Authors: Rosemary Nabaweesi, Jonathan Goree, Kevin Sexton, Brian Gittens
Abstract
Purpose of Study
In the US, opioids have caused significant morbidity and mortality over the last decade. In 2017 drug overdose accounted for 70,237 deaths and 67.7% of these involved an opioid. In 2016, the Centers for Disease Control and Prevention developed an opioid prescribing guideline with twelve recommendations for chronic pain management intended to improve communication between providers and patients, about opioid therapy safety and effectiveness and opioid use disorder risks.
Long-term opioid use typically begins with treatment of acute pain. Opioids can effectively relieve pain but judicious use should be taken to minimize the risk of abuse. Research indicates that 6% of patients have continued opioid use 90 days post-surgery, even though the length of initial opioid prescription directly correlates with chronic opioid use risk. Conversely, poorly controlled acute post-surgical pain increases rates of chronic post-surgical pain syndromes; thus adequately controlling acute pain is vital to preventing long-term opioid use.
Black and Latino patients are commonly prescribed less opioids than White patients for similar chief complaint and diagnosis. A retrospective review of pediatric emergency department admissions for appendicitis, found that White patients were twice as likely to be prescribed opioids compared to Black patients. Factors associated with racially disparate opioid-prescribing practices include implicit bias, provider patient communication gaps, lack of trust, historical trauma, lack of or limited healthcare access. In order to improve acute post-surgical pain management, decrease opioid use and eliminate prescribing disparities, many academic centers have developed standardized pain protocols. The pain protocols often include anesthetic plan standardization, acute pain regimens, and post-surgical opioid and adjuvant prescriptions. While literature demonstrates that the pain protocols have decreased peri-operative opioid prescription, there is a knowledge gap on the effect of pain protocols on improving opioid-prescribing racial disparities.
Aims
1) Identify opioid prescribing racial disparities among patients admitted to the trauma surgery service at a Level I Trauma Center
2) Determine the impact of implementing a standardized acute pain protocol intervention on identified prescribing disparities
Data and Methods
The trauma acute pain protocol to standardize opioid prescribing (ordering) was established mid-2017. We conducted a retrospective review of all adult trauma admissions at Level I trauma center between 2015 and 2018. Opioid prescription was our primary outcome for the logistic regression. Patients were matched for age, gender and injury severity. Eligibility criteria were adult patients admitted to a level I Trauma Center.
Key Findings
Of eligible patients, 7,581 met inclusion criteria, 5,115 pre-intervention and 2,466 post intervention. African American patients were significantly less likely to receive opioids than Caucasian patients after controlling for injury severity, age and gender; Odds ratio (OR) 0.61 95% Confidence Interval (CI) 0.49, 0.74; p-value <0.001. Similarly, Asian and Latino patients also were significantly less likely to receive opioids than Caucasian patients post intervention; OR 0.65, CI: 0.42, 0.98, p-value 0.042.
Table 1: Logistic Regression of Opioid Administration by Admitted Patients’ Race
Pre- Intervention Race Odds Ratio
(95% Confidence Interval)
(95% Confidence Interval)
African American 0.64 (0.56, 0.73) Latina/ Asian 0.78 (0.59, 1.03)
Post-Intervention
P-Value P-Value
Odds Ratio
<0.001 <0.001
0.084 0.65 (0.42, 0.98) 0.042
Submitted to GDI 12/16/2019
Implications
When trauma surgeons used a standardized acute pain protocol, the odds of African American, Asian and Latino patients being prescribed opioids following a traumatic event remained lower compared to Caucasian patients with matched injury severity, age and gender.
Next Steps
We posit that since prescribers adhered to the acute pain protocol, we have to examine the dispensation practices of nurses for as-needed medications. We propose to implement three educational interventions to mitigate the problem of disparate opioid dispensing and recommendation by nurses working with Trauma Surgery inpatients.
Conference/Symposium/Course name, dates and location where the work was supposed to be presented:
16th Annual AAMC Health Workforce Research Conference, Bethesda, MD May 6-8, 2020