Disparities in Opioid Pain Management for Long Bone Fractures

Racial Disparities in Opioid Prescribing in the United States from 2011 to 2021: A Systematic Review and Meta-Analysis

Background

This meta-analysis is an update to a seminal meta-analysis on racial/ethnic disparities in pain treatment in the United States (US) published in 2012. Since then, literature has accumulated on the topic and important policy changes were made.

Objective

Examining racial/ethnic disparities in pain management and investigating key moderators of the association between race/ethnicity and pain outcomes in the US.

Methods

We performed a systematic search of publications (between January 2011 and February 2021) from the Scopus database. Search terms included: race, racial, racialized, ethnic, ethnicity, minority, minorities, minoritized, pain treatment, pain management, and analgesia. All studies were observational, examining differences in receipt of pain prescription medication in various settings, across racial or ethnic categories in US adult patient populations. Two binary analgesic outcomes were extracted: 1) prescription of "any" analgesia, and 2) prescription of "opioid" analgesia. We analyzed these outcomes in two populations: 1) Black patients, with White patients as a reference; and 2) Hispanic patients, with non-Hispanic White patients as a reference.

Results

The meta-analysis included twelve studies, and the systematic review included forty-three studies. Meta-analysis showed that, compared to White patients, Black patients were less likely to receive opioid analgesia (OR 0.83, 95% CI [0.73-0.94]). Compared to non-Hispanic White patients, Hispanic patients were less likely to receive opioid analgesia (OR 0.80, 95% CI [0.72-0.88]).

Conclusion

Despite a decade's gap, the findings indicate persistent disparities in prescription of, and access to opioid analgesics for pain among Black and Hispanic populations in the US.

Highlights From the 2023 Revision of Pediatric Tactical Emergency Casualty Care Guidelines

ABSTRACT

In 2023 the Committee for Tactical Emergency Casualty Care (C-TECC) issued updated Pediatric Tactical Emergency Casualty Care (TECC) Guidelines (Guidelines) that focus on the delivery of stabilizing care of children who are the victims of high-threat incidents such as an active shooter event. The Guidelines provide evidence-based and best practice recommendations to those individuals and departments that specifically provide operational medical support to law enforcement agencies caring for children in this uniquely dangerous environment where traditional resources may not be available. This article highlights key takeaway points from the Guidelines, including several updates since the first version was released in 2013.The evidence base for the care of children in this environment is lacking, and medical care delivered in the high-threat environment is inconsistent and often not optimized for the care of infants and children. The Guidelines are supported from the existing literature base where possible, and where it is not, by consensus as to the current best practices as determined by iterative deliberations among the diverse and experienced group of stakeholders who are members of C-TECC. The Guidelines provide patient assessment and management information specific to the care of children in the following 3 dynamic phases of the high-threat environment: Direct Threat, Indirect Threat, and Evacuation. The phases represent a continuum of risk to the patient and the responder ranging from extreme (such as ongoing gunfire) to minimal (during movement toward definitive medical care).The high-threat environment is dynamic and there is competing safety, tactical/operational, and patient care priorities for responders when infants and children are injured. The Guidelines provide recommendations on the type of medical and psychological care that should be considered under each phase of threat and establishes the context for how and why to deliver (or potentially defer) certain interventions under some circumstances in order the maximize the opportunity for a good outcome for an injured pediatric patient. The Guidelines also emphasize the importance of synergizing hospital-based pediatric trauma care with those law enforcement and fire/emergency medical services that may provide field care to children under high-threat circumstances.

Older age and risk for delayed abdominal pain care in the emergency department

BACKGROUND AND IMPORTANCE

Suboptimal acute pain care has been previously reported to be associated with demographic characteristics.

OBJECTIVES

The aim of this study was to assess a healthcare system's multi-facility database of emergency attendances for abdominal pain, to assess for an association between demographics (age, sex, and ethnicity) and two endpoints: time delay to initial analgesia (primary endpoint) and selection of an opioid as the initial analgesic (secondary endpoint).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective observational study assessed four consecutive months' visits by adults (≥18 years) with a chief complaint of abdominal pain, in a UK National Health Service Trust's emergency department (ED). Data collected included demographics, pain scores, and analgesia variables.

OUTCOME MEASURES AND ANALYSIS

Categorical data were described with proportions and binomial exact 95% confidence intervals (CIs). Continuous data were described using median (with 95% CIs) and interquartile range (IQR). Multivariable associations between demographics and endpoints were executed with quantile median regression (National Health Service primary endpoint) and logistic regression (secondary endpoint).

MAIN RESULTS

In 4231 patients, 1457 (34.4%) receiving analgesia had a median time to initial analgesia of 110 min (95% CI, 104-120, IQR, 55-229). The univariate assessment identified only one demographic variable, age decade ( P = 0.0001), associated with the time to initial analgesia. Association between age and time to initial analgesia persisted in multivariable analysis adjusting for initial pain score, facility type, and time of presentation; for each decade increase the time to initial analgesia was linearly prolonged by 6.9 min (95% CI, 1.9-11.9; P = 0.007). In univariable assessment, time to initial analgesia was not associated with either detailed ethnicity (14 categories, P = 0.109) or four-category ethnicity ( P = 0.138); in multivariable analysis ethnicity remained non-significant as either 14-category (all ethnicities' P ≥ 0.085) or four-category (all P ≥ 0.138). No demographic or operational variables were associated with the secondary endpoint; opioid initial choice was associated only with pain score ( P = 0.003).

CONCLUSION

In a consecutive series of patients with abdominal pain, advancing age was the only demographic variable associated with prolonged time to initial analgesia. Older patients were found to have a linearly increasing, age-dependent risk for prolonged wait for pain care.

Pain experiences of marginalized children in the emergency department: A scoping review protocol

INTRODUCTION

Pain affects all children, and in hospitals across North America, this pain is often undertreated. Children who visit the emergency department (ED) experience similar undertreatment, and they will often experience a painful procedure as part of their diagnostic journey. Further, children and their caregivers who experience social injustices through marginalization are more likely to experience healthcare disparities in their pain management. Still, most of our knowledge about children's pain management comes from research focused on well-educated, white children and caregivers from a middle- or upper-class background. The aim of this scoping review is to identify, map, and describe existing research on (a) how aspects of marginalization are documented in randomized controlled trials related to children's pain and (b) to understand the pain treatment and experiences of marginalized children and their caregivers in the ED setting.

METHODS AND ANALYSIS

The review will follow Joanna Briggs Institute methodology for scoping reviews using the Participant, Concept, Context (PCC) framework and key terms related to children, youth, pain, ED, and aspects of marginalization. We will search Medline, Embase, PsychInfo, CINAHL, Web of Science, Cochrane Library Trials, iPortal, and Native Health Database for articles published in the last 10 years to identify records that meet our inclusion criteria. We will screen articles in a two-step process using two reviewers during the abstract and full-text screening stages. Data will be extracted using Covidence for data management and we will use a narrative approach to synthesize the data.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. Findings will be disseminated in academic manuscripts, at academic conferences, and with partners and knowledge users including funders of pain research and healthcare professionals. Results of this scoping review will inform subsequent quantitative and qualitative studies regarding pain experiences and treatment of marginalized children in the ED.

Comprehensive overview of the anesthesiology research landscape: A machine Learning Analysis of 737 NIH-funded anesthesiology primary Investigator's publication trends

Background

Anesthesiology plays a crucial role in perioperative care, critical care, and pain management, impacting patient experiences and clinical outcomes. However, our understanding of the anesthesiology research landscape is limited. Accordingly, we initiated a data-driven analysis through topic modeling to uncover research trends, enabling informed decision-making and fostering progress within the field.

Methods

The easyPubMed R package was used to collect 32,300 PubMed abstracts spanning from 2000 to 2022. These abstracts were authored by 737 Anesthesiology Principal Investigators (PIs) who were recipients of National Institute of Health (NIH) funding from 2010 to 2022. Abstracts were preprocessed, vectorized, and analyzed with the state-of-the-art BERTopic algorithm to identify pillar topics and trending subtopics within anesthesiology research. Temporal trends were assessed using the Mann-Kendall test.

Results

The publishing journals with most abstracts in this dataset were Anesthesia & Analgesia 1133, Anesthesiology 992, and Pain 671. Eight pillar topics were identified and categorized as basic or clinical sciences based on a hierarchical clustering analysis. Amongst the pillar topics, "Cells & Proteomics" had both the highest annual and total number of abstracts. Interestingly, there was an overall upward trend for all topics spanning the years 2000-2022. However, when focusing on the period from 2015 to 2022, topics "Cells & Proteomics" and "Pulmonology" exhibit a downward trajectory. Additionally, various subtopics were identified, with notable increasing trends in "Aneurysms", "Covid 19 Pandemic", and "Artificial intelligence & Machine Learning".

Conclusion

Our work offers a comprehensive analysis of the anesthesiology research landscape by providing insights into pillar topics, and trending subtopics. These findings contribute to a better understanding of anesthesiology research and can guide future directions.

Are There Racial Disparities in Perioperative Pain? A Retrospective Study of a Gynecological Surgery Cohort

PURPOSE

The purpose of this study was to examine whether racial disparities exist in immediate postoperative pain scores and intraoperative analgesic regimens in a single surgical cohort.

DESIGN

A single-center, retrospective analysis.

METHODS

This retrospective study of a single surgical cohort was conducted via chart review of the existing electronic health record. A total of 203 patients who underwent minimally invasive hysterectomy were included in the analysis. Three initially reviewed patient records were excluded from the final analysis due to the small size of their racial cohorts (two Asian or Pacific Islander and one Native American). The White patients (n = 103) and Black patients (n = 100) were compared for differences in pain scores in the postanesthesia care unit (PACU). The patients' intraoperative analgesic regimens were also compared.

FINDINGS

There were no significant differences between races in the postoperative pain scores in the PACU or in the analgesia administered by the anesthesia provider intraoperatively.

CONCLUSIONS

In this specific population, there was no evidence of racial disparities in postoperative pain or intraoperative analgesia administration. Further research is needed to understand the unique factors of the perioperative period, to see if the absence of disparities in this study is repeated in other cohorts, and to mitigate any disparities that are found.

Implicit Racial Bias in Evaluation of Neonatal Opioid Withdrawal Syndrome

OBJECTIVE

To assess implicit bias by administrating the Modified Finnegan Score (MFS) for quantifying neonatal opioid withdrawal and to evaluate risk of decreased opioid treatment of Black versus White infants.

STUDY DESIGN

Study participants were nurses recruited from a large tertiary care center who received three clinical vignettes portraying withdrawing infants and were randomized to receive an accompanying photo of either a Black or White infant. MFS results were compared for identical vignettes based on race of infant photo.

RESULTS

Out of 275 nurses, 70 completed the survey. In vignette 2, nurses aged ≤35 years scored Black infants lower than White infants (MFS=8.3 ± 2 vs. 9.5 ± 1.2, p=0.012). Nurses with <5 years of experience and ≤10 years of experience also scored Black infants lower for the same vignette (8.2 ± 2.3 vs. 9.6 ± 1.2, p=0.032 and 8.3 ± 2 vs. 9.5 ± 1.2, p=0.0083).

CONCLUSION

Implicit bias may contribute to the difference in opioid treatment.

Patient perceptions of microaggressions and discrimination toward patients during emergency department care

BACKGROUND

Disparities in emergency department (ED) care based on race and ethnicity have been demonstrated. Patient perceptions of emergency care can have broad impacts, including poor health outcomes. Our objective was to measure and explore patient experiences of microaggressions and discrimination during ED care.

METHODS

This mixed-methods study of adult patients from two urban academic EDs integrates quantitative discrimination measures and semistructured interviews of discrimination experiences during ED care. Participants completed demographic questionnaires and the Discrimination in Medical Settings (DMS) scale and were invited for a follow-up interview. Transcripts of recorded interviews were analyzed leveraging conventional content analysis with line-by-line coding for thematic descriptions.

RESULTS

The cohort included 52 participants, with 30 completing the interview. Nearly half the participants were Black (n = 24, 46.1%) and half were male (n = 26, 50%). "No" or "rare" experiences of discrimination during the ED visit were reported by 22/48 (46%), some/moderate discrimination by 19/48 (39%), and significant discrimination in 7/48 (15%). Five main themes were found: (1) clinician behaviors-communication and empathy, (2) emotional response to health care team actions, (3) perceived reasons for discrimination, (4) environmental pressures in the ED, and (5) patients are hesitant to complain. We found an emergent concept where persons with moderate/high DMS scores, in discussing instances of discrimination, frequently reflected on previous health care experiences rather than on their current ED visit.

CONCLUSIONS

Patients attributed microaggressions to many factors beyond race and gender, including age, socioeconomic status, and environmental pressures in the ED. Of those who endorsed moderate to significant discrimination via survey response during their recent ED visit, most described historical experiences of discrimination during their interview. Previous experiences of discrimination may have lasting effects on patient perceptions of current health care. System and clinician investment in patient rapport and satisfaction is important to prevent negative expectations for future encounters and counteract those already in place.

Racial disparities in pain management: Historical maleficence and solutions for equity

ABSTRACT

Medical journals from the 1800s described differences in disease susceptibility, skin thickness, and pain tolerance among races. These misconceptions about biologic differences, the historical exploitation of minorities in research, and implicit biases among healthcare workers have all affected patient care. Discrepancies still exist in pain assessment and management for minority patients compared with their White counterparts and lead to poor health outcomes. By implementing specific changes in policy and practice, including standardization, implicit bias training, and building a diverse workforce, clinicians can begin to provide care that more equitably manages pain for all patients, regardless of race.

Narcotic Utilization After Cleft Lip Repair: Does Local Anesthetic Choice Matter?

To analyze whether the choice of intraoperative local anesthetic for cleft lip repair is associated with the amount of perioperative narcotic utilization.

Retrospective cohort study.

Hospitals participating in the Pediatric Health Information System.

Primary cleft lip repairs performed in the United States from 2010 to 2020.

Local anesthesia injected-treatment with lidocaine alone, bupivacaine alone, or treatment with both agents.

Perioperative narcotic administration.

During the study interval, 8954 patients underwent primary cleft lip repair. Narcotic utilization for unilateral (P < .001) and bilateral (P = .004) cleft lip repair has decreased over the last 5 years. Overall, 21.8% (n = 1950) of infants were administered perioperative narcotics for cleft lip repair, such that 14.3% (n = 1282) required narcotics on POD 0, and 7.2% (n = 647) required narcotics on POD 1.In this study, 36.5% (n = 3269) patients received lidocaine, 22.0% (n = 1966) patients received bupivacaine, and 19.7% (n = 1762) patients received both local anesthetics. Administration of any perioperative narcotic was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P = .001, 17.5% vs 21.7%) or only bupivacaine (P < .001, 17.5% vs 22.9%). Narcotic utilization on the day of surgery was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P < .001, 11.5% vs 15.1%) or only bupivacaine (P = .004, 11.5% vs 14.6%). Narcotic utilization on the first postoperative day was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only bupivacaine (P = .009, 5.9% vs 8.1%).

CONCLUSIONS

In children undergoing cleft lip repair, local anesthetic combination of lidocaine and bupivacaine is associated with decreased perioperative narcotic use compared to lidocaine or bupivacaine alone.

Evidence-Based Guidelines for Prehospital Pain Management: Recommendations

This project sought to develop evidence-based guidelines for the administration of analgesics for moderate to severe pain by Emergency Medical Services (EMS) clinicians based on a separate, previously published, systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel (TEP) was assembled consisting of subject matter experts in prehospital and emergency care, and the development of evidence-based guidelines and patient care guidelines. A series of nine "patient/population-intervention-comparison-outcome" (PICO) questions were developed based on the Key Questions identified in the AHRQ systematic review, and an additional PICO question was developed to specifically address analgesia in pediatric patients. The panel made a strong recommendation for the use of intranasal fentanyl over intravenous (IV) opioids for pediatric patients without intravenous access given the supporting evidence, its effectiveness, ease of administration, and acceptance by patients and providers. The panel made a conditional recommendation for the use of IV non-steroidal anti-inflammatory drugs (NSAIDs) over IV acetaminophen (APAP). The panel made conditional recommendations for the use of either IV ketamine or IV opioids; for either IV NSAIDs or IV opioids; for either IV fentanyl or IV morphine; and for either IV ketamine or IV NSAIDs. A conditional recommendation was made for IV APAP over IV opioids. The panel made a conditional recommendation against the use of weight-based IV ketamine in combination with weight-based IV opioids versus weight-based IV opioids alone. The panel considered the use of oral analgesics and a conditional recommendation was made for either oral APAP or oral NSAIDs when the oral route of administration was preferred. Given the lack of a supporting evidence base, the panel was unable to make recommendations for the use of nitrous oxide versus IV opioids, or for IV ketamine in combination with IV opioids versus IV ketamine alone. Taken together, the recommendations emphasize that EMS medical directors and EMS clinicians have a variety of effective options for the management of moderate to severe pain in addition to opioids when designing patient care guidelines and caring for patients suffering from acute pain.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future

OBJECTIVES

The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas.

METHODS

A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult).

RESULTS

A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout.

CONCLUSIONS

Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

Emergency Department-initiated Buprenorphine and Referral to Follow-up Addiction Care: A Program Description

INTRODUCTION

Emergency department (ED) initiated opioid use disorder (OUD) care is effective; however, real-world predictors of patient engagement are lacking.

OBJECTIVE

This program evaluation examined predictors of ED-based OUD treatment and subsequent engagement.

METHOD

Program evaluation in Boston, MA. Adult patients who met criteria for OUD during an ED visit in 2019 were included. Patients were included if a diagnosis of OUD or opioid-related overdose was associated with the ED visit or if they met previously validated criteria for OUD within the previous 12 months. We assessed predictors of ED-OUD treatment receipt and subsequent engagement, using Healthcare Effectiveness Data and Information Set definition of initial encounter within 14 days of discharge and either 2 subsequent encounters or a subsequent buprenorphine prescription within 34 days of the initial encounter. We used generalized estimating equations for panel data.

RESULTS

During 2019, 1946 patients met criteria for OUD. Referrals to Bridge Clinic were made for 207 (11%), buprenorphine initiated for 106 (5%), and home induction buprenorphine kits given to 56 (3%). Following ED discharge, 237 patients (12%) had a visit within 14 days, 122 (6%) had ≥2 additional visits, and 207 (11%) received a subsequent buprenorphine prescription. Young, White, male patients were most likely to receive ED-OUD care. Patients who received ED-OUD care were more likely to have subsequent treatment engagement (adjusted rate ratio: 2.30, 95% confidence intervals: 1.62-3.27). Referrals were made less often than predicted for Black (-49%) or Hispanic/Latinx (-25%) patients.

CONCLUSIONS

Initiating treatment for OUD in the ED was associated with increased engagement in outpatient addiction care.

A multisociety organizational consensus process to define guiding principles for acute perioperative pain management

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

Review article: Implicit bias towards Aboriginal and Torres Strait Islander patients within Australian emergency departments

Aboriginal and Torres Strait Islander peoples continue to suffer adverse experiences in healthcare, with inequitable care prevalent in emergency settings. Individual, institutional and systemic factors play a significant part in these persisting healthcare disparities, with biases remaining entrenched in healthcare institutions. This includes implicit racial bias which can result in stereotyping of racial minorities and premature diagnostic closure. Furthermore, it may contribute to distrust of medical professionals resulting in higher rates of leave events and hinder racial minorities from seeking care or following treatment recommendations. The aim of this review is to analyse the effect of implicit bias on patient outcomes in the ED in international literature and explore how these studies correlate to an Australian context.