/2008/HEALTH/01/01/painkillers.race.ap/index.html

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[Hard24Get]

This study does not surprise me. This is one of those studies that shows that hegemony is alive and well. It is hard to let go of these deeply ingrained stereotypes. As it turns out, about the same percentage of blacks and whites abuse drugs according to the NIH (go to page 29 of the minority pdf). http://www.nida.nih.gov/infofacts/treatmenttrends.html. Even I was surprised by this fact and I'm black. It will take some hard work to change this way of thinking.


Also, I haven't read the study yet, but I hope it excluded proven drug addicts and repeat flyers.

 

[EM2BE]

I also wonder what kind of pain complaints they used in the study. If they were all abd pain, 5/10 or if they were all different kinds and different levels of pain.

 

[EctopicFetus]

yawn.. perhaps they should look at which "races" abuse more drugs and then we can see if this makes a difference.

I mean thats fine.. I dont doubt that this is the truth but maybe whites are better at scamming or other reasons. ehh im not excited about this.

 

[pseudoknot]

yawn.. perhaps they should look at which "races" abuse more drugs and then we can see if this makes a difference.

I mean thats fine.. I dont doubt that this is the truth but maybe whites are better at scamming or other reasons. ehh im not excited about this.

Apparently white people are most likely to abuse prescription (not street) drugs:
http://www.ajph.org/cgi/content/full/94/2/266
They also found that "Past-year illicit drug use reduced the odds of problem use of all 3 classes." Makes some sense...

 

[southerndoc]

Apparently white people are most likely to abuse prescription (not street) drugs:
http://www.ajph.org/cgi/content/full/94/2/266
They also found that "Past-year illicit drug use reduced the odds of problem use of all 3 classes." Makes some sense...

Yep, which is why they're more likely to get scripts for narcotics. If physicians would quit being candy factories for the drug seekers, we might not have this problem.

 

[docB]

Yep, which is why they're more likely to get scripts for narcotics. If physicians would quit being candy factories for the drug seekers, we might not have this problem.

A lot of that has to do with the JCAHO "pain is the 5th vital sign" stupidity.

 

[CueDoc]

I would rather give 10 drug seekers 20mg of dilaudid in the ED and a script for oxycontin than undertreat 1 person with legitimate pain. I dont understand doctors that make it a personal vendetta against people who come in with questionable pain. We have all heard someone say "There's no f-ing way he;s gonna get any percocet out of me." I think you have to pick your battles and not make things personal. Pain cannot be measured objectively. Tachycardia/ elevated BP is a marginal at best indicator for a pts. pain level. Dont get me wrong, it is a little irritating when the sickler comes in eating a big mac, listening to his I-pod, plugs his phone charger into the wall outlet and then tells you that rather that getting his normal 8mg of dilaudid q1h he would rather have 4mg q30 minutes and then once he is gorked the only words he can muster is "10/10". But this is the world we live in and its a battle you can't win, fight the ones you can. Besides, I can GUARANTEE that at least once in all of our careers we have written someone off as a drug seeker and given them 600mg of Motrin who actually had legitimate pain.

 

[RxnMan]

Here's another perspective on the study.

 

[GeneralVeers]

I only withhold narcotics if two criteria are met:

1. The "pain" is obviously not something severe (i.e. paper cut, bruise on leg).

2. They are obviously drug seeking, i.e. have multiple ED visits for the same complaint, and specifically ask for certain meds by name.

 

[spyderdoc]

I would rather give 10 drug seekers 20mg of dilaudid in the ED and a script for oxycontin than undertreat 1 person with legitimate pain. I dont understand doctors that make it a personal vendetta against people who come in with questionable pain. We have all heard someone say "There's no f-ing way he;s gonna get any percocet out of me." I think you have to pick your battles and not make things personal. Pain cannot be measured objectively. Tachycardia/ elevated BP is a marginal at best indicator for a pts. pain level. Dont get me wrong, it is a little irritating when the sickler comes in eating a big mac, listening to his I-pod, plugs his phone charger into the wall outlet and then tells you that rather that getting his normal 8mg of dilaudid q1h he would rather have 4mg q30 minutes and then once he is gorked the only words he can muster is "10/10". But this is the world we live in and its a battle you can't win, fight the ones you can. Besides, I can GUARANTEE that at least once in all of our careers we have written someone off as a drug seeker and given them 600mg of Motrin who actually had legitimate pain.

I really do appericiate you doing this so that you can get all the drug seekers coming to see you, the candy man, instead of me....Our frequent fliers call ahead, sometimes pretending to be another doctor, to see who is on. If they hear that I or a couple of my colleagues are on, they will not come in during our shift...So really, thanks...

Don't get me wrong. I do treat pain and give people the benefit of the doubt if it is their 1st or 2nd visit, or if there are new complaints....But I think with time, you get a good feel for those that are drug seekers....

 

[EctopicFetus]

So as not to be deemed "racist" I will give narcs to every other patient I see. Yep.. thats it regardless of complaint.

 

[CueDoc]

Spyder
Glad I could help. Out of curiosity, how do you deal with sickler that I mentioned in my earlier post?

 

[southerndoc]

I really do appericiate you doing this so that you can get all the drug seekers coming to see you, the candy man, instead of me....Our frequent fliers call ahead, sometimes pretending to be another doctor, to see who is on. If they hear that I or a couple of my colleagues are on, they will not come in during our shift...So really, thanks...

Don't get me wrong. I do treat pain and give people the benefit of the doubt if it is their 1st or 2nd visit, or if there are new complaints....But I think with time, you get a good feel for those that are drug seekers....

Yea, Johnny Five who has presented every Friday night at 1 am for the past 2 months because he has a toothache due to his caries and poor dentition isn't getting any narcs out of me. Sorry. You get some local anesthestic, and if they're truly in pain, they will be praising you for the temporary relief.

If it's a first-time visit, I may write a script for a narc. If they're a repeat visitor; if their allergy list includes Toradol, Motrin, Tylenol, and Lidocaine; if their primary care physician is one of the known drug factories in town; or if they start prompting me with "doc, the only thing that works is that stuff that starts with an 'O'. what is it? ox, oxy something?" then chances are, they're leaving the ED without a script for any narcs.

You feed a bear and he'll hang around forever.

 

[southerndoc]

Spyder
Glad I could help. Out of curiosity, how do you deal with sickler that I mentioned in my earlier post?

We have an interesting hospital policy now: sicklers get one dose of narcs (their usual dose), and if they need a second dose, we have to call the on-call hematology fellow. The third dose requires hospital admission. No narcotic prescriptions for sicklers can be written from the emergency department until the person has spoken with the hematology fellow. We are only allowed to write enough narcotics for the sickler to get to the hematology clinic the following day they are open (obviously if they get a script on Friday it's for more narcs than on a Wednesday night).

This has had mixed results, including some sicklers balking at the idea of calling hematology with the second med administration because they claim the nurse didn't push their Dilaudid fast enough to relieve their pain, or they didn't combine it with the usual 50 mg Benadryl and 25 mg Phenergan when they gave their 8 mg of Dilaudid.

Don't get me wrong. I do aggressively treat sicklers' and anyone else's pain. I write pain meds quickly, and I dispense liberally when discharging patients with conditions that require them (broken ribs, wrist fractures, or anything else that is painful). However, I do listen to my inner sense that might scream "hey, this guy chewing on the cheeseburger can't be suffering too much pain from his toothache." If in doubt, I prescribe them.

 

[shortbread9]

GeneralVeers, i agree with you.

If a patient seems to be in severe pain i have no problem giving narcs or sending them home on something PO.
I also agree you can't subjectively measure someones pain but you wont always find a drug seeker in your system...if they are a first timer to your ER. I think the best way is to watch them throughout their stay...if im not quite convinced they are in severe pain..ill start with tylenol/motrin
There are so many times patients say they are dying with 12 out of 10 abdominal pain but the minute they lay down in bed they are out like a light for hours and when you try to wake them out of their rem sleep they mumble how horrible they feel...then pull the sheet back over their heads....clearly this is not real pain...but you see it a lot in inner cities.

Some patients appear legitimate but you will never always be able to tell with 100% certainty..so i agree that you may just have to give narcs b/c its better to over than undertreat...and you certainly dont send patients home with a script for 50 pills...just enough for a fews days so they can follow up outpatient (regardless if they do or not)

 

[Faze2]

Here's another perspective on the study.

I have to agree with the doctor who wrote this article. There are entirely too many factors that should be taken into account that were completely ignored. For example, in the ER where I work, our patients are predominantly black and hispannic, and as you can imagine they come to the ER for anything and everything. Most, not all, but most of the white population that live in this area know not to come to the ER unless it is absolutely necessary, otherwise, they will have a nice little 6 hour wait ahead of them. So, at least in this ER, a higher percentage of white patients that come in for pain are more likely to truely be in excruciating pain than the non-white patients. It does not change the work up we do on either patient, but at the end of that work up the white patients we see are more likely to be in need of some sort of narcotic to help ease their pain. But according to the article, if we see 100 black patients and give 20 of them narcotics (20%) and we see 20 white patients and give 6 of them narcotics (30%), we are basing this decision on race? Give me a break.

 

[Painter1]

There are entirely too many factors that should be taken into account that were completely ignored. For example, in the ER where I work, our patients are predominantly black and hispannic, and as you can imagine they come to the ER for anything and everything. Most, not all, but most of the white population that live in this area know not to come to the ER unless it is absolutely necessary, otherwise, they will have a nice little 6 hour wait ahead of them. .

two separate studies were done which looked exclusively at patients coming in with fractures which found that both Blacks and Hispanics were signficantly less likely to get pain medication.

what's your explanation now?

 

[roja]

That one isnt capable of thinking critical, looking at data and drawing appropriate inferences from it?

Quite simply, a FRACTURE does not equate with pain level. Some people have excrutiating pain with a sprain. Another with a fracture will have minimal pain. That is why, when you look at pain data as a whole, it is impossible to make any real inferences because pain is SUBJECTIVE. And the point being made is that PAIN MANAGEMENT is not synonymous with opiods. (ie Migraines: severe headaches respond well to varying combos of reglan, toradol, IVF, plus/minus benadryl. severe back spasm often does well with NSAID and valium).


So, the point is the same. Just because blacks and hispanics might have gotten less narcotics might not be because thier pain was not managed appropriately. maybe the whites were just wimpy. or complained more. If you truly want to assess pain management and prescribing practices, you must look at pain scale datas, offers of pain meds, refusals, reasons for refusals, etc. You must take into account MUCH more than prescriptions given. It is what is called a proxy measure and an incredibly poor one at that. (http://en.wikipedia.org/wiki/Proxy_%28statistics))

 

[paramed2premed]

Table 2.
4348 people had long bone fractures.
2215 people had kidney stones.

Do the critics mean to suggest that there was such significant heterogeneity (in terms of the actual pain/suffering/nociception) between the white and the non-white groups such that a comparison is invalid?

Both these diagnosis are pretty objective, so a few of the arguments about blacks and hispanics flooding the ED with BS complaints should not be germane. Whether such arguments are legitimate I leave for others to banter about.

 

[mfrederi]

There are all sorts of reasons why these statistics come out looking like this, some PC and some not very PC. Demographic wise, blacks are much more likely to go to the inner city ED where the docs are jaded and suspicious and don't have as much time per patient to check on them every 30 minutes and make sure their dilaudid is working. And, in those same inner city EDs where are larger number of blacks are seen there is a much higher percentage of your fake pain drug seeker, also frequently black (though of course we've all seen the 35 year old white guy with back pain). As far as hispanic patients go (again in my limited experience) they don't complain too much. Just yesterday I saw a migrant worker with an open ankle, gave him 1 of Dilaudid right off the bat, and when I asked him how he felt he smiled and said "I OK main." They are just really freaking tough and they don't know English so often don't feel comfortable and / or don't want to waste their effort trying to communicate with non-spanish speakers. If I was in Japan and couldn't speak a lick of Japanese, I would probably tolerate a little more pain to not go through all the mess of trying to talk to an RN that couldn't understand anything I said.

We also have to realize that their is some bias / stereotype present in ED docs, who honestly get tired of bogus painers and don't want to reinforce their habit. However, at least with me that bias has more to do with the way a patient presents themselves to me (their appearance {relaxed vs peritoneal}, their speech {respectful vs "give me some freaking Dilaudid doc!"}, and their previous visits). Is this right? Don't know. But it doesn't have a whole lot to do with race.

 

[Tone2002]

There are all sorts of reasons why these statistics come out looking like this, some PC and some not very PC. Demographic wise, blacks are much more likely to go to the inner city ED where the docs are jaded and suspicious and don't have as much time per patient to check on them every 30 minutes and make sure their dilaudid is working. And, in those same inner city EDs where are larger number of blacks are seen there is a much higher percentage of your fake pain drug seeker, also frequently black (though of course we've all seen the 35 year old white guy with back pain). As far as hispanic patients go (again in my limited experience) they don't complain too much. Just yesterday I saw a migrant worker with an open ankle, gave him 1 of Dilaudid right off the bat, and when I asked him how he felt he smiled and said "I OK main." They are just really freaking tough and they don't know English so often don't feel comfortable and / or don't want to waste their effort trying to communicate with non-spanish speakers. If I was in Japan and couldn't speak a lick of Japanese, I would probably tolerate a little more pain to not go through all the mess of trying to talk to an RN that couldn't understand anything I said.

We also have to realize that their is some bias / stereotype present in ED docs, who honestly get tired of bogus painers and don't want to reinforce their habit. However, at least with me that bias has more to do with the way a patient presents themselves to me (their appearance {relaxed vs peritoneal}, their speech {respectful vs "give me some freaking Dilaudid doc!"}, and their previous visits). Is this right? Don't know. But it doesn't have a whole lot to do with race.

But yet you have a post full of racial stereotypes. Go figure.

 

[GeneralVeers]

So what do these studies want me to do in practice?

Am I expected to change how I give narcotics based on race?

"Well, that guy is obviously drug seeking, but he's Black so I'll give him Dilaudid anyway".

 

[pseudoknot]

I think the idea is to try to come up with protocols such that narcotics are NOT being given by race, in contrast to what seems to happening today.

I think it's fairly well established that most people of all races have some degree of subconscious racial bias. It's hard for me to believe that the studies mentioned in previous posts aren't a subtle result of that.

 

[totalbodypain]

I think the idea is to try to come up with protocols such that narcotics are NOT being given by race, in contrast to what seems to happening today.

I think it's fairly well established that most people of all races have some degree of subconscious racial bias. It's hard for me to believe that the studies mentioned in previous posts aren't a subtle result of that.

I have a problem with protocols in medicine. It seems that as soon as you institute a protocol, you start coming across ways that the protocol falls apart. Peoples perceptions of pain don't fall into nice neat orderly classifications so why would we try to force them to fit into a "protocol". The minute one is instituted we will all start looking for a way around it. Why bother?

 

[GeneralVeers]

I think the idea is to try to come up with protocols such that narcotics are NOT being given by race, in contrast to what seems to happening today.

I think it's fairly well established that most people of all races have some degree of subconscious racial bias. It's hard for me to believe that the studies mentioned in previous posts aren't a subtle result of that.

This is not something for which you can develop a protocol. It's not based on objective data and outcomes, like for example giving beta-blockers to acute MI patients. Pain is completely subjective (hence the uselessness of the pain scale), and likewise the response to pain medication is completely subjective and individual. To think that a protocol would address any of the perceived racial issues is to delude oneself.

 

[pseudoknot]

This is not something for which you can develop a protocol. It's not based on objective data and outcomes, like for example giving beta-blockers to acute MI patients. Pain is completely subjective (hence the uselessness of the pain scale), and likewise the response to pain medication is completely subjective and individual. To think that a protocol would address any of the perceived racial issues is to delude oneself.

I agree the above are valid points. I also think that this is both a possibly valid issue and one that cannot easily be address on an individual level. Therefore it seems like some level of systematic change would be necessary to address it. But of course the first step would be for people in the field to believe that there is a problem, which doesn't seem to be happening.

A question then: assuming one rejects the studies above, and that clearly pain is difficult to study given its subjectivity, what sort of evidence might really show that race makes a difference in narcotic prescribing?

 

[Painter1]

So what do these studies want me to do in practice?

Am I expected to change how I give narcotics based on race?

"Well, that guy is obviously drug seeking, but he's Black so I'll give him Dilaudid anyway".

You just demonstrated to us why these studies are important. It's to help you stop associating black patients who say they are in pain with drug-seeking.

 

[Painter1]

Quite simply, a FRACTURE does not equate with pain level. Some people have excrutiating pain with a sprain. Another with a fracture will have minimal pain. (http://en.wikipedia.org/wiki/Proxy_(statistics))

still, how do you explain why blacks and hispanics are significantly less likley to get pain medication in acute fractures?

language barrier? blacks speak English though. black people's nocieptive physiology is significantly different and they experience minimal pain when they break a bone?

i agree, u have to be critical of studies, but maybe, just maybe--there is an unconscious bias by providers out there?

 

[GeneralVeers]

You just demonstrated to us why these studies are important. It's to help you stop associating black patients who say they are in pain with drug-seeking.

It must be loose-association day for you. I used that example to illustrate the pointlessness of the study. I never stated that I thought any one specific group was all drug seekers. I've seen seekers in every racial category. My point was that I'm not going to change the way I practice just to correct perceived social injustice.

 

[BADMD]

two separate studies were done which looked exclusively at patients coming in with fractures which found that both Blacks and Hispanics were signficantly less likely to get pain medication.

what's your explanation now?

Provide citations please. The methodology behind these studies are critical.

 

[dhb]

still, how do you explain why blacks and hispanics are significantly less likley to get pain medication in acute fractures?

language barrier? blacks speak English though. black people's nocieptive physiology is significantly different and they experience minimal pain when they break a bone?

i agree, u have to be critical of studies, but maybe, just maybe--there is an unconscious bias by providers out there?

Fractures don't hurt when they're not mobilized, opiates are notoriously bad at controlling pain due to mobilization. I've never seen morphine given to patients with non complicated closed fractures...

 

[pseudoknot]

Provide citations please. The methodology behind these studies are critical.

I don't know if these are the studies alluded to by Painter1 but they were referenced in the JAMA paper:

Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(12):1537-1539. link
"Hispanics with isolated long-bone fractures are twice as likely as non-Hispanic whites to receive no pain medication in the UCLA Emergency Medicine Center."

Todd KH, Deaton C, D'Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11-16. link
"Black patients with isolated long-bone fractures were less likely than white patients to receive analgesics in this ED."

Also of interest:
Tamayo-Sarver JH, Hinze SW, Cydulka RK, Baker DW. Racial and ethnic disparities in emergency department analgesic prescription. Am J Public Health. 2003;93(12):2067-2073. link
"Physicians were less likely to prescribe opioids to Blacks; this disparity appears greatest for conditions with fewer objective findings (e.g., migraine)."

Hostetler MA, Auinger P, Szilagyi PG. Parenteral analgesic and sedative use among ED patients in the United States: combined results from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 1992-1997. Am J Emerg Med. 2002;20(3):139-143. link
"For patients with orthopedic fractures, African-American children covered by Medicaid insurance were the least likely to receive PAS"

 

[mfrederi]

But yet you have a post full of racial stereotypes. Go figure.

Racial stereotypes like what?

More blacks go to inner city EDs- this is demographics, not stereotyping

There are more drug seekers in inner city EDs- again, not a stereotype

There are a large percentage of hispanics in these EDs that do not speak English- if you ever worked in one you know this is true, I spend time every day interpretting for non-Spanish speaking residents.

Hispanics are very tough- this is obviously a stereotype, but being that 3/4 of my family is Mexican I feel it is probably pretty safe for me to say in general, people who swam a river, avoided armed guards, walked across a desert to have a job where they make 4.00 an hour are pretty tough. And, no it is not a stereotype to say that a lot of Spanish speaking migrant workers are illegals, its the truth. Obviously if you live in California you experience a largely different population of Hispanics...that is the English speaking citizen, but in NC these are rare.

 

[Faze2]

two separate studies were done which looked exclusively at patients coming in with fractures which found that both Blacks and Hispanics were signficantly less likely to get pain medication.

what's your explanation now?

Haven't been on in a while, but to answer your question I think it was answered by a few others, so I waste time and repeat what others have already said. I will add that you cannot use the same injury/complaint and automatically claim it as objective. We see plenty if GSW here, but each one is unique to the other, including the pain level experienced by the patient. We've had grown men brought in by fire resue screaming and crying, and we've had people who were shot walk in and calmly tell triage that they were shot in the back. So you cannot say thay the pain experienced by a GSW or a fracture is not subjective to a degree.

Another point to be said is the fact that since this ER is an inner city one, a lot of the patients, who yes, are mostly black, are not as educated, especially about medicine. With this lack of education comes fear. I have seen many times these patients refuse drugs because they are "afraid that it is no different than street drugs." A lot of these patients are afraid of drugs, IVs, etc., because they fear addiction, and they fear what they don't know. If you think people are abusing stereotypes in this thread, let me say that a lot of our non-white patients are not drug seeking, but drug fearing. I'm not saying this is the sole reason behind the numbers, but it is just another one of the many factors that was left out of this study.

The study also does not take into account the insane number of patients that come in with pain 3 times in one week because they "lost their first prescription" or "pt has not been taking his ______, complains of continued back pain." I spoke to a patient once that refused to get his 4 prescriptions filled, which he desperatley needed, because they pharmacy charged him a $1 copay for each. I don't know many doctors who would write waste his/her times writing a script, for the second or third time in a week mind you, for a pt who is not going to get it filled and/or take it. I'm sure happens a lot with white patients that are in poor white areas as well, but because of the demographics of our patients, 9 times out of 10 this patient is black.

 

[paramed2premed]

... I will add that you cannot use the same injury/complaint and automatically claim it as objective. ...

Yeah, you can. We tend to use x-ray technology to objectively diagnose fractures, for example. Okay, that's a little facetious - I imagine that you were trying to say that a patient's experience of suffering cannot be objectively defined or quantified.

Now, no one would argue that there is a predictable level of pain or suffering that results from a fracture. But, it does seem valid to predict that, if a number of patients with fractures of long bones are asked to describe, say, their level of pain, there will be a nice, bell-shaped, curve of responses.

Now, hold on to your hat, because I now will assert that it is reasonable to assume that sufficiently large groups of white patients and of black patients, all with fractures, will have the same mean level of pain, and same standard deviation of responses. Of course, their will be significant variation within each group, just not between the groups themselves.

Any issue with these predicates so far?

If you accept the above, it seems difficult to justify lower opiod, and higher NSAID use, in blacks versus whites.

Of course, if you don't agree with the above, then you are left to explain how black patients with fractures, on the whole, feel less pain than whites. Good luck with that.

 

[GeneralVeers]

Now, hold on to your hat, because I now will assert that it is reasonable to assume that sufficiently large groups of white patients and of black patients, all with fractures, will have the same mean level of pain, and same standard deviation of responses. Of course, their will be significant variation within each group, just not between the groups themselves.

Again, my question, which no one has answered: How am I expected to change my practice based upon this research?

 

[docB]

Again, my question, which no one has answered: How am I expected to change my practice based upon this research?

I second this question. Studies like this seem to come out every few years with the predictable media coverage. But what does it say, if anything, to the practicing EP in the pit?

 

[BADMD]

I now will assert that it is reasonable to assume that sufficiently large groups of white patients and of black patients, all with fractures, will have the same mean level of pain, and same standard deviation of responses. Of course, their will be significant variation within each group, just not between the groups themselves.

The problem is that you are assuming a normal distribution throughout regions. While you can make that assumption about pain, there are regional patterns to race and regional patterns to practice. Fundamental to this study is the assumption that opioids treat pain better then NSAIDs and that is not a valid assumption. For several painful conditions, renal stones and toothache, for example, NSAIDs have been found equivalent to opioids. For headache, NSAIDs and an antiemetic are clearly superior. For many fractures, immobilization, an ice pack and an NSAID are all that is really needed, yet, instead of a multi-tiered approach, some docs give a homeopathic 2 mg of morphine and call the pain treated. This study would try to convince you that the second guy got better pain management than the first. What a joke.

So, if one area, with more AAs, tends to take an NSAID first approach, then add opiates as needed, versus an opiate first approach, you will get a "racial" disparity that is actually a regional difference. That still doesn't mean that the pain is any less treated.

I'm not going say that there isn't a racial difference, but that there are a huge number of confounders involved in this kind of study and this methodology actually opens itself up to more confounders as more of the country is involved. Statistical approaches that make assumptions using a normal distribution may be flawed.

 

[docB]

The problem is that you are assuming a normal distribution throughout regions. There are regional patterns to race and regional patterns to practice. Fundamental to your statement is the assumption that opioids treat pain better then NSAIDs and that is not a valid assumption. For several painful conditions, renal stones and toothache, for example, NSAIDs have been found equivalent to opioids. For headache, NSAIDs and an antiemetic are clearly superior. For many fractures, immobilization, an ice pack and an NSAID are all that is really needed, yet, instead of a multi-tiered approach, some docs give a homeopathic 2 mg of morphine and call the pain treated. This study would try to convince you that the second guy got better pain management than the first. What a joke.

So, if one area, with more AAs, tends to take an NSAID first approach, then add opiates as needed, versus an opiate first approach, you will get a "racial" disparity that is actually a regional difference. That still doesn't mean that the pain is any less treated.

I'm not going say that there isn't a racial difference, but that there are a huge number of confounders involved in this kind of study and this methodology actually opens itself up to more confounders as more of the country is involved. Statistical approaches that make assumptions using a normal distribution may be flawed.

Valid points. Has anyone ever heard of a study that looked at racial prescribing differences while controlling for some of those confounders? For example has anyone taken a look at analgesic patterns for blacks and whites with the same injury like a shoulder dislocation or a tib fib?

 

[BADMD]

Valid points. Has anyone ever heard of a study that looked at racial prescribing differences while controlling for some of those confounders? For example has anyone taken a look at analgesic patterns for blacks and whites with the same injury like a shoulder dislocation or a tib fib?

The studies that Pseudoknot posted above tried to do that. Generally they found there was a disparity. The studies suffer from time and also have methodology problems (what study doesn't?). In one of the studies, patients with long bone fractures received no analgesia at all...which seems bizarre in my mind. Generally they also had small enough numbers that one or two providers having a different practice pattern could skew the results.

 

[Faze2]

Yeah, you can. We tend to use x-ray technology to objectively diagnose fractures, for example. Okay, that's a little facetious - I imagine that you were trying to say that a patient's experience of suffering cannot be objectively defined or quantified.

Yes I was. My apologies if it was misunderstood.

 

[docB]

The studies that Pseudoknot posted above tried to do that. Generally they found there was a disparity. The studies suffer from time and also have methodology problems (what study doesn't?). In one of the studies, patients with long bone fractures received no analgesia at all...which seems bizarre in my mind. Generally they also had small enough numbers that one or two providers having a different practice pattern could skew the results.

I was troubled by this too. I wonder if such a situation, where a long bone fx gets nothing, coud be due to being in a academic center. I can imagine a situation where the ED consults Ortho and everyone assumes the other gave some pain meds. In my practice in community centers I know I'm going to be the only doc ever seeing the pateint so I write the meds.

 

[roja]

I think the questions being asked underscore the difficulty of making broad interpretations when there are many many variables that have to be accounted for.

1. Just because something is *possible* doesn't make it so.
2. Just because the study is inadequate, doesn't mean that there might not be something there. (causation/correlation)
3. No one has brought up cultural differences. (do certain cultures deal with pain differently? more stoicly? more verbally? don't want to take medications? narcotics?)
4. Was there any data on pain scales?

 

[BADMD]

Welcome to the world of pain protocols people:

Here is one I got in my email courtesy of the Society of Critical Care medicine. It is an example protocol for the management of pain/agitation in neurotrauma patients. Specifically for those with an initial (but not necessarily current) GCS < 8 and a suspected or confirmed ICH.

http://sccmwww.sccm.org/Documents/Dec_Revision.pdf

The protocol I'm referring to is on page 8. Most of it is probably reasonable, however...

Under "Not intubated" (thus I have to assume GCS is now better than 8) the dose of pain medication available by the protocol is a single dose of 12.5 mcg of fentanyl.

Seriously, 12.5 mcg of fentanyl, with nothing available to repeat without a physician order. I realize the need to monitor the patient's mental status, but this is ridiculous...ICHs hurt. Why bother to try and protocolize it, since the physician is going to have to write for more.

Interns: If you were to prescribe this level of pain management to a patient in the ED, how may tylenol #3s would you have to order?

This is what pain management protocols are going to devolve into. There is not going to be individualization except maybe "high dose," "medium dose" and "low dose", there is not going to attention to alternate pain management technique (like an ice pack). Worst off, interns are going to get the idea that these doses of meds are normal or appropriate and will start using the protocol instead of actually trying to address the pain.

But don't worry...everyone will be treated "equally" and JACHO will get their dose of pain medication.

Edited to add: When my hospital went to a tight glycemic control protocol, interns stopped caring about blood sugar. The intern would fill out the form, using the standard dose of insulin glargine and then check off the box for "normal" correction doses. The nurses would then follow the protocol, advancing the patient's "correction" level as per the protocol. The interns would never look at the blood sugar again, unless the patient got "out of control" i.e. a blood sugar consistently above 250. It was not unusual to see patient on 10 or 20 units of glargine and then get 35-40 units at meal time as a "correction" dose. But it was all good per the protocol, so why bother to change the basal insulin dose?

 

[pseudoknot]

3. No one has brought up cultural differences. (do certain cultures deal with pain differently? more stoicly? more verbally? don't want to take medications? narcotics?)
4. Was there any data on pain scales?

It's kind of sad that we got to page 2 of a discussion prompted by a paper that apparently no one else has bothered to read.

Here is a link to the abstract of the JAMA paper that started this thread.

They did have pain scale information for some of the years in their database, but not all. The difference in opioid prescribing was greater with increasing severity of the pain.

 

[roja]

It's kind of sad that we got to page 2 of a discussion prompted by a paper that apparently no one else has bothered to read.

Here is a link to the abstract of the JAMA paper that started this thread.

They did have pain scale information for some of the years in their database, but not all. The difference in opioid prescribing was greater with increasing severity of the pain.

Actually, I did read it. My comments were about pain studies in general.

I certainly hope that I am merely tired and ill and misinterpreting what seems to be a general attitude that we as physicians are stupid, racist, and uncaring.

pain scales on *some* patients in essence equals inadequate and thus useless data.

Diagnosis are poor proxy measures in these studies.
Terminology is inadequately defined.
Outcomes are inadequately defined.
Evaluation scales are inadequately defined.

Thus, any valid statistical inferences are inadequate and not helpful except for proposing possible future studies.

 

[pseudoknot]

Actually, I did read it. My comments were about pain studies in general.

Oh, I'm sorry then. It wasn't clear to me what you meant. I do see a lot of comments in the thread from others that make me think that people aren't actually reading the papers. Im sure some are and some aren't.

I certainly hope that I am merely tired and ill and misinterpreting what seems to be a general attitude that we as physicians are stupid, racist, and uncaring.

I'm sorry to hear that you're ill! As for this general attitude, if it's me you are talking about then I certainly don't think any of those things. Well, I guess I do think that most physicians, along with most other people and myself, do have some degree of unconscious racial prejudice, but that's not the same thing in my mind as saying that someone is "racist."

If you're talking about a general attitude expressed in this thread, I feel like most of the opinions expressed have been quite the opposite and only a handful of people, including myself, have been anything other than very dismissive of the paper that started the thread.

pain scales on *some* patients in essence equals inadequate and thus useless data.

I don't see the logic of this. If there is a subset of data where they have a pain scale, and n is large enough in that subgroup to make statistically significant conclusions, why is that "useless?" In the JAMA 2008 paper, they had pain scale information for over 50,000 patients. I agree that it would be better if they had it for everyone, but don't see how this utterly invalidates the whole paper.

Diagnosis are poor proxy measures in these studies.
Terminology is inadequately defined.
Outcomes are inadequately defined.
Evaluation scales are inadequately defined.

Thus, any valid statistical inferences are inadequate and not helpful except for proposing possible future studies.

Well, the term "inadequate" implies a binary partition in which studies are either Good or Bad. Since clinical data is almost never perfect and usually is very far from it, I wonder how practical such a view would be. Again, I don't know if you are referring here to the JAMA 2008 paper, or the others previously mentioned in the thread, but I do find them somewhat convincing, particularly given the large population in the JAMA paper. My saying that is not intended as any sort of attack on EM or anyone in this forum, however.

 

[RxnMan]

I don't see the logic of this. If there is a subset of data where they have a pain scale, and n is large enough in that subgroup to make statistically significant conclusions, why is that "useless?" In the JAMA 2008 paper, they had pain scale information for over 50,000 patients. I agree that it would be better if they had it for everyone, but don't see how this utterly invalidates the whole paper...

What would be better practice is to use the data subset with pain scales and do the full analysis on it alone. As it is now, it makes for a poor comparison. In most cases, maybe not here, this inapropriately inflates the n.

 

[Bwrecks]

There are all sorts of reasons why these statistics come out looking like this, some PC and some not very PC. Demographic wise, blacks are much more likely to go to the inner city ED where the docs are jaded and suspicious and don't have as much time per patient to check on them every 30 minutes and make sure their dilaudid is working. And, in those same inner city EDs where are larger number of blacks are seen there is a much higher percentage of your fake pain drug seeker, also frequently black (though of course we've all seen the 35 year old white guy with back pain). As far as hispanic patients go (again in my limited experience) they don't complain too much. Just yesterday I saw a migrant worker with an open ankle, gave him 1 of Dilaudid right off the bat, and when I asked him how he felt he smiled and said "I OK main." They are just really freaking tough and they don't know English so often don't feel comfortable and / or don't want to waste their effort trying to communicate with non-spanish speakers. If I was in Japan and couldn't speak a lick of Japanese, I would probably tolerate a little more pain to not go through all the mess of trying to talk to an RN that couldn't understand anything I said.

We also have to realize that their is some bias / stereotype present in ED docs, who honestly get tired of bogus painers and don't want to reinforce their habit. However, at least with me that bias has more to do with the way a patient presents themselves to me (their appearance {relaxed vs peritoneal}, their speech {respectful vs "give me some freaking Dilaudid doc!"}, and their previous visits). Is this right? Don't know. But it doesn't have a whole lot to do with race.

I think this article is talking about doctors such as yourself. The fact that you think that the majority of fake pain seekers are black already shows that you are inherently biased towards minority patients seeking pain medications. I work at a predominantly white, suburban ED, where we see a CRAPLOAD of pain seeking patients. Hell, I dont go a shift without pushing narcs to at least 8 chronic pain patinets a day!

Hell, we even had one guy who claimed to have had a known spinal abscess he sustained after a complication from a nail gun accident, and claimed to be paralyzed from the waist down! It wasn't until after his MRI (which was negative) that one of our nurses recognized the gentleman from a previous ER visit, and called the man out to be a lier. He promptly got up and left the ED!

Pain seekers come in ALL colors, sizes, and shapes. If you get into the habit of classifying one population as being "more likely to be drug seeking" over another, you are part of the problem, and not the solution