Although a combination of certain pain medications has been found to be more effective than opioids alone at managing discomfort after surgery, Black patients are less likely to receive this level of care while recovering from a major procedure, new research suggests.
In a study presented Sunday at the American Society of Anesthesiologists’ annual meeting in Philadelphia, post-surgery Black patients were more likely to be prescribed oral opioids and less likely to receive multimodal analgesia, involving four modes of pain management, compared with their White peers.
Multimodal analgesia is a method of pain management that uses multiple types of medications to reduce pain, and some experts argue that this approach not only can decrease the use of dangerously addictive opioids but may be a more effective pain control strategy.
“Multimodal analgesia means using medicines and techniques that act in different ways to reduce pain. By combining different modes patients get better pain relief and require less narcotics,” Dr. Nauder Faraday, an author of the study and professor at the Johns Hopkins University School of Medicine, said in an email.
For a patient to determine whether they will be receiving multimodal analgesia, they “could ask their physicians, before surgery starts, how their pain will be managed after surgery and what drugs that they will be prescribed,” Faraday said. “They can also ask the same questions of their practitioners after surgery.”
The new study included data on thoracic or abdominal surgical procedures conducted at the Johns Hopkins Hospital between July 2016 and July 2021. These complex procedures required admissions to the intensive care unit less than 24 hours after surgery.
The researchers from Johns Hopkins University analyzed how 482 Black adults and 2,460 White adults were treated after those surgeries.
The analysis revealed that the Black patients were about 74% more likely than the White patients to receive opioid pills in their post-surgery recovery and that being Black was associated with a 29% lower likelihood of receiving multimodal analgesia involving four or more modes. The researchers found no difference in the use of two or three modes of analgesia, only in four or more modes, Faraday said.
“We expected most patients in both races would receive multimodal analgesia and that is what we found. Based on previously published work, we hypothesized that Black patients would receive less multimodal analgesia than White patients, and we found that as well,” Faraday said.
The researchers wrote in their abstract that their findings highlight how “racial disparities may exist” in the application of multimodal analgesia but that more research is needed to determine whether similar disparities may emerge among other racial groups and ethnicities.
‘It has a direct effect on people’s livelihood’
Overall, the study showed some correlation between race and the administration of pain medication, but “one thing that is a little bit different about this abstract is, it didn’t quite 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.
Having data on each patient’s self-reported level of pain – and whether there was any difference in the amount of pain among Black and White patients – would have added to the findings, Carrillo said.
Additionally, “most post-operative pain management systems usually have a well-thought-out bundle of care, something called an ERAS, which is an ‘enhanced recovery after surgery’ protocol,” Carrillo said. “So it would be interesting to know if these patients received more opioids in addition to them being part of a protocol that already had a preference for non-opioids – because that would indicate that, despite having a protocol, they were being treated outside 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 who were treated by paramedics with acute traumatic injuries, Black and Brown patients were less likely to have their level of pain recorded in their health data.
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 important because it affects not only quality of life, but any time where opioids are introduced, there’s always a risk-benefit we have to consider,” Carrillo said.
“Understanding how to provide the maximum amount of benefit while reducing risk of addiction or overdose is our number one job when it comes to acute or even chronic pain management,” he said. “It has a direct effect on people’s livelihood and their ability to function and also their wanting to be engaged in the health care system in the future.”
Dr. Dionne Ibekie, an anesthesiologist in central Illinois who was not involved in the new study, said that whenever she meets with a patient before they have an operation, she makes sure to explain the multimodal analgesia approach that will be used: They can receive opioid medications as well as non-opioid medications to treat their pain.
“That way we reduce the amount of opioid medications we need to use because of their side effects, but also because there are other pain pathways and receptors in the body that opioids don’t even touch. I try to emphasize that all of the medications work synergistically to address pain and increase our probability of achieving adequate pain control,” Ibekie, who has talked about 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, points to a need for systemic changes in medicine and further research and policies to ensure equitable healthcare for all,” Ibekie wrote.
“Unfortunately, medical racism is a thing, primarily in the area of unconscious bias. There have been numerous studies in different fields of medicine that have revealed, repeatedly, that black patients are undertreated or poorly managed when treating their pain,” she said. “From the emergency room to the obstetric ward, whether it is black children or adults, or patients with known chronic illnesses like sickle cell or an acute process like a heart attack, we are seeing patients suffer from missed diagnoses and inadequate pain management leading to adverse outcomes.”
The new study hasn’t been published in a peer-reviewed journal, but it isn’t the first time research has revealed deep-rooted racial inequities in health care when it comes to managing and treating pain.
Research published in 2007 in the Journal of the National Medical Association found that physicians are twice as likely to underestimate pain in Black patients compared with all other ethnicities combined.
Another study, published in 2016 in the Proceedings of the National Academy of Science, found that among 222 medical students and residents, many held racist false beliefs about Black patients. For instance, about 12% said they thought Black people’s nerve endings were less sensitive than those of White people, and about 58% reported that they thought Black people’s skin to be thicker than Whites’.
“Taken together, this work provides evidence that false beliefs about biological differences between blacks and whites continue to shape the way we perceive and treat black people—they are associated with racial disparities in pain assessment and treatment recommendations,” the authors of the 2016 study wrote.
A KFF Survey on Racism, Discrimination and Health released last year found that 15% of Black patients who used health care in the previous three years said they were refused pain medication that they thought they needed, compared with 8% of Asian patients, 9% of White patients and 10% of Hispanic patients.
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Another study presented Sunday at the annual meeting of the American Society of Anesthesiologists suggested that Black and Brown trauma patients were less likely to receive timely helicopter transport in a medical emergency.
Among more than 300,000 people older than 15 who received severe injuries requiring urgent surgery or intensive care, helicopter transport was associated with a lower risk of dying compared with ground transport, at 17.6% versus 19.4%, according to the study. However, the data showed that White patients were twice as likely to be airlifted compared with Black patients and almost two times more likely compared with Hispanics and other races.
“Despite the clear survival benefit of helicopter transport following severe trauma, minority patients are less likely to be airlifted than White patients,” the researchers, from Nationwide Children’s Hospital in Ohio and Montefiore Medical Center in New York, wrote in their abstract.
“These disparities have not begun to narrow over time, challenging the effectiveness of current efforts to expand helicopter ambulance programs,” they wrote. “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.”
