Pain management, Opioids Prescriptions and Race
Rita Agarwal MD, Lynne G. Maxwell MD, and Myron Yaster MD
Over the past year we’ve had multiple PAADs devoted to the opioid epidemic, the increasing use of opioid free or sparing anesthetics, the opioid ecosystem, and the “opioid paradox” of increasing opioid overdose deaths despite a steady reduction in opioid prescribing by physicians. We’ve also highlighted articles particularly by Dr. Olubukola O. Nafiu of Nationwide Children’s Hospital on racial and ethnic disparities in pain assessment, treatment, and outcomes.1-3 Today’s PAAD is by Rita Agarwal, the PAAD’s primary pain reviewer, who reviewed yet another article on racial disparities in pain (and opioid) management in the Pediatric Emergency Department. Why the ED? Pain is the most common reason that most children present to an ED. Therefore, understanding the experience of these children can be helpful when we are treating them in the perioperative, pain, or critical care setting. Myron Yaster MD
Orignal article
Goyal MK, Johnson TJ, Chamberlain JM, Cook L, Webb M, Drendel AL, Alessandrini E, Bajaj L, Lorch S, Grundmeier RW, Alpern ER; PEDIATRIC EMERGENCY CARE APPLIED RESEARCH NETWORK (PECARN). Racial and Ethnic Differences in Emergency Department Pain Management of Children With Fractures. Pediatrics. 2020 May;145(5):e20193370. PMID: 32312910
Original article
Goyal MK, Drendel AL, Chamberlain JM, Wheeler J, Olsen C, Grundmeier RW, Cook L, Bajaj L, Babcock L, Zorc JJ, Johnson T, Alpern ER; Pediatric Emergency Care Applied Research Network (PECARN) Registry Study Group. Racial/Ethnic Differences in ED Opioid Prescriptions for Long Bone Fractures: Trends Over Time. Pediatrics. 2021 Nov;148(5):e2021052481. doi: 10.1542/peds.2021-052481. Epub 2021 Oct 13. PMID: 34645690
Although there have been many previous papers noting disparities in pain management in children based on race and ethnicity,4 in today’s PAAD, we are reviewing 2 from the same group of authors published 2 years apart. The data in these 2 articles comes from the Pediatric Emergency Care Applied Research Network Registry (PECARN registry) which uses deidentified electronic medical records from 7 large pediatric EDs across the country. The sites are geographically diverse and are composed of 4 large tertiary-care children’s hospital health systems with 4 pediatric EDs and 3 affiliated satellite pediatric EDs in the northeast, south, west, and midwest.
The initial paper5 looked at children <18 with long bone fractures from July 1, 2014, through June 30, 2017. There was adequate data on over 20,000 patients who presented with a long bone fracture and had pain on presentation. The majority, 85-90% of all children, had moderate to severe pain and were treated with an analgesic (acetaminophen, ibuprofen or other NSAID) and/or an opioid. Surprisingly a higher percentage of children of color (Hispanic or Black[there was not enough data on children of other ethnicities]) received an analgesic than non-Hispanic whites. However non-Hispanic white children were more likely to receive an opioid despite presenting with overall lower pain scores than children of color. So the good news is “that minority children are more likely to receive analgesics and achieve ≥2-point reduction in pain”. The bad news is “that they are significantly less likely to receive opioids and achieve optimal pain reduction”.
The second study just published last November6 expands on the first by looking at prescription of opioid at discharge from the ED from using the same PECARN registry and revealed that opioid prescriptions declined over time in all groups. Thus, by 2019 only 5% of all children presenting to the ED with a long bone fracture received an opioid prescription on discharge so the gap between minority and non-Hispanic whites vanished.
There was considerable variation in prescription of opioids between sites and racial and ethnic differences persisted more at some locations than others. This study raises important questions such as: What is optimal pain management for these children? How do we explain the variations in prescribing practices across the sites? Are prescriptions being offered and families refusing? Following these patients after discharge would provide information about pain intensity and analgesic and/or opioid use after discharge. Such follow-up would generate essential information about optimal safe and effective analgesic regimens in this population. When so little is known about outcome in these patients, it is difficult to judge the significance of the trends reported by these authors. Did the patients who received a discharge opioid prescription in the more recent study have better pain control than those who didn’t? Did they even fill the prescription and take the opioid? This situation is similar to early perioperative analgesia studies which reported only PACU pain levels, analgesic rescue and length of stay, ignoring the experience of the patients after discharge.
I (MY) wonder if is this progress? It appears to me that we now have made pain management as bad in non-Hispanic whites as it was in minority children. What does the omission of opioids accomplish? It surely doesn’t appear to have any effect on the opioid related deaths which are now primarily caused by illicit fentanyl. Is the story of these two papers more about disparity among races and ethnicities in analgesic prescribing or about evolution in opioid prescribing in response to recent changes in guidelines and concern about the opioid epidemic? Further, these retrospective studies also do not look beyond the ED and we do not know what happens to these children when they leave the ED.
References
1. Burke CN, Voepel-Lewis T, Wagner D, Lau I, Baldock A, Malviya S, Nafiu O: A retrospective description of anesthetic medication dosing in overweight and obese children. Paediatr Anaesth 2014; 24: 857-62
2. Sivak E, Mpody C, Willer BL, Tobias J, Nafiu OO: Race and major pulmonary complications following inpatient pediatric otolaryngology surgery. Paediatr Anaesth 2021; 31: 444-451
3. Nafiu OO, Mpody C, Kim SS, Uffman JC, Tobias JD: Race, Postoperative Complications, and Death in Apparently Healthy Children. Pediatrics 2020; 146
4. Jette CG, Rosenbloom JM, Wang E, De Souza E, Anderson TA: Association Between Race and Ethnicity with Intraoperative Analgesic Administration and Initial Recovery Room Pain Scores in Pediatric Patients: a Single-Center Study of 21,229 Surgeries. J Racial Ethn Health Disparities 2021; 8: 547-558
5. Goyal MK, Johnson TJ, Chamberlain JM, Cook L, Webb M, Drendel AL, Alessandrini E, Bajaj L, Lorch S, Grundmeier RW, Alpern ER: Racial and Ethnic Differences in Emergency Department Pain Management of Children With Fractures. Pediatrics 2020; 145
6. Goyal MK, Drendel AL, Chamberlain JM, Wheeler J, Olsen C, Grundmeier RW, Cook L, Bajaj L, Babcock L, Zorc JJ, Johnson T, Alpern ER: Racial/Ethnic Differences in ED Opioid Prescriptions for Long Bone Fractures: Trends Over Time. Pediatrics 2021; 148