Black Kids Receive Less Pain Meds for Appendicitis in ER

[secretlyevil]

www.nbcnews.com/health/kids-health/black-kids-get-less-pain-medication-white-kids-er-n427056

Couldn't c&p from phone.

[orangeblossom]

Of course. Sickening.

[laurenpetro]

I'm not even opening this. Holy shit.

[sfy]

I'll summarize for anyone who doesn't feel like reading.

Black people of all ages, sizes, ethnicities, religions, genders, etc.,: Can we live?

The world: NO.

You guys are welcome.

[lyssbobiss, Command, B613]

...the fuck?

How are there not just standing orders for pain meds for this diagnosis based on the child's height and weight?

[WOT?*]

So, only 57% of kids got pain killers for acute appendicitis, only 41% got opiates and only 12!!!!!!% of black children (so less than 1:3 ratio of black to white) got opiates?

What.the.hell? Leaving children in pain because why?

[orangeblossom]

Black children with acute appendicitis -- a clearly painful emergency -- are less likely than white children to get painkillers in the emergency room, researchers reported Monday.

And nearly as troubling, only about half of any of the kids got painkillers, even though they're strongly recommended in cases of appendicitis, the researchers found.

"Black patients with moderate pain were less likely to receive any analgesia, and black patients with severe pain were less likely to be treated with opioids," Dr. Monika Goyal of the Children's National Health System in Washington and colleagues wrote in the Journal of the American Medical Association's JAMA Pediatrics.

What's to blame? Probably a combination of an unwarranted fear of opioids such as morphine and fentanyl, combined with unconscious bias against African-American kids, experts said.

"BLACK PATIENTS WITH SEVERE PAIN WERE LESS LIKELY TO BE TREATED WITH OPIOIDS."
The researchers used national survey data from 2003 to 2010, covering more than 900,000 children with acute appendicitis. They thought studying appendicitis would be a good starting point since there's broad agreement among experts that it's a condition that merits pain relief.

Only 57 percent of the kids got anything for their pain in the emergency department, they found, and only 41 percent got an opioid drug. And just 12 percent of black children got an opioid drug for pain.

"Our findings suggest that there are racial disparities in opioid administration to children with appendicitis," Goyal's team wrote.

"Our findings suggest that although clinicians may recognize pain equally across racial groups, they may be reacting to the pain differently by treating black patients with nonopioid analgesia, such as ibuprofen and acetaminophen, while treating white patients with opioid analgesia for similar pain."

The researchers note that painkillers, including opioids, are strongly recommended for appendicitis. There were fears in the past that giving painkillers would mask symptoms important for diagnosing the causes of abdominal pain, but those fears have long been shown to be unfounded.

There's also a fear of giving opioids to children. It's possible to overdose and to have dependence develop. But the whole point of opioids is to control severe pain like that seen in appendicitis, and there are protocols for making sure children don't overdose and don't become dependent.

"WE ARE LEFT WITH THE NOTION THAT SUBTLE BIASES, IMPLICIT AND EXPLICIT, CONSCIOUS AND UNCONSCIOUS, INFLUENCE THE CLINICIAN'S JUDGMENT."
Dr. Eric Fleegler and Dr. Neil Schechter of Boston Children's Hospital and Harvard Medical School say emergency department doctors aren't doing their jobs if they don't control pain in all children, including black children.

"If there is no physiological explanation for differing treatment of the same phenomena, we are left with the notion that subtle biases, implicit and explicit, conscious and unconscious, influence the clinician's judgment," they wrote in a commentary.

"It is clear that despite broad recognition that controlling pain is a cornerstone of compassionate care, significant disparities remain in our approach to pain management among different populations," they added.

"Strategies and available knowledge exist to remedy this unfortunate situation; we can and should do better."

The findings are not surprising, they added. Other studies have shown biases in giving pain medication and in medical treatment in general.

"Unfortunately, however, these findings fit a longstanding pattern. There is a substantial body of evidence documenting health care disparities during the past three decades, including disparities in pain management," they wrote.

It's possible that black kids are less likely to say they're in pain

There's one easy solution, the researchers suggested: Ask patients if they want pain medication.

[orangeblossom]

Sadly, this is wholly surprising to me, though I wouldn't have expected the biases to trickle down to kids like this, but being black and receiving disparate narcotic treatment, not surprised at all.

The one and only time, I wrote a response/commented on an article, was an article about black sickle cell patients being seen as "drug seekers", rather than you know wanting to be out of serious pain.  You can't refute the facts of the study, that poor treatment of patients was happening, but the author wrote from such an Ivory Tower perspective, and didn't go into the science/history of why sickle cell patients might be concentrated in urban areas, I had to say something.

My comment was deleted.  It wasn't even rude, just very matter of fact.  Truth hurts some times, I guess.

[lyssbobiss, Command, B613]

CHILDREN ARE NOT DRUG-SEEKING. This is just fucking unbelievable.

[ttt]

So wait, 43% of all kids got no pain medications for appendicitis at all?

[ttt]

I'm curious to know the ages of these kids too. I could almost see doctors viewing a 17 year old as "drug seeking" but not a 5 year old.

[ttt]

Original study :

archpedi.jamanetwork.com/Mobile/article.aspx?articleid=2441797

"Children" is defined as 21 and under, which seems a little odd to me.

[ttt]

So now I'm confused because it says there was no difference in overall pain medication administration but only a difference in opioid administration:

There was no statistically significant difference in overall analgesia administration by race, but there was a statistically significant difference in opioid administration by race.

[Deleted]

Sept 14, 2015 20:43:31 GMT -5 ttt said:

Original study :

archpedi.jamanetwork.com/Mobile/article.aspx?articleid=2441797

"Children" is defined as 21 and under, which seems a little odd to me.

Under 21 isn't odd. Pediatricians train and will treat until a patient is 21. 

And thanks for the original study, I definitely want to read it. 

[ttt]

Sept 14, 2015 20:49:16 GMT -5 @wandering said:

Sept 14, 2015 20:43:31 GMT -5 ttt said:

Original study :

archpedi.jamanetwork.com/Mobile/article.aspx?articleid=2441797

"Children" is defined as 21 and under, which seems a little odd to me.

Under 21 isn't odd. Pediatricians train and will treat until a patient is 21. 

And thanks for the original study, I definitely want to read it. 

Ok thanks - it just sounds odd to a layman to hear 21 year olds referred to as "children"!

[Deleted]

Sept 14, 2015 20:40:06 GMT -5 ttt said:

So wait, 43% of all kids got no pain medications for appendicitis at all?

And this is why I definitely want to read the original article that you posted. Because having an appendicitis doesn't mean that you always need pain medication and are in excruciating pain. So how did they account for that? I'm thinking about the last appendicitis patient that I saw...by the time she came to the ER her pain had subsided (I think she graded it a 4 out of 10 on the pain scale), but her CT and her history was still very suspicious for appendicitis so she had her appendix taken out the next day.

So since it seems like this is a retrospective study, I wonder what exactly they looked at in the medical records. 

[Deleted]

Ok I think I need to read this whole thing when I'm completely sober....

First, the racial breakdown is 8.8% blacks vs 86.6% whites. I assume their numbers are still enough for statistically significant results, but still, those numbers did make my eye brow raise a little bit.

Second, several instances of the study saying "In bivariable analysis, there were no statistically significant differences in administration of any analgesia by race; however, black patients were less likely to receive opioid analgesia than white patients"

So it looks like black patients were just less likely to receive opioids?

I'm going to read it fully tomorrow. Very interesting study. I really need to brush up on my statistics  (wilted)

[asdfjkl]

Sept 14, 2015 19:52:15 GMT -5 lyssbobiss, Command, B613 said:

...the fuck?

How are there not just standing orders for pain meds for this diagnosis based on the child's height and weight?

Because pain is subjective and one person's 3 is another person's 8.  Not trying to disagree with the conclusions of the research. Just saying the answer isn't standing orders; it's doctors not being racist.  

[lyssbobiss, Command, B613]

Sept 14, 2015 21:11:17 GMT -5 asdfjkl said:

Sept 14, 2015 19:52:15 GMT -5 lyssbobiss, Command, B613 said:

...the fuck?

How are there not just standing orders for pain meds for this diagnosis based on the child's height and weight?

Because pain is subjective and one person's 3 is another person's 8.  Not trying to disagree with the conclusions of the research. Just saying the answer isn't standing orders; it's doctors not being racist.  

I agree that the solution needs to be doctors not being racist assholes; I just don't understand how it happens that they're not even offering these meds.  A kid comes in with a confirmed case of appendicitis and someone throws some tylenol at them?  I would be livid.

[decemberwedding07]

Sept 14, 2015 21:11:17 GMT -5 asdfjkl said:

Sept 14, 2015 19:52:15 GMT -5 lyssbobiss, Command, B613 said:

...the fuck?

How are there not just standing orders for pain meds for this diagnosis based on the child's height and weight?

Because pain is subjective and one person's 3 is another person's 8.  Not trying to disagree with the conclusions of the research. Just saying the answer isn't standing orders; it's doctors not being racist.  

Anecdote time! I would just like to add in that whenever I have described my pain as anything more than a 3, I've been given a prescription for painkillers. If I say I don't want it, I'm told to take it anyway, because I might want it later. 
-very white woman

[ttt]

Sept 14, 2015 21:16:25 GMT -5 lyssbobiss, Command, B613 said:

Sept 14, 2015 21:11:17 GMT -5 asdfjkl said:

Because pain is subjective and one person's 3 is another person's 8.  Not trying to disagree with the conclusions of the research. Just saying the answer isn't standing orders; it's doctors not being racist.  

I agree that the solution needs to be doctors not being racist assholes; I just don't understand how it happens that they're not even offering these meds.  A kid comes in with a confirmed case of appendicitis and someone throws some tylenol at them?  I would be livid.

I could see it, though, if you have a 20 year old who says their pain levels are low, they may not offer stronger pain meds because they don't seem to be needed. It's not an explanation for the racial disparities but I'm not upset that not everyone with appendicitis automatically gets prescribed narcotics.

[ttt]

Sept 14, 2015 21:03:01 GMT -5 @wandering said:

Ok I think I need to read this whole thing when I'm completely sober....

First, the racial breakdown is 8.8% blacks vs 86.6% whites. I assume their numbers are still enough for statistically significant results, but still, those numbers did make my eye brow raise a little bit.

Second, several instances of the study saying "In bivariable analysis, there were no statistically significant differences in administration of any analgesia by race; however, black patients were less likely to receive opioid analgesia than white patients"

So it looks like black patients were just less likely to receive opioids?

I'm going to read it fully tomorrow. Very interesting study. I really need to brush up on my statistics  (wilted)

I will be interested to hear your take on it!

[Deleted]

Sept 14, 2015 21:16:25 GMT -5 lyssbobiss, Command, B613 said:

Sept 14, 2015 21:11:17 GMT -5 asdfjkl said:

Because pain is subjective and one person's 3 is another person's 8.  Not trying to disagree with the conclusions of the research. Just saying the answer isn't standing orders; it's doctors not being racist.  

I agree that the solution needs to be doctors not being racist assholes; I just don't understand how it happens that they're not even offering these meds.  A kid comes in with a confirmed case of appendicitis and someone throws some tylenol at them?  I would be livid.

The study isn't designed to know if the meds were offered. 

It even says "There are several potential limitations to this study. First, it is possible that patients declined analgesia despite having pain, and this phenomenon could be different between races. Unfortunately, the database we used and the study design do not allow us to test this hypothesis."

I believe there are plenty of disparities in healthcare and this is a good topic for discussion, but after my brief look at the study I'm not so sure if I'm going to be in an outrage yet. 

[asdfjkl]

Sept 14, 2015 21:16:25 GMT -5 lyssbobiss, Command, B613 said:

Sept 14, 2015 21:11:17 GMT -5 asdfjkl said:

Because pain is subjective and one person's 3 is another person's 8.  Not trying to disagree with the conclusions of the research. Just saying the answer isn't standing orders; it's doctors not being racist.  

I agree that the solution needs to be doctors not being racist assholes; I just don't understand how it happens that they're not even offering these meds.  A kid comes in with a confirmed case of appendicitis and someone throws some tylenol at them?  I would be livid.

Anecdote time:  I got dilaudid (sp?) for what turned out to be really bad indigestion.  So, I partially get what you're saying.  But I think that the significance of this study is that they controlled for the subjective pain report and STILL found that there was a difference in treatment.  So, I'm not mad that not every kid gets narcotics, not every kid should.  But there shouldn't be a racial difference in the way "severe" reports of pain are treated.  There's no way to get around the significance of that finding.

[overture]

This admittedly has very little to do with the article:

My husband had appendicitis, we went to the ER (Catholic hospital) and I had to literally beg the nursing staff to give him pain meds. They outright refused until they got results from an ultrasound. Then they waited a good hour to even give me a time he would be given an ultrasound. This was like 9:00 in the morning, and there were maybe four other people in the ER when we got there. He writhed in pain for three hours before they gave him any pain meds. I was 100% convinced that because he was a twenty something guy covered in tattoos they thought "drug seeker until proven otherwise." They were sure as hell a lot nicer to us after the ultrasound. And by "a lot nicer" I mean "acknowledged our existence."

[downtoearth]

Really?!?! WTF?!?! So even some of the most intelligent and caring of our society (ie doctors and med staff) are not aware of their own racist bias?!

ETA - after reading @wandering 's posts, maybe the study was flawed, but I would hope doctors still read this and check their own actions for bias.

[lyssbobiss, Command, B613]

I appreciate the thoughtful responses to my (admitted) outright rage last night at what appeared to be a huge racial disparity between the way white kids are treated versus black kids. I'm still not convinced something isn't fishy with how they're treated but I'm also seeing now that there may have been things I didn't read clearly the first time out. I'd like to see what all of the kids reported their pain as on the scale and if there was a difference between races about whether or not narcotic meds were given. I always think appendicitis would be like a 8/9 out of 10 but that's my bias! Obviously it's not always that severe. It's certainly something worth looking into further, though.

[twohearted]

i think this needs to be investigated further. It mentioned in the original article that similar disparities have not been seen in other studies. One even used similar methods apparently but looked at long bone fractures. No significant differences were found there.

In a different study I once read who determined the patients' race was important. There wasn't always agreement between the patient and the person who recorded it in the chart. I don't know that this explains the different findings here, but I think it does highlight how methodology is very important and simple things can be overlooked or incorrect assumptions can be made.

Kind of a side note, but it sounds like multiple studies have established that younger children are less likely to be offered appropriate pain management. It makes me think that this is an area where I might really need to advocate for my kid.