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.
Why it matters
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.
What still isn’t known
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.
What’s next?
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.
