Appendicitis is painful. Having been lucky enough to experience it in my late twenties myself, I can personally verify this bit of common knowledge. It hurts.
However, despite the clear association between appendicitis and pain, which can be quite severe, the management of that pain is not always consistent. A new study in the journal JAMA Pediatrics finds that there are racial disparities in the medications used to treat it for children in American emergency departments, with black patients far less likely to get more potent pain medication than white ones.
The authors of the study sought to build on previous reports that had documented disparities between white and black patients regarding pain management. They chose appendicitis as their particular focus because it more clearly warrants stronger pain medications. There are many causes of broader categories like abdominal pain, and for some of these treating with opioid medications like morphine or Demerol would be inappropriate. By selecting appendicitis, investigating the proper pain control is less ambiguous.
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Using a survey of hospitals conducted annually by the Centers for Disease Control and Prevention (CDC), the study looked at how often any pain medication was prescribed for pediatric patients diagnosed with appendicitis, and beyond that, how often opioids specifically were given. While their results showed no racial difference in how often analgesics as a whole were delivered to control patients’ pain, there was a big difference when it came to opioids.
Black patients received the stronger medications in about 20 percent of overall cases, compared to about 43 percent of white patients. When controlling for additional factors such as ethnicity, age, sex, insurance status, triage level, and pain score, black children were likely to get opioids for their pain about 12 percent of the time, compared to 34 percent for white children.
This disparity remained even when patients rated their pain as moderate, with a 60 percent likelihood for white patients to receive any pain medication at all, compared to only about 16 percent for black patients. When the pain rating was severe, black patients were likely to receive the stronger opioid class of medication about 25 percent of the time, compared to 58 percent for white ones.
In other words, three-quarters of the time black children presented to emergency departments complaining of severe abdominal pain from appendicitis, if they received any pain medication at all it was likely to be a comparatively weak choice such as Tylenol. Two-thirds of white patients in similar levels of pain were likely to get something like Demerol or morphine.
The results when it comes to the appropriate management of appendicitis weren’t great across the board. Overall, a little less than 60 percent of all patients surveyed received pain medication of any kind. That means a sizeable minority weren’t given anything, which is distressing in itself. As the authors note, good pain control is a benchmark of quality care, and large numbers of kids during the study period weren’t getting it.
Much of this lack may be related to providers’ mistaken belief that appropriately controlling patients’ pain can delay proper diagnosis, which could then delay necessary surgery. Location and severity of pain are among the criteria for diagnosing appendicitis, after all. However, there are numerous studies that debunk that misapprehension, and patients who present in pain should have that pain alleviated.
However, the racial disparity in how appendicitis pain was treated is stark in this report. The authors found that the odds of a black child being given appropriate pain medication were one-fifth those for a white child. That is egregious.
In their discussion of the data, the authors posit that this disparity is the result of bias. Providers may be more skeptical of complaints of pain by black patients and/or more sympathetic to similar complaints from white ones. Interestingly, they reference a different study that found no such disparity in the treatment of pain from broken bones.
While the authors offer no explanation for this difference in finding, I wonder if the objective finding of a broken bone on an X-ray mitigates bias a bit, whereas diagnosing appendicitis is often based on a variety of factors, and in many cases relies more on a provider’s clinical judgment.
Reading this study, I also found myself wondering if there was an alternative or complementary explanation for the difference in pain management beyond provider bias, perhaps some additional pernicious racial disparity in treatment. As mentioned, lack of opioid prescription could be due to providers failing to be aware of newer standards of care regarding treatment of appendicitis, and may reflect poorer quality of care in general.
The authors cite another study conducted within a single emergency department that found no racial disparity in opioid prescription, though it lacked enough black patients to be very powerful in that regard. An additional factor affecting how often black patients are given appropriate pain medication may be that they lack access to higher-quality medical centers where standards of care are more up to date. That factor was not investigated in this new study from what I see, and bears further scrutiny.
What does seem all too clear, however, is that far too many children with pain from appendicitis are going untreated or under-treated, and they are far more likely to be black. This is disgraceful. All patients should be treated by doctors who know the standards for relieving their pain, and all patients deserve to have their symptoms taken seriously, regardless of race. That should go without saying, and that patients may have been treated otherwise is inexcusable.
