Whites Get Better Pain Control In The ED??

Look out, Scalpel. Now “researchers” are throwing fuel on the pain control debate.

Today’s JAMA has a study claiming to show that ED physicians preferentially control pain in whites more than in non-whites. News agencies are already picking up on it including the Chicago Tribune and Yahoo.

I’m not really sure what to make of this study. They could have titled their study “White patients are wussies” but that wouldn’t have gotten as much press. They could have titled their study “Old White Grandpa Is A Drug Addict.” That would have gotten the AARP up in arms. Instead, they just went for the bread and butter “discrimination” theme. However you want to frame your conclusions, guys, your study sucks.

In summary, these researchers looked at 375,000 emergency department visits over a period of 13 years. Of those visits, opioid prescribing was more likely for pain-related visits made by whites (31%) than by blacks (23%), Hispanics (24%), or Asians/others (28%). White patients in their study tended to be older, but they didn’t release that demographic data. Overall, though, the rate at which patients received some form of analgesic (narcotic and non-narcotic combined) was almost identical between the study groups.

Using this data, the researchers come to a conclusion that “The presence of differential opioid prescribing by race/ethnicity throughout the study period suggests that disparities in pain management persist in the emergency department.”

Wait a minute. You’re study didn’t show anything about pain management. Your study showed a trend in lesser prescription of narcotics in non-whites. That’s it. Where does “pain management” come into play in all of this? Reminds me of the drug seeker “pain control = narcotic” mindset.

The “study” flings around kidney stones and long bone fractures as “2 specific diagnoses that are consistently painful.” That statement just tells me that these people are non-clinicians. I can’t count how many times a patient with a hip fracture will lay in bed comfortably and repeatedly refuse pain medication as long as their leg isn’t moved. Any physician who has treated patients with kidney stones knows how well they tend to respond to Toradol.

The study admits that the researchers had access to pain scores for most of the study years. But they chose not to publish the pain scores or analyze the prescription trends with the pain scores. Just because someone receives a non-narcotic for pain does not mean their pain was not effectively managed. Have biostatisticians ever heard of using Imitrex for headaches or are you too wrapped up in your chi-squares? How about Toradol as first line therapy for kidney stones? Or GI cocktails for abdominal pain? Oops … all those non-narcotic medications would skew the results, wouldn’t they? Anyone beginning to wonder why the researchers chose to report on the use of narcotics rather than amount of pain control?

The study talks about “inadequately treated pain” but there is NO study data to back their assertion that anyone was in more pain than anyone else. All they looked at was whether a patient received narcotics. If someone received half a Tylenol with Codeine tablet and was in excruciating pain, their study concluded that the patient received “good” pain control. Conversely, someone who was pain-free after a shot of non-narcotic Toradol or Imitrex had “bad” pain control. This just isn’t the way medicine is practiced. The failure to consider pain control as a study variable makes the whole study worthless.

The researchers even have the gonads to suggest that the “differential prescribing by race/ethnicity” was “unlikely” to be an “appropriate pattern of care.” If there’s discrimination in treating pain, look at a really painful condition - sickle cell disease. This is almost exclusively a disease in African Americans. Did the researchers’ theory hold true with sickle cell pain? Not a bit. Their analysis showed that sickle cell patients received narcotics a “high percentage” of the time. If emergency physicians are a bunch of bigots, why do we provide all those narcotics to the sickle cell patients?

Older white patients received narcotics more often than younger non-whites. Therefore, the researchers come to the conclusion that there is a “differential undertreatment of pain in minority patients.” Then they discuss how “emergency department physicians may be less likely to detect signs of abuse in white patients than in nonwhite patients.” Good segue. So older white people are a bunch of drug addicts and the ED physicians are just too dumb to catch them at it. I knew I should have given that 98 year old with toothaches some Motrin. Dang it. Next time I see her in MY emergency department, granny’s going on “the List.”

Who knows, maybe all these narcotic prescriptions for whites show that white patients are just whimps who need narcotics for splinters and bug bites while non-whites have the intestinal fortitude to “tough it out.”

The fact of the matter is that this study shows a trend in prescription of a class of medications. The explanation for the trend can be anything - including discrimination - or could be nothing at all.

Congratulations to a bunch of non-emergency physicians who chose the most politically-charged explanation to create a headline-catching journal article about emergency medicine to grab their 15 minutes of fame.

Crotch kicks to all of you.

N.B. One author, Michael Kohn, is “affiliated” with Mills-Peninsula Medical Center in California. But his online profile at UCSF doesn’t seem to mention his emergency department experience at all — just all his biostatistics achievements.

UPDATE — January 3, 2008

There are a lot of questions about why the researchers came up with the results that they did. I’m going to give an explanation a shot using my kids’ favorite toys - the Webkinz.

Let’s assume that of all the Webkinz for sale, there are only 7 birds and 50 different types of other animals. I publish a study showing that Webkinz birds are sold at only 75% of the rate of other animals this Christmas. Therefore, I conclude that the American public is discriminating against Webkinz birds.

But wait. I didn’t tell you that Webkinz birds are more expensive than the other animals. Well, I find some data about sales prices and compare the sales of birds with equally-priced animals. The disparity still exists. Now it must be discrimination. But I also didn’t tell you that the supplier ran out of Webkinz birds, so most of the West coast didn’t have them available on the shelves. Ooops. I also didn’t tell you that Webkinz cats are the in vogue new animal on Dizney World and is outselling all the other Webkinz by tenfold. Did I mention that the wings fall off the Webkinz birds after a few months of normal use? Oh, and the Webkinz birds are coated with a chemical that can turn toxic when exposed to water. But the decrease in sales must be due to discrimination against Webkinz birds, right? Or could it be a combination of a bunch of these factors?

Differences in prescription of certain pain medications could be due to an increased incidence of NSAID allergies in white patients, higher likelihood of severely painful conditions in white patients (abdomimal aneurysms or intestinal blockages in the elderly versus PID and UTIs in the young), less overestimation of pain in white patients, doctor preferences (some may treat UTI pain with pyridium while others give Tylenol #3), sampling errors, or a hundred other variables. So why, without discussing all of these variables, do the researchers hang their hats on “discrimination” as the sole cause for a disparity in who receives what pain medication? And why do the researchers assume that narcotics are always the panacea for pain control?

Bigger question - why did the researchers hide the results of pain control? My bet is that pain was equally controlled, and there was no racial disparity. But that study wouldn’t grab many headlines, would it?

There are three kinds of lies: Lies, damned lies, and statistics. - Mark Twain