Recent studies indicate a possible disparity in the administration of certain pain relief measures following surgery for Black patients.
At a presentation yesterday at the American Society of Anesthesiologists' annual gathering in Philadelphia, it was found that post-surgery, Black patients were more likely to receive oral opioids and less likely to be provided with multimodal analgesia, a comprehensive pain management technique involving four distinct approaches, compared to their White counterparts.
Multimodal analgesia is a strategy that employs various types of medications to alleviate pain, and certain specialists claim that this method not only lessens the reliance on dangerously addictive opioids but could potentially be a more potent pain control solution.
As Dr. Nauder Faraday, the study's author and a professor at the Johns Hopkins University School of Medicine, put it in an email, "Multimodal analgesia means using medications and techniques that operate differently to reduce pain. By combining various methods, patients experience better pain relief and require fewer narcotics."
To ascertain whether a patient will receive multimodal analgesia, they can ask their doctors before surgery begins about their post-operative pain management strategy and the drugs that will be prescribed to them, according to Faraday. Additionally, they can pose the same questions to their caregivers after the operation.
The new study utilized data collected from thoracic or abdominal surgical procedures carried out at Johns Hopkins Hospital between July 2016 and July 2021. These intricate procedures necessitated ICU admissions within 24 hours of surgery.
Researchers from Johns Hopkins University analyzed the treatment of 482 Black adults and 2,460 White adults following these surgeries.
The study revealed that Black patients were approximately 74% more likely to receive opioid pills during their post-surgery recovery period and that being Black was related to a 29% decrease in the likelihood of receiving multimodal analgesia involving four or more approaches. The team found no difference in the use of two or three methods of analgesia, only in four or more methods, Faraday said.
“We anticipated that most patients in both races would receive multimodal analgesia, and that is what we found. Based on previous research, we hypothesized that Black patients would receive less multimodal analgesia than White patients, and we found that to be the case,” Faraday said.
The researchers wrote in their abstract that their findings suggest that "racial disparities may exist" in the application of multimodal analgesia, but further study is needed to determine whether similar disparities may emerge among other racial groups and ethnicities.
‘It has a direct impact on people’s livelihoods’
Overall, the study shows a correlation between race and pain medication administration, but "one thing that is slightly different about this abstract is that it does not fully address pain levels," said Dr. Eli Carrillo, an emergency physician and director of prehospital education at Stanford Medicine, who was not involved in the new study.
Data on each patient's self-reported pain level – and any potential differences in pain levels between Black and White patients – would have strengthened the findings, Carrillo said.
In addition, "most post-operative pain management systems generally have a well-developed care plan, known as an ERAS (enhanced recovery after surgery) protocol," Carrillo said. "Therefore, it would be intriguing to know if these patients received more opioids despite already being part of a protocol that prioritizes non-opioids, indicating that they were being treated outside of the norm for that institution."
Last year, Carrillo and his colleagues at Stanford authored a similar study published in the journal JAMA Network Open that found that among more than 4.7 million patients treated by paramedics for acute traumatic injuries, Black and Brown patients were less likely to have their pain levels recorded in their medical records.
The researchers also found that, among those with the highest pain scores recorded, Black patients were significantly less likely to receive painkillers than White patients.
“Pain treatment is vital because it impacts not only quality of life, but whenever opioids are administered, there's always a risk-benefit analysis we must consider,” Carrillo said.
“Determining how to provide the maximum benefit while minimizing the risk of addiction or overdose is our primary responsibility when it comes to both acute and chronic pain management,” he said. “It has a direct impact on people’s livelihoods, their ability to function correctly, and their future involvement in the healthcare system.”
Dr. Dionne Ibekie, an anesthesiologist in central Illinois who was not involved in the new study, said that during her discussions with patients before surgery, she ensures they understand the multimodal analgesia approach, which involves receiving both opioid medications and non-opioid medications to treat pain.
“By doing this, we decrease the amount of opioid medications we have to use because of their side effects, but also because various pain pathways and receptors in the body that opioids do not affect can be activated with non-opioid medications. I emphasize that all medications work together more effectively to address pain and boost our chances of achieving adequate pain control,” Ibekie, who has discussed ways to limit opioids after surgery on her podcast “The Ivy Drip,” wrote in an email.
The new study suggests "possible biases in treatment decisions. This once again underscores the need for systemic changes in medicine and further research and policies to ensure equitable healthcare for all,” Ibekie wrote.
Unfortunately, medical bias, notably unconscious prejudice, remains prevalent, particularly in the realm of pain management for individuals of color. Multiple studies across medical fields have consistently shown that black patients often receive insufficient treatment or inadequate care for their pain, from emergency rooms to obstetric wards, affecting both children and adults with chronic diseases like sickle cell or acute situations such as heart attacks.
A yet-unpublished study isn't the first to unveil entrenched racial disparities in health care when it comes to pain management and treatment.
A study published in 2007 in the Journal of the National Medical Association discovered that physicians are more likely to underestimate pain in black patients than any other ethnicity.
Another study, published in 2016 in the Proceedings of the National Academy of Science, revealed that many medical students and residents harbor racist misconceptions about black patients. For instance, around 12% believed that black people's nerve endings are less sensitive, and about 58% thought black people's skin was thicker.
The 2016 study authors concluded that these erroneous beliefs about racial differences continue to shape how we perceive and treat black people, leading to racial disparities in pain assessment and treatment recommendations.
A KFF survey on Racism, Discrimination, and Health released last year found that 15% of black patients who utilized healthcare services in the previous three years reported being denied necessary pain medication, higher than 8% of Asian patients, 9% of white patients, and 10% of Hispanic patients.
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Another study presented at the American Society of Anesthesiologists annual meeting suggested that black and brown trauma patients were less likely to receive timely helicopter transport in a medical emergency.
Among over 300,000 people aged 15 and above requiring urgent surgery or intensive care, helicopter transportation reduced the risk of death compared with ground transportation, at 17.6% versus 19.4%. However, the data indicated that white patients were twice as likely to receive a helicopter ride compared to black patients and nearly twice as likely compared to Hispanics and other races.
The researchers, from Nationwide Children's Hospital in Ohio and Montefiore Medical Center in New York, wrote, "Despite the clear survival benefit of helicopter transport following severe trauma, minority patients are less likely to be airlifted than white patients." They also noted that these disparities have yet to decrease with time, questioning the success of current efforts to expand helicopter ambulance programs. "As trauma care continues to evolve, we must ensure that use of rapid and life-saving care, such as helicopter transport, is not influenced by non-clinical factors, such as race and ethnicity."
The findings of the study suggest that Black patients are more likely to receive oral opioids and less likely to receive multimodal analgesia, a comprehensive pain management technique, compared to their White counterparts post-surgery. This discrepancy in pain management strategies can have a significant impact on patients' experiences with pain and their overall health.
In light of these findings, it is crucial for patients to discuss their post-operative pain management strategy with their doctors before surgery begins and to ask about the drugs that will be prescribed to them. This open dialogue can help ensure that patients receive the most effective pain management solutions tailored to their needs, promoting better health outcomes.
