Background: Prior studies have found Black and Hispanic patients are more likely to experience disparities in pain management. Fewer studies have evaluated pain control based on age, sex, body mass index (BMI), or presence of a substance use disorder (SUD). While factors influencing management of acute pain are complex, striving for adequate pain control remains an important goal. Acute pancreatitis is uniquely suited for a study in patient-reported pain control as it is a clinical condition for which analgesia is a cornerstone of management. We aim to explore if there are differences in patient-reported pain control in acute pancreatitis depending on several patient characteristics that may impart risk for inequitable care.
Methods: We performed a retrospective cohort study of patients admitted to Denver Health between 1/1/2017–12/31/2019 for acute pancreatitis; 659 patients met inclusion and exclusion criteria. The primary outcome was patient-reported pain control during the first 24 hours of hospital admission, which was determined by comparing controlled vs uncontrolled reports of pain and mean pain scores. Achievement of “controlled pain” was defined as ≥1 verbal pain scores equal to or less than the patient’s stated functional pain goal. Patients were stratified by age group; sex; self-reported race/ethnicity; BMI group; and presence of a SUD as defined by ICD-10 discharge summary codes. A chi-squared analysis was performed to identify differences within and between groups and a t-test was used to compare mean pain scores between groups.
Results: We identified statistically significant differences in pain control at 24 hours for patients with SUD and based on age group (p< 0.01); 39% of those aged 18-40 met the primary outcome, compared with 49% of those aged 41-64 and 66% of those 65 years and older. Among those with a SUD, 41% met the primary outcome compared with 58% of those without a SUD. Patients with SUD comprised 61% of the study population and among those with SUD, 88% received opioids within the first 24 hours of hospitalization Among those who achieved pain control, the average initial pain score was 5, which decreased to 4 within 24 hours. Among those who did not achieve pain control, the average initial pain score was 7; pain remained at an average of 7 at 24 hours (p< 0.01).
Conclusions: There were no significant differences in ability to achieve tolerable pain based on sex, BMI, or race/ethnicity. There were significant differences identified based on age—with older age correlating with better pain control—and presence of a SUD, with SUD correlating with a lower probability of patient-reported pain control. Within the SUD group, 88% received opioids, suggesting that difficulty with pain control may not be entirely explained by reluctance to treat with opioids. Limitations of this study include inability to distinguish between subtypes of SUDs and to differentiate White Hispanic and White non-Hispanic patients. Notably, across all patients, there was a low rate of achieving pain control goals. Additional studies should be performed to assess if differences in pain control are related to amount of morphine equivalents ordered, use of pain adjuncts, titration of medication orders in response to uncontrolled pain, and possible psychological differences in pain experiences. Patients with SUD may benefit from initiatives to improve rates of pain control. Finally, these methods provide a framework with which other institutions can evaluate for differences in patient-reported pain control in their hospitals.
