An article published this past week through the Public Library of Science (PLOS ONE) provided an in-depth look at opioid prescription trends in emergency departments (Singhal, 2016). It has been well documented that minorities are less likely to be prescribed opioids by emergency rooms, with a major 2008 article by Pletcher et al providing some significant data on the subject (Pletcher, 2008). In an attempt to reassess the current literature and view the data through a new lens, Singhal and colleagues specifically looked at whether the opioids were administered in the emergency room or prescribed at discharge (Singhal, 2016). The distinction is a meaningful one, providing insight into provider-patient trust while potentially highlighting the presence of a systemic treatment bias against racial minorities.
Through the analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) data collected from 2007-2012, the group found significant racial disparities in both administration and prescription of opioid medication for certain “non-definitive conditions,” including back pain and abdominal pain (Singhal, 2016). Odds ratios, which are statistical measures of an association between an exposure and an outcome, were computed. In this case, the exposure was race, the outcome opioid prescription. It was found that non-Hispanic blacks had 0.67 and 0.58 times the odds of receiving opioids at discharge and in the emergency department, respectively (Singhal, 2016). Both odds ratios were statistically significant, with P values less than 0.05. These ratios, along with the large sample sizes ranging from 3000-10,000 for the significant ailments, speak to the strength of the analysis.
These findings come on the tail of a recent social psychology report out of the University of Virginia by Hoffman et al. which exposed inherent bias against black patients by both laypeople and medical students (Hoffman, 2016). In the later experiment, 222 medical students were presented with patient scenarios and asked about their perception of patient pain, revealing that false beliefs about biological disparity between races led to a “racial bias in pain perception” (Hoffman, 2016). These two articles together highlight the need for further study of, and a focus on counteracting these pervasive biases. However, Singhal’s discussion also highlighted the complexity of assessing doctor-patient interaction and accurately representing the presence of minority bias via discrete data points.
One confounding variable that complicates this assessment is socioeconomic status. A recent New York Times article, which set out to review the Singhal article, points out that in many cases, racial disparity and low socioeconomic status are intertwined, complicating patient care, and the data corresponding to that care (Goodnough, 2016). Despite this confounder, though, the researchers interviewed for the article, including Raymond Tait, a pain researcher in St. Louis, are certain that race plays a role that should not be ignored.
Given this data, it appears as though further inquiry will be necessary to flesh out the problem more fully before meaningful interventions can be executed. The pain management field must self-assess while attempting to create metrics to more specifically explain clinical decision making. One of the major pitfalls of the Singhal paper was the acknowledgement that, even if there is bias, every patient presents differently, complicating the statistical analysis. Additionally, proper control of socioeconomic factors in analyzing racial disparity data should enhance the current picture of minority bias, and potentially point to opinions for intervention.
References:
Goodnough, A. (2016, Aug). Finding Good Pain Treatment is Hard. If You’re Not White, It’s Even Harder. New York Times. Retrieved from http://www.nytimes.com/2016/08/10/us/how-race-plays-a-role-in-patients-pain-treatment.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health®ion=stream&module=stream_unit&version=latest&contentPlacement=3&pgtype=sectionfront&_r=1
Hoffman, KM, Trawalter, S, Axt, JR, and Oliver, MN (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS 2016 113 (16) 4296-4301. Retrived from http://www.pnas.org/content/113/16/4296.abstract
Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R (2008).Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. 2008;299:70–78. Retrived from http://www.ncbi.nlm.nih.gov/pubmed/18167408
Singhal A, Tien Y-Y, Hsia RY (2016). Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse. PLoS ONE 11(8). Retrived from http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0159224