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Black Children with Appendicitis Less Likely to Get ED Opioids for Severe Pain

October 6th, 2016

WASHINGTON, DC – No one likes to think they harbor subtle racial bias, least of all emergency department clinicians. Yet, a new study finds that, at EDs in the United States, black children with appendicitis were less likely to be given opioids for severe pain than white children with the same condition. The report also suggests some variations in treatment of more moderate discomfort.

The study on racial disparities in the pain management of children in EDs was published online by JAMA Pediatrics. Background information in the article notes that racial and ethnic differences in ED management of pain have been previously described in terms of lower rates of opioid prescriptions for black and Hispanic patients, but this is one of the few that has looked at possible bias with children.

The study team, led by researchers at the Children's National Health System in Washington, opted to examine the use of analgesics among children diagnosed with appendicitis because guidelines generally recommend pain management in that situation.

Using data from the National Hospital Ambulatory Medical Care Survey from 2003 to 2010 to analyze both the administration of opioid and non-opioid analgesia, the researchers found that, of about 1 million children evaluated in EDs who were diagnosed with appendicitis, 56.8% of patients received any analgesia and 41.3% received any opioid pain medication.

The study team then analyzed the data, adjusting for pain score and ethnicity, finding that black patients with moderate pain were less likely to receive any analgesia than white patients. For severe pain, black patients were less likely to receive opioids than white patients.

No significant difference in overall analgesia administration by race was detected when multiple variables were introduced, but the researchers still found a variance in opioid administration by race: While 12.2% of black children with appendicitis received opioid analgesia, the rate for white children was 33.9%.

Study authors pointed out that the research was limited because they did not know which patients might have declined analgesia and there was no information on analgesia received before arrival at the ED.

"Our findings suggest that there are racial disparities in opioid administration to children with appendicitis, even after adjustment for potential confounders,” the study authors conclude. “More research is needed to understand why such disparities exist. This could help inform the design of interventions to address and eliminate these disparities and to improve pain management for all youths.”

In a related commentary, Eric W. Fleegler, MD, MPH, and Neil L. Schechter, MD, of Boston Children's Hospital and Harvard Medical School, Boston, questioned how the persistence of disparities in treatment could be explained.

“If there is no physiological explanation for differing treatment of the same phenomena, we are left with the notion that subtle biases, implicit and explicit, conscious and unconscious, influence the clinician's judgment,” Fleeger and Schechter write. “It is clear that despite broad recognition that controlling pain is a cornerstone of compassionate care, significant disparities remain in our approach to pain management among different populations. Strategies and available knowledge exist to remedy this unfortunate situation; we can and should do better."

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