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38 Epidemiologic overview of ED pain treatment
for analgesia studies because the pain from fractures is thought to be of similar
intensity; the situation approximates an experimental paradigm in which all
subjects are exposed to the same pain stimulus. However, it has been suggested
that the long-bone fracture model may fail to identify race/ethnicitybased
differences in treatment of pain from conditions that are less objective
and verifiable. 4 This concern is supported by the NHAMCS analysis finding of
racial and ethnic disparities in treatment of migraines and back pain. Patients
with conditions that rely more heavily on patient–doctor communication may
be more vulnerable to disparate treatment. The evidence continues to be
mixed on this subject. Two large studies of patients with varied painful conditions,
comprising a mix of subjective and objective complaints, failed to
find racial/ethnic disparities in pain management. 6,7 As investigation of this
area continues, clinicians must remember the potential for significant interpatient
variation in pain experiences (even with similar diagnoses), pain
reporting, and attitude toward medication use. The goal for acute care physicians
should be to assess pain as objectively as possible, preventing provider
characteristics (e.g. race, sex, stereotyping) from affecting the decision to treat
patients in pain.
Age-related disparities in pain treatment represent another problem.
Younger patients are clearly at risk for receiving insufficient analgesia – the
younger the patient, the higher the risk. The reasons for pediatric oligoanalgesia
can include concerns over adverse events, difficulty in communication
(particularly with young children), and discounting of pain. Some of the same
concerns are in effect in the geriatric population; these issues are discussed in
a separate chapter. Like geriatric oligoanalgesia, the undertreatment of pain
in children is an area of serious concern. The problem of age-related disparities
in pain treatment warrants close attention in order to elucidate further
the reasons for oligoanalgesia, and to identify strategies to improve pain
management in vulnerable populations.
In contrast to the situations with race, ethnicity, and age, it appears that
gender is not a major determinant of analgesia administration. Although
there are some conflicting data, high-quality evidence suggests that the initial
pain report and physician assessment of pain level account for apparent
gender-related differences in treatment. 15