Poor Pain Treatment in ER Raises Risk of Opioid Misuse Later

By Pat Anson

Patients with acute pain who are dissatisfied with their pain treatment in emergency departments are more likely to misuse opioids three months later, according to a new study. The findings are particularly true for black patients, who are more likely to be unhappy with their treatment and to be sent home without an opioid prescription.

“While a great deal of studies on opioid misuse focus on overprescribing, this study flips the script by showing that under-prescribing—or more precisely, ignoring a patient’s pain treatment preferences—can also lead to harmful outcomes, especially when patients are dissatisfied with their care,” said Max Jordan Nguemeni Tiako, MD, an assistant professor at the David Geffen School of Medicine at UCLA and lead author of the study in the Journal of General Internal Medicine.

Previous studies have found disparities in pain treatment between white and black patients in emergency rooms, with white patients 26% more likely to get opioid medication. This new study has similar findings, but went a step further to see what the long-term consequences of poor treatment could be.

Nguemeni Tiako and his colleagues analyzed data for 735 ER patients treated for acute back or kidney stone pain, and surveyed them about their experiences 90 days later. The survey asked a series of questions about their medication use, appointment problems, emotional/psychiatric issues, and drug misuse --- and then assigned a current opioid misuse (COMM score) based on their answers.

Researchers found that black patients (21.8%) were more likely than white patients (15%) to have an “unmet opioid preference” when they were discharged from the ER. They were also more likely to be dissatisfied with their pain treatment overall.

Black patients with poor satisfaction and unmet opioid preferences had higher COMM scores compared to white patients. Both blacks and whites who were highly satisfied with their pain treatment had low risk of opioid misuse.

“The finding that unmet opioid preference had a unique effect on opioid misuse risk among Black participants is consistent with our prior analyses of this cohort, in which we found that receiving a prescription for opioids at discharge was associated with lower odds of reported non-prescribed opioid use,” researchers reported.

“Similarly novel to our study is the finding that satisfaction with pain treatment significantly mediates the impact of unmet preference on opioid misuse, especially among Black participants.”    

While an unmet preference for opioids may lead some patients to seek relief through nonprescribed opioids, researchers think other factors in the ER could mitigate such risks, such as more empathy by providers, more patient-centered communication, and patient education about effective therapies and opioid risks.

White Patients More Likely Than Blacks to Get Opioids at ER

By Drs. Trevor Thompson and Sofia Stathi, University of Greenwich

White people who visit hospital emergency departments with pain are 26% more likely than Black people to be given opioid pain medications such as morphine. This was a key finding from our recent study, published in the Journal of General Internal Medicine.

We also found that Black patients were 25% more likely than white patients to be given only non-opioid painkillers such as ibuprofen, which are typically available over the counter.

We examined more than 200,000 visit records of patients treated for pain, taken from a representative sample of U.S. emergency departments from 1999 to 2020. Although white patients were far more likely to be prescribed opioid medication for their pain, we found no significant differences across race in either the type or severity of patients’ pain.

Furthermore, racial disparities in pain medication remained even after we adjusted for any differences in insurance status, patient age, census region or other potentially important factors.

Our analysis of prescribing trends spanning over two decades’ worth of records found that opioid prescribing rates rose and fell, reflecting changing attitudes in clinical practice toward the use of opioid drugs. Notably, however, there appeared to be little change over time in the prescribing disparity across race.

These findings are important because they suggest that efforts to promote equitable health care in the U.S. over the past two decades, such as the Affordable Care Act, or “Obamacare,” do not appear to have translated to clinical practice – at least with regards to pain management in hospital emergency departments.

There’s no question that as the ongoing opioid crisis continues to escalate, a careful balance must be struck between the risks and benefits of prescribing opioids. But their appropriate use is an essential component of pain control in the emergency department, and they typically provide superior relief to non-opioids for short-term moderate to severe pain.

Undertreated pain produces unnecessary suffering and can result in a range of negative outcomes, even including a greater likelihood of developing long-term pain. There are over 40 million pain-related emergency department visits annually, so it is clear that equitable pain treatment is a fundamental component of a fair health care system.

We do not know why such marked racial disparities exist. Some researchers have argued that prescribing fewer opioids may be beneficial for Black patients as it reduces the risk of addiction. But this argument doesn’t square with the data, which show that overdose rates have traditionally been lower in Black populations compared with white people. However, this trend has started to change in recent years.

In addition, some evidence suggests that clinicians may hold unconscious biases, incorrectly believing Black patients to be less sensitive to pain or that certain racial groups are less willing to accept pain medication.

While there is preliminary evidence that these factors may be important, there is not enough research that examines the degree to which they influence clinical practice. Researchers like us also know very little about whether promising remedial strategies based on these factors – such as educational training during medical school that challenges stereotypical beliefs – are effective, or indeed even implemented, in the real world.

The need for tackling racial disparities in health was brought into focus once more in February 2023, when the Biden-Harris administration signed an executive order on further advancing racial equity. Given the long history of these issues, it is clear that more research is needed to help develop better strategies for tackling health inequalities.

The most effective strategies for addressing racial disparities in pain treatment are likely to be those that target the underlying causes. We are currently undertaking research to try to better understand these causes, how they contribute to disparities in real-world clinical practice and whether strategies designed to address them are actually effective.

Trevor Thompson, PhD, is an Associate Professor of Clinical Research and works in the Centre for Chronic Illness and Ageing at the University of Greenwich.  

Sofia Stathi, PhD, is a Professor of Social Psychology in the School of Human Sciences at the University of Greenwich, where she leads the Centre for Inequalities.

This article originally appeared in The Conversation and is republished with permission.

Blacks and Hispanics More Likely to Develop Chronic Back Pain

By Pat Anson, PNN Editor

Chronic lower back pain is the leading cause of disability worldwide, with an estimated 72 million people suffering from it in the United States alone.   

New research suggests that Black and Hispanic Americans are significantly more likely to develop “high-impact” lower back pain than Whites. High impact pain is chronic pain that lasts at least six months and is severe enough to interfere with daily life or work activities.

Researchers at Boston Medical Center analyzed health data for over 9,000 patients experiencing acute lower back pain, who were being treated at primary care practices in the Baltimore, Boston, Pittsburgh and Salt Lake City areas.

After six months, patients who were Black (30%) or Hispanic (25%) were more likely than White patients (15%) to develop high impact chronic lower back pain. The Black and Hispanic patients were more likely to be younger, female, obese, have Medicaid insurance, and at higher risk of disability. They were also about half as likely to be prescribed opioids than Whites after their initial visit to a doctor.

“Our study has highlighted both a concern in the absolute number of patients with acute low back pain who develop chronic low back pain and concerns about racial and ethnic disparities in outcomes,” said lead author Eric Roseen, DC, director of the Program for Integrative Medicine and Health Disparities at Boston Medical Center.

“High-impact chronic pain has a negative impact on the lives of millions of Americans, particularly Black Americans, yet possible and significant causes of racial and ethnic disparities in long-term pain outcomes remain understudied and largely unaddressed. The disparities that emerged in this study shed light on the direct correlation among lived experiences, physical, and mental health, which must be addressed in order to improve patient outcomes.”

Roseen and his colleagues reported in the journal Pain Medicine that the risk of developing high-impact chronic pain was highest among Black women. They attribute that partially to socioeconomic reasons, suggesting that racial and ethnic differences in health insurance or neighborhood resources may impact the long-term outcomes of patients with new episodes of low back pain. 

Getting effective treatment for low back pain is problematic, regardless of race or ethnic group. A recent Harris Poll of over 5,000 U.S. adults found that over a third of those with chronic low back pain have never been told by a healthcare professional what causes their pain. Nearly half said they’ve experienced back pain for at least five years.

The survey found the typical back pain sufferer had sought relief from at least three different healthcare providers. About one in five had epidural steroid injections, which were rated as one of the least effective treatments for chronic low back pain. Opioid pain medication was rated as the most effective treatment, slightly ahead of physical therapy, chiropractic care and acupuncture.

Study Finds Racial Bias in Drug Testing

By Pat Anson, Editor

African-American patients on long-term opioid therapy are more likely to be drug tested by their doctors and significantly more likely to have their opioid prescriptions stopped if an illicit drug is detected, according to a new study.

Yale researchers analyzed the health records of more than 15,000 patients who received opioids from the Veterans Administration between 2000 and 2010. About half of the VA patients were white and half black.

Over 25 percent of the black patients had a urine drug test within the first six months of opioid treatment, compared to nearly 16% of whites.

When patients tested positive for either marijuana or cocaine, the vast majority – 90 percent -- continued to receive their opioid prescriptions. But there were significant differences in how patients were treated depending on their race.

Black patients that tested positive for marijuana were twice as likely as whites to have opioid therapy stopped and three times more likely to have opioids discontinued if cocaine was detected in their urine.

The findings, published in the journal Drug and Alcohol Dependence, are consistent with previous research showing disparities in how blacks and whites are treated by the healthcare system in general, and particularly when opioids are involved.

“There is no mandate to immediately stop a patient from taking prescription opioids if they test positive for illicit drugs,” said first author Julie Gaither, PhD, a pediatrics instructor at the Yale School of Medicine.

“It’s our feeling that without clear guidance, physicians are falling back on ingrained stereotypes, including racial stereotyping. When faced with evidence of illicit drug use, clinicians are more likely to discontinue opioids when a patient is black, even though research has shown that whites are the group at highest risk for overdose and death.”

A 2016 study of emergency room patients found that blacks were significantly less likely to get an opioid for abdominal pain than whites. Another study of white medical students and residents found that half had at least one false belief about black patients. Those that did were more likely to report lower pain ratings for black patients.

Drug Testing for Marijuana Not Recommended

The 2016 CDC opioid guideline encourages doctors to conduct urine drug tests before starting opioid therapy and at least annually after patients start taking the drugs. But the guideline also urges physicians not to test opioid patients for tetrahyrdocannabinol (THC), the psychoactive ingredient in marijuana that makes people high.

“Clinicians should not test for substances for which results would not affect patient management or for which implications for patient management are unclear. For example, experts noted that there might be uncertainty about the clinical implications of a positive urine drug test for tetrahyrdocannabinol (THC).” the guideline states.

"Clinicians should not dismiss patients from care based on a urine drug test result because this could constitute patient abandonment and could have adverse consequences for patient safety, potentially including the patient obtaining opioids from alternative sources and the clinician missing opportunities to facilitate treatment for substance use disorder."

Another factor to consider is the unreliability of urine drug tests. As PNN has reported, “point-of care” (POC) urine drug tests, the kind widely used in doctor’s offices, frequently giving false positive or false negative results for marijuana, cocaine and other drugs. 

A 2015 study found that 21% of POC tests for marijuana and 12% of those for cocaine produced a false positive result.

Race and Economic Insecurity Play Key Roles in Pain

By Pat Anson, Editor

Two new studies are adding to the growing evidence that links pain with economic, social and racial differences in the United States.

Researchers at Indiana University-Purdue University say African-Americans use coping strategies that often make their pain worse; while researchers at the University of Virginia found that people who feel that their financial outlook is shaky experience more physical pain.

“The past decade has seen a rise in both economic insecurity and frequency of physical pain. The current research reveals a causal connection between these two growing and consequential social trends,” wrote lead author Eileen Chou of the University of Virginia in the journal Psychological Science.

Chou and her colleagues looked at six different studies and found that economic insecurity produces physical pain, reduces pain tolerance, and predicts consumption of over-the-counter pain relievers. The researchers believe economic insecurity also leads people to feel a lack of control in their lives, which activates psychological processes associated with anxiety, fear, and stress.

Data from a consumer panel of nearly 34,000 individuals revealed that households in which both adults were unemployed spent 20% more on over-the-counter pain relievers than households in which at least one adult was working.

Smaller studies also found that unemployment was correlated with reports of pain. And people who recalled periods of economic instability reported almost double the amount of physical pain than those who recalled economically stable periods.

“Overall, the findings show that it physically hurts to be economically insecure,” Chou said.

Financial stress and economic insecurity were also blamed in a recent landmark study by Princeton University researchers who found that nearly half a million middle aged white Americans died prematurely in the last 15 years. The rising death rate for whites was also attributed to drug and alcohol poisoning, suicide, chronic pain and disability.

Blacks and Whites Cope with Pain Differently

The researchers at Indiana University-Purdue University also used a meta-analysis (a study of studies) to reach their conclusion that black and white Americans cope with pain differently. The review of 19 studies, which included 2,719 black and 3,770 white adults, is the first to quantify the relationship between race and the use of pain-coping strategies.

"Coping" was broadly defined as the use of behavioral and cognitive techniques to manage stress.

Blacks were significantly more likely to use prayer and hoping as pain-coping strategies than whites, according to researchers. Blacks were also more likely than whites to think about their pain in a catastrophic manner.

"Our findings suggest that blacks frequently use coping strategies that are associated with worse pain and functioning," said Adam Hirsh, a clinical health psychologist. "They view themselves as helpless in the face of pain. They see the pain as magnified -- the worst pain ever. They ruminate, think about the pain all the time, and it occupies a lot of their mind space."

While that kind of coping might be considered a negative approach to pain, Hirsch says it also may have benefits.

“It may also be a potent communication strategy -- it tells others in a culture with a strong communal component that the person is really suffering and needs help. Thus, it may be helpful in some ways, such as eliciting support from other people, and unhelpful in other ways. In future studies, we will give this more nuanced investigation," said Hirsch, whose study is published in the Journal of Pain.

Ignoring pain rather than allowing it to interfere with the task at hand was the only coping strategy employed by whites more than blacks. Several studies reviewed by researchers found that ignoring strategies are associated with less pain, whereas praying, hoping and catastrophizing are associated with higher pain levels.

"How people think about their pain matters," said Hirsh. "For example, religion can be used as a passive coping strategy -- asking a higher authority to take the pain away -- or as an active coping strategy -- asking to be given strength to manage pain.”

Blacks reported higher levels of pain than whites for a number of conditions including arthritis, post-operative pain and lower-back pain. Blacks also experience greater pain in both clinical and experimental studies. Blacks reported less-effective pain care, are unable to return to work for a longer time due to pain, and have worse functional outcomes.

Hirsch says understanding how different racial groups cope with pain may improve pain care and support individually tailored treatment.