These are challenging times for clinicians who care for children and adults in pain. The general philosophy regarding the level of attention that should be paid to pain as well as its treatment has changed dramatically during the past 30 years, swinging wildly between extremes, and remains a moving target.
The first published recognition of pain undertreatment in adults occurred in the 1970s, with identification of similar and more dramatic concerns for children emerging a few years later. Research documenting the short- and long-term negative consequences of poorly-treated pain—coupled with the development and marketing of new opioid compounds—led to a dramatic increase in analgesia prescribing for essentially all painful conditions.
Unfortunately, although most patients who were prescribed opioids benefited, it became clear that these agents were not as benign as had been assumed, and that addiction, diversion, opioid hyperalgesia and other adverse effects were legitimate concerns. Although one would assume that these concerns would only limit the indiscriminate use of these drugs for inappropriate situations, in fact, the pendulum swung to the other extreme, with a wave of negative publicity leading to the scrutiny of essentially any use of narcotic analgesics.
As a result, at this time, we run the genuine risk of returning to a state of opiophobia and denying individuals in severe pain the mercy of access to these incredibly valuable drugs.
It is with these societal currents in mind that we read a recent article in JAMA Pediatrics that identified significant undertreatment of children with severe pain associated with appendicitis while in the emergency department (ED). Looking at a large national sample of over 940,000 children diagnosed with acute appendicitis, the authors found that only 56.8 percent of children received any form of analgesia and only 41.3 percent received opioids. These are striking results; given that the old dictum about opioids masking a surgical condition in patients with acute abdominal pain has been debunked, we would expect that most children with appendicitis would receive some type of analgesia.
We run the genuine risk of returning to a state of opiophobia and denying individuals in severe pain the mercy of access to these incredibly valuable drugs.
Perhaps the most salient and most concerning finding of this article, however, is the existence of major racial disparities in administration of opioids. Black children received opioids for severe pain at a miserly 20 percent of the rate of white children, despite there being no concern about diversion (the medications were administered in the hospital) and the fact that each child had a clear diagnosis of appendicitis.
A pattern of disparity
Unfortunately, however, these findings fit a long-standing pattern. There is a substantial body of evidence documenting health care disparities during the past three decades, including disparities across the country in pain management for ED presentations ranging from leg fractures to abdominal pain.
These studies reveal differences not only in analgesia administration but also in the frequency of pain assessment and the timeliness of analgesia administration. In a study of nearly 2,000 patients in 53 EDs, for instance, not only did black patients receive opioids for severe pain at 60 percent the rate of white patients, but also their pain was reassessed less than half as frequently. When they did receive medications, the medications were delivered an average of 32 minutes later than for their white counterparts.
How do we explain the persistence of these disparities in treatment? The likelihood that physiological differences explain these phenomena is negligible. We are thus left with two disturbing but unsurprising notions, that:
- the institutions where black children are likely to receive their care are less sensitive to the needs of individuals in pain, and
- in all institutions subtle biases—implicit and explicit, conscious and unconscious—influence clinicians’ judgment.
Objective approaches to pain management
Pain management, in many ways, is a subjective art as much as an objective practice. It requires a complex set of evaluations based on multiple factors, such as:
- the clinician’s assessment of the patient’s physical condition
- the child’s interaction with the medical team
- the patient’s self-report of pain
- the clinician’s history with the patient
- in the case of children, parent’s report and input
- the culture and traditional practices of the emergency department where the care is being offered
All of these elements are subject to multiple influences and potential biases. But if we become aware of the potential for subtle bias, often unintentional, at multiple points in the assessment and treatment of pain, we will take a step in the right direction of reducing disparities in care.
How else can we improve our practice? Although each medical decision should be tailored to the specific child and based on the available evidence, it is certainly possible to develop protocols for a number of ED or inpatient scenarios to reduce the possibility of bias. Such policies would eliminate the possibility that lack of clinical expertise or factors external to the child would influence the quality of care. Monitoring can occur through quality audits and measures of patient satisfaction and deficits can be addressed through targeted clinician education.
Finally, a more radical concept calls for simply asking the patient, “Do you want more pain medication?” This approach deemphasizes the clinician’s sole judgment and creates a more patient-centric approach to care. This approach has been advocated by clinicians in our Emergency Department and while this approach may have its own inherent difficulties, it offers a new paradigm to consider in an area that has been strikingly resistant to change, and it should be adaptable to the pediatric setting.
It is clear that despite the 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.
Neil Schechter, MD, is the director of the Chronic Pain Clinic in the Boston Children’s Department of Anesthesiology, Perioperative and Pain Medicine, and an associate professor of anesthesiology at Harvard Medical School.
This article was adapted from a recent editorial published by Fleegler and Schechter in JAMA Pediatrics.
Listen to Eric Fleegler, MD, MPH, discuss racial disparities in pain management in an interview on 900AM WURD.