Race Plays Role in Emergency Department Opioid Prescribing

A new analysis of nationwide emergency department (ED) records led by UC San Francisco researchers has revealed that black patients seen for back or abdominal pain are roughly half as likely as white patients to be prescribed opioids in the ED or at discharge. The study’s authors suggest that addressing such race-based disparities will require unearthing and discussing subconscious bias in hospitals and beyond.

“Even when we are trying our best to care for our patients, bias can creep in,” said UCSF’s Renee Y. Hsia, MD, professor of emergency medicine, senior author of the new study, adding that, while cases of racial bias discussed in the media are largely focused on policing, the problem is much broader. “When we actually look at the data on how medical professionals prescribe opioids, we see differences,” said Hsia, also a member of UCSF’s Philip R. Lee Institute for Health Policy Studies.

The new study, published online August 8, 2016 in PLOS ONE, examined national data gathered at EDs from 2007 to 2011. Hsia and colleagues examined records from over 60 million pain-related ED visits by adult, non-elderly patients to determine whether patients were prescribed opioids in the ED, or at hospital discharge, taking into account the patients’ race and the type of condition that led to the visits.

The conditions causing pain in patients were categorized as either “definitive,” for objectively diagnosable conditions like long-bone fractures or kidney stones, or “non-definitive,” which included less easily diagnosed conditions such as back or abdominal pain.

Hsia and colleagues showed that black patients seen for pain resulting from non-definitive conditions have roughly half the odds of being prescribed opioids in the ED or at discharge compared to white patients. Other minorities were also less likely to be prescribed opioids at discharge for abdominal pain.

The researchers found no race-based differences in opioid prescribing for definitive conditions, or for toothaches, which the group had initially classified as non-definitive, but for which Hsia suggests there are often visible signs, such as abscesses.

Previous research by other groups has generated mixed results regarding racial disparities in opioid prescribing. Hsia said this may be because other researchers did not separately investigate prescribing practices during ED visits as well as at discharge.

The current study also revealed that a majority of pain-related ED visits led to opioids being prescribed while in the ED or at discharge, and that opioids were more often prescribed for definitive than non-definitive conditions across the board. All race-based comparisons were corrected for self-reported severity of pain, which in most conditions was a significant predictor of whether opioids were prescribed.

Considering the nationwide opioid addiction epidemic, which disproportionally affects white Americans, it’s difficult to tell from the current study which racial group may be receiving inappropriate prescriptions, Hsia said. “Whether or not someone ‘needs’ opioids is a very subjective decision—there isn’t an objective test.”

Hsia and colleagues suggest that incorporating sensitivity training into medical provider education could help eliminate the prescribing disparities revealed in the new study.

“In the media you see a lot about how we need to change the culture because we have inherent biases, and this study shows these biases even affect healthcare,” Hsia said. “The first step is looking for these disparities. We can’t do anything about them unless we know that they exist.”

The study was coauthored by Astha Singhal, MPH, PhD, of Boston University’s Henry M. Goldman School of Dental Medicine, and Yu-Yu Tien, of the University of Iowa’s College of Pharmacy. No funding was provided for this study. 

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises two top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospital San Francisco, and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.