Pain and Prejudice

These are challenging times for clinicians who care for children andadults in pain. The general philosophy regarding the level of attention that shouldbepaid topainaswell as its treatmenthaschangeddramaticallyduring thepast30years, swinging wildly between extremes, and remains a moving target. The first published recognitionof painundertreatment in adults occurred in the 1970s,1 with identification of similar and more dramatic concerns for children emerging a few years later.2At that time,postoperative,procedural,andcancerrelated pain were essentially ignored.3 Research documenting the shortand longterm 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.4Thecommonopiophobia, inwhichexcessive fears about addictionandnarcotic adverseeffects limitedeven their judicioususe, graduallydiminished formanyphysiciansasnumerous articles proclaimed the utility of these agents and as algorithmsandconsensus statements emerged tooutline their safe administration. Unfortunately, although most patients who were prescribed opioids benefited from the reduction of unnecessary pain, 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 that could not be swept under the rug.5 Although one would assume that these concernswould only limit the indiscriminate use of these drugs for inappropriate situations, in fact, the pendulum swung to the other extreme and thewave of negative publicity has led to the scrutiny of essentially any use of narcotic analgesics. Currently, most articles in the lay and even professional press highlight the problems associated with these drugs as opposed to the significant benefits thatmayaccrue fromtheir appropriateuse.5As a result, at this time, we run the genuine risk of returning to a state of opiophobia anddenying individuals in severepain themercyof access to these incredibly valuable drugs. It is with these societal currents inmind thatwe read the article byGoyal et al6 in this issue of JAMAPediatrics. It not only identifies the significant undertreatment of children with severe pain associated withappendicitiswhile in theemergencydepartment (ED)but also reveals major disparities in opioid administration between black and white children with this condition. As in other areas, pain management in emergency medicine has undergone a significant evolution, although unfortunately studies continue to reveal oligoanalgesia in the ED, especially of children.7,8 In a review of this literature, Motov and Khan9 identified a number of causes of poor pain management that are common to all settings: failure to acknowledgepain, failure to assess, failureofdocumentation, and failure to establish standardizedguidelines. They concluded that inadequate knowledge and formal training in acutepainmanagement, opiophobia, various biases (sex, racial, age), and the ED culture itself are barriers to adequate pain management. As compared with adults, children fare even more poorly in receiving analgesia for painful situations in the ED. Numerous studieshave comparedchildrenandadults and found that children receive far less analgesia for similar conditions.10 A national studycomparingadult andpediatricpatientswithappendicitisdemonstrated increaseduseofpainmedicationover time (for adults, 24.8% in 1992 to 69.9% in 2006; for children, 27.2% in 1992 to 42.8% in 2006) but also a clearly widening gap between adults and children in the use of pain medications.11 Although therewasnoadult comparison in the articlebyGoyal andcolleagues, the fact thatonly56.8%ofchildren with acute appendicitis received any form of analgesia and only 41.3% received opioids is striking given that the old dictum about opioids masking a surgical condition in patients with acute abdominal pain has been debunked.12 Perhapsthemostsalientandmostconcerningfindingofthis article,however, is theexistenceof racial differences inadministration of opioids. Black children received opioids for severe painatamiserlyadjustedoddsratioof0.2comparedwithwhite children. In this research, as opposed to others, there was no concern about diversion as medications were administered in the hospital. Likewise, all of these patients were diagnosed as having appendicitis, so issues that had plagued other abdominalpain studieswere less relevant (suchas increaseduseof the ED byAfrican American individuals, whichmay dilute the potential severity of the complaint of abdominal pain). Unfortunately, however, these findings fit a long-standing pattern. There is a substantial body of evidence documenting health caredisparitiesduring thepast 3decades, includingdisparities in pain management. The Institute of Medicine’s reportUnequalTreatment:ConfrontingRacialandEthnicDisparities in Health Care states that “Racial and ethnic disparities in healthcare... are consistent and extensive across a range of medical conditionsandhealthcareservices, areassociatedwith worse health outcomes, and occur independently of insurance status, income, and education....”13 As early as 1993, Todd et al14 demonstrated that Hispanic patientsweremore thantwiceas likely to receivenopainmedications for long-bone fractures as compared with nonHispanic white patients. Although only representative of 139 patients in a single ED in Los Angeles, California, this finding drew national attention. Seven years later, Todd et al15 again Related article page 996 Opinion