Disparities in pain medication given to kidney-stone emergency patients

(Reuters Health) - Black and Latino patients treated for kidney stones in emergency departments around the U.S. tend to get less pain-killing medication compared to whites, a new study finds.

After reviewing the medical histories of more than 250,000 patients, researchers found that black patients who had been diagnosed with kidney stones were more likely to get lower doses of opioid medications and less likely to be given an intravenous anti-inflammatory drug compared to whites. Black patients were also more likely to get no pain medication at all.

Latino patients tended to get even lower doses of opioid medications, but did receive the nonsteroidal anti-inflammatory drug (NSAID) ketorolac in similar proportions to white patients, researchers report in the American Journal of Emergency Medicine.

White patients were more likely than either black or Hispanic patients to get the highest opioid dosage.

“Despite efforts to diminish narcotic use in healthcare and despite the availability of effective non-narcotic pain medications, we still see more narcotics are prescribed than non-narcotics,” said study coauthor Dr. George Haleblian, an assistant professor of surgery at Harvard Medical School and director of the urology residency program at Brigham and Women’s Hospital in Boston.

Moreover, Haleblian said in an email, “we see that there is a racial disparity in how pain medications are given.”

The study can’t explain why black and Hispanic patients would be getting different treatment in the ER, Haleblian said. “While we can’t completely tell from the database that this difference is from racial bias, the fact that black patients were most likely to receive no pain medications is telling,” he said. “We hypothesize that it’s likely some overt or subconscious bias may be at play.”

To take a closer look at the possibility of racial bias in the care of those with kidney stones, Haleblian and his colleagues turned to a hospital discharge database that includes patient information such as age, gender, race, insurance status and substance abuse history.

The researchers focused on patients aged 18 and older who were diagnosed in the ER with pain due to kidney stones.

Just over half, 55.4%, of white patients received ketorolac, the non-narcotic medication, as compared with 49.2% of the black patients and 59.3% of Hispanic patients.

“We were surprised that more ketorolac was not used across the board,” Haleblian said.

More black (18%) than white (16.2%) or Hispanic (15%) patients received no injections at all to relieve pain. Hispanic patients were most likely to receive ketorolac only.

Haleblian and his colleagues note that the database does not offer information on the drugs that were prescribed to the patients to take after they were discharged.

The new findings are “disturbing,” said Dr. Michael Lynch, an assistant professor in the department of emergency medicine at the University of Pittsburgh School of Medicine, who wasn’t involved in the study.

“But unfortunately, they are replicating other work that has been done,” Lynch said. “And unfortunately, as in all facets of our society, when we look for instances of bias, it is often found.”

Lynch suspects that the doctors who treated patients in the study wouldn’t see themselves as biased. “It’s easy to think it can’t be you,” Lynch said. “The more it’s identified and studied and objectively defined, the more likely we are to recognize it in ourselves and take a step back and reflect. That’s the first step, honest self-reflection.”

Previous studies have found this kind of bias even in the pediatric population, said Dr. Nathan Irvin, an assistant professor in the department of emergency medicine at Johns Hopkins Medicine in Baltimore, who also wasn’t involved in the study.

Irvin suspects that implicit biases are more likely to be on display in fast-paced situations like emergency rooms, where healthcare providers don’t have time to reflect on possible biases.

“A workaround that might be effective is if an order list pops up (on the computer screen) with everything pertinent to someone with kidney stones,” Irvin said. “It’s one way to standardize care. And biases don’t have a chance to flare up.”

SOURCE: American Journal of Emergency Medicine, online January 8, 2020.