White ED patients more likely to get narcotics

White ED patients are more likely to receive narcotics such as oxycodone and morphine than patients of other races or ethnicities, says a new study.1

Researchers examined 156,729 pain-related ED visits in 500 hospitals over 13 years and found differences in urban and rural hospitals, in every region of the United States, and for all types of pain. Opioid narcotics were given for severe pain in 31% of whites, 28% of Asians, 24% of Hispanics, and 23% of blacks.

Signs of painkiller abuse may be overlooked in white patients, or minority patients may be less likely to keep complaining about their pain, says study co-author Mark J. Pletcher, MD, MPH, an assistant adjunct professor in the Department of Medicine at the University of California, San Francisco.

As an ED nurse, you need to put aside your thoughts and feelings about the patient's race, creed, national origin, sexual orientation, socioeconomic class, or ability to pay, and provide the highest quality of care to everyone equally, says Christian N. Burchill, PhD, RN, an ED nurse at Hospital of the University of Pennsylvania in Philadelphia. "That is part of our professional code of conduct," Burchill says. "Pain treatment is a totally subjective experience, and we need to advocate for the best treatment possible."

Here are ways to ensure all ED patients receive consistent pain management:

• Assign the patient a high acuity level.

"Patients are flagged in our tracking system indicating acute pain and are triaged as an Emergency Severity Index Level 2," says Ann Heywood, RN, BSN, CEN, SANE, clinical practice coordinator for the Emergency Care Center at Champlain Valley Physicians Hospital Medical Center in Plattsburgh, NY.

The patient's chart is brought to the ED physician for early pharmacological support, and nurses implement nonpharmacological measures immediately, such as ice, elevation, or dimmed lights, says Heywood.

• Ask the right questions.

Most patients that present to any ED have some complaint of pain, says Burchill. "Understanding the where, when, and how long is key to making the right triage decision and starting the pain management process."

Ask patients these questions, advises Burchill: Have you had this pain before? How was it treated? How effective was that treatment at keeping the pain manageable? "That gives you a clue as to how to start the process and some sense of their tolerance for analgesics," says Burchill.

• Make clear statements about a patient's pain.

"Ensuring that my physician colleague understands who has the worst pain or appears the most uncomfortable is key to getting treatment started," says Burchill. "I've found that many nurses ask for pain medication for their patient. I believe that we need to make clear statements about patients' pain and not take a lower position in the relationship."

Instead of saying, "Can I give this patient some pain medication?" Burchill recommends saying, "This patient is having severe pain. We need to treat it before we can proceed with our exam."

• Make pain part of every interaction.

"If you are running from room to room, keep pain assessment in the back of your mind and ask every time you see a patient or their family," says Burchill. "Use family members as your partners in pain control, and document that interaction." For example, document, "Discussed pain control with Mr. Smith's family, who reports that he was treated with morphine the last time with good relief. Encouraged them to report how well the pain control plan is working."

• Utilize support people.

"Encourage your assistive personnel to be involved in the pain control process," says Burchill. "They can ask a patient about the effectiveness of interventions, and give you a sense of who is in pain and who is relatively comfortable."

Inform these individuals which patients are getting what medications and when so they can check on how well the treatment plan is working, advises Burchill. "If you're using a 0-10 pain scale, the assistive personnel can certainly ask the patient to give a number, document that, and share it with you," he says.


  1. Pletcher MJ, Kertesz SG, Kohn MA, et al. Trends in opioid prescribing by race/ethnicity for patients seeking care in U.S. emergency departments. JAMA 2008; 299:70-78.