Pain caused by long bone fractures is a common reason for opioid prescribing in the emergency department (ED) setting.1  Approximately 40% of opioid overdose deaths involve a prescription,2  and in response, opioid prescribing has declined in the last decade.3  We previously demonstrated racial and/or ethnic disparities in the ED management of pain among children with long bone fractures.4  We now perform this study to investigate whether racial and/or ethnic differences in provision of outpatient opioid prescriptions for children discharged from the ED with long bone fractures have attenuated over time.

We performed a retrospective cross-sectional study of children aged 4 to <18 years with long bone fractures (clavicle, humerus, ulna, radius, femur, tibia, and fibula, as identified by International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, 10th Revision, Clinical Modification, diagnosis codes or natural-language processing of radiology reports5 ) using the Pediatric Emergency Care Applied Research Network Registry, an electronic health record registry of 4 geographically diverse (northeast, south, west, and midwest) pediatric EDs from January 1, 2012, to December 31, 2019.6  We included patients with an Emergency Severity Index of 2 to 4, at least 1 pain score, and disposition of ED discharge. Race and/or ethnicity were categorized as non-Hispanic White, non-Hispanic Black, Hispanic, and other. We performed bivariable and multivariable logistic regression to measure the association between patient race and/or ethnicity and outpatient prescription. Covariates included patient-, visit-, and injury severity–level factors. Models were fit to all years combined, 2019 only, and 2019 with an interaction testing for site differences. We calculated relative reductions [RRs] in opioid prescription rates over time for each race and/or ethnicity group and assessed trends using Cochran-Armitage tests. The study was approved by the institutional review boards of all sites.

There were 42 803 ED eligible visits; 6441 (15.0%) children received an opioid prescription at ED discharge. Prescribing varied by race and/or ethnicity; 19.8% of non-Hispanic White children received opioids compared with 10.1% of non-Hispanic Black (adjusted odds ratio [aOR] 0.69; 95% confidence interval [CI] 0.63–0.76) and 13.2% of Hispanic (aOR 0.72; 95% CI 0.66–0.80) children (Table 1).

TABLE 1

Study Population: Patient- and Visit-Level Variables and Opioid Prescription

Overall (N = 42803), n (%)No Opioid Prescribed (n = 36362), n (%)Opioid Prescribed (n = 6441), n (%)Unadjusted Odds Ratio (95% CI)aORa (95% CI)
Race and/or ethnicity      
 Non-Hispanic White 17754 (41.5) 14245 (80.2) 3509 (19.8) (Reference) (Reference) 
 Non-Hispanic Black 12331 (28.8) 11088 (89.9) 1243 (10.1) 0.46 (0.42–0.49) 0.69 (0.63–0.76) 
 Hispanic 8526 (19.9) 7398 (86.8) 1128 (13.2) 0.62 (0.58–0.67) 0.72 (0.66–0.80) 
 Other 3712 (8.7) 3228 (87.0) 484 (13.0) 0.61 (0.55–0.67) 0.77 (0.69–0.87) 
 Unknown 480 (1.1) 403 (84.0) 77 (16.0)   
Age categories, y      
 4–<8 14828 (34.6) 13058 (88.1) 1770 (11.9) (Reference) (Reference) 
 8–<11 10521 (24.6) 9099 (86.5) 1422 (13.5) 1.15 (1.07–1.24) 1.08 (0.99–1.18) 
 11–<14 10540 (24.6) 8669 (82.2) 1871 (17.8) 1.59 (1.48–1.71) 1.53 (1.41–1.67) 
 14–<18 6914 (16.2) 5536 (80.1) 1378 (19.9) 1.84 (1.70–1.98) 2.09 (1.90–2.29) 
Sex      
 Male 27172 (63.5) 22865 (84.1) 4307 (15.9) (Reference) (Reference) 
 Female 15631 (36.5) 13497 (86.3) 2134 (13.7) 0.84 (0.79–0.89) 0.98 (0.91–1.04) 
Insurance type      
 Private 18281 (42.7) 14794 (80.9) 3487 (19.1) (Reference) (Reference) 
 Government 22129 (51.7) 19462 (87.9) 2667 (12.1) 0.58 (0.55–0.61) 0.78 (0.72–0.83) 
 Self-pay 2032 (4.7) 1749 (86.1) 283 (13.9) 0.69 (0.60–0.78) 0.82 (0.71–0.95) 
 Other or unknown 361 (0.8) 357 (98.9) 4 (1.1)   
ED year      
 2012 5146 (12.0) 3775 (73.4) 1371 (26.6) (Reference) (Reference) 
 2013 5136 (12.0) 3975 (77.4) 1161 (22.6) 0.80 (0.74–0.88) 0.77 (0.70–0.85) 
 2014 5715 (13.4) 4722 (82.6) 993 (17.4) 0.58 (0.53–0.63) 0.52 (0.47–0.58) 
 2015 5581 (13.0) 4684 (83.9) 897 (16.1) 0.53 (0.48–0.58) 0.45 (0.40–0.50) 
 2016 5586 (13.1) 4805 (86.0) 781 (14.0) 0.45 (0.41–0.49) 0.36 (0.32–0.40) 
 2017 5708 (13.3) 5077 (88.9) 631 (11.1) 0.34 (0.31–0.38) 0.26 (0.23–0.29) 
 2018 4778 (11.2) 4425 (92.6) 353 (7.4) 0.22 (0.19–0.25) 0.15 (0.13–0.18) 
 2019 5153 (12.0) 4899 (95.1) 254 (4.9) 0.14 (0.12–0.16) 0.09 (0.08–0.10) 
Provider type      
 PEM attending 26023 (60.8) 21471 (82.5) 4552 (17.5) (Reference) (Reference) 
 EM attending 527 (1.2) 450 (85.4) 77 (14.6) 0.81 (0.63–1.03) 1.07 (0.82–1.39) 
 Peds attending 4657 (10.9) 4238 (91.0) 419 (9.0) 0.47 (0.42–0.52) 0.71 (0.63–0.80) 
 Fellow 1154 (2.7) 1050 (91.0) 104 (9.0) 0.47 (0.38–0.57) 0.62 (0.50–0.78) 
 NP/PA 4333 (10.1) 3975 (91.7) 358 (8.3) 0.42 (0.38–0.48) 0.66 (0.58–0.75) 
 Other 6109 (14.3) 5178 (84.8) 931 (15.2) 0.85 (0.79–0.92) 0.89 (0.82–0.98) 
Triage level      
 ESI4 13886 (32.4) 13204 (95.1) 682 (4.9) (Reference) (Reference) 
 ESI3 22520 (52.6) 18756 (83.3) 3764 (16.7) 3.89 (3.57–4.23) 2.79 (2.53–3.07) 
 ESI2 6397 (14.9) 4402 (68.8) 1995 (31.2) 8.77 (7.99–9.63) 4.30 (3.84–4.83) 
Site      
 A 11010 (25.7) 8725 (79.2) 2285 (20.8) (Reference) (Reference) 
 B 10642 (24.9) 8418 (79.1) 2224 (20.9) 1.01 (0.94–1.08) 1.88 (1.72–2.05) 
 C 11713 (27.4) 10862 (92.7) 851 (7.3) 0.30 (0.28–0.33) 0.41 (0.37–0.45) 
 D 9438 (22.0) 8357 (88.5) 1081 (11.5) 0.49 (0.46–0.53) 0.97 (0.87–1.07) 
Highest pain score category      
 No pain 6390 (14.9) 5910 (92.5) 480 (7.5) (Reference) (Reference) 
 Mild pain 6579 (15.4) 5799 (88.1) 780 (11.9) 1.66 (1.47–1.87) 1.28 (1.13–1.46) 
 Moderate pain 12955 (30.3) 11099 (85.7) 1856 (14.3) 2.06 (1.85–2.29) 1.55 (1.38–1.74) 
 Severe pain 16879 (39.4) 13554 (80.3) 3325 (19.7) 3.02 (2.73–3.34) 2.16 (1.93–2.42) 
Procedural sedation      
 No 30027 (70.2) 27008 (89.9) 3019 (10.1) (Reference) (Reference) 
 Yes 12776 (29.8) 9354 (73.2) 3422 (26.8) 3.27 (3.10–3.46) 2.68 (2.51–2.87) 
Multitrauma      
 No 41380 (96.7) 35181 (85.0) 6199 (15.0) (Reference) (Reference) 
 Yes 1423 (3.3) 1181 (83.0) 242 (17.0) 1.16 (1.01–1.34) 0.83 (0.71–0.97) 
Overall (N = 42803), n (%)No Opioid Prescribed (n = 36362), n (%)Opioid Prescribed (n = 6441), n (%)Unadjusted Odds Ratio (95% CI)aORa (95% CI)
Race and/or ethnicity      
 Non-Hispanic White 17754 (41.5) 14245 (80.2) 3509 (19.8) (Reference) (Reference) 
 Non-Hispanic Black 12331 (28.8) 11088 (89.9) 1243 (10.1) 0.46 (0.42–0.49) 0.69 (0.63–0.76) 
 Hispanic 8526 (19.9) 7398 (86.8) 1128 (13.2) 0.62 (0.58–0.67) 0.72 (0.66–0.80) 
 Other 3712 (8.7) 3228 (87.0) 484 (13.0) 0.61 (0.55–0.67) 0.77 (0.69–0.87) 
 Unknown 480 (1.1) 403 (84.0) 77 (16.0)   
Age categories, y      
 4–<8 14828 (34.6) 13058 (88.1) 1770 (11.9) (Reference) (Reference) 
 8–<11 10521 (24.6) 9099 (86.5) 1422 (13.5) 1.15 (1.07–1.24) 1.08 (0.99–1.18) 
 11–<14 10540 (24.6) 8669 (82.2) 1871 (17.8) 1.59 (1.48–1.71) 1.53 (1.41–1.67) 
 14–<18 6914 (16.2) 5536 (80.1) 1378 (19.9) 1.84 (1.70–1.98) 2.09 (1.90–2.29) 
Sex      
 Male 27172 (63.5) 22865 (84.1) 4307 (15.9) (Reference) (Reference) 
 Female 15631 (36.5) 13497 (86.3) 2134 (13.7) 0.84 (0.79–0.89) 0.98 (0.91–1.04) 
Insurance type      
 Private 18281 (42.7) 14794 (80.9) 3487 (19.1) (Reference) (Reference) 
 Government 22129 (51.7) 19462 (87.9) 2667 (12.1) 0.58 (0.55–0.61) 0.78 (0.72–0.83) 
 Self-pay 2032 (4.7) 1749 (86.1) 283 (13.9) 0.69 (0.60–0.78) 0.82 (0.71–0.95) 
 Other or unknown 361 (0.8) 357 (98.9) 4 (1.1)   
ED year      
 2012 5146 (12.0) 3775 (73.4) 1371 (26.6) (Reference) (Reference) 
 2013 5136 (12.0) 3975 (77.4) 1161 (22.6) 0.80 (0.74–0.88) 0.77 (0.70–0.85) 
 2014 5715 (13.4) 4722 (82.6) 993 (17.4) 0.58 (0.53–0.63) 0.52 (0.47–0.58) 
 2015 5581 (13.0) 4684 (83.9) 897 (16.1) 0.53 (0.48–0.58) 0.45 (0.40–0.50) 
 2016 5586 (13.1) 4805 (86.0) 781 (14.0) 0.45 (0.41–0.49) 0.36 (0.32–0.40) 
 2017 5708 (13.3) 5077 (88.9) 631 (11.1) 0.34 (0.31–0.38) 0.26 (0.23–0.29) 
 2018 4778 (11.2) 4425 (92.6) 353 (7.4) 0.22 (0.19–0.25) 0.15 (0.13–0.18) 
 2019 5153 (12.0) 4899 (95.1) 254 (4.9) 0.14 (0.12–0.16) 0.09 (0.08–0.10) 
Provider type      
 PEM attending 26023 (60.8) 21471 (82.5) 4552 (17.5) (Reference) (Reference) 
 EM attending 527 (1.2) 450 (85.4) 77 (14.6) 0.81 (0.63–1.03) 1.07 (0.82–1.39) 
 Peds attending 4657 (10.9) 4238 (91.0) 419 (9.0) 0.47 (0.42–0.52) 0.71 (0.63–0.80) 
 Fellow 1154 (2.7) 1050 (91.0) 104 (9.0) 0.47 (0.38–0.57) 0.62 (0.50–0.78) 
 NP/PA 4333 (10.1) 3975 (91.7) 358 (8.3) 0.42 (0.38–0.48) 0.66 (0.58–0.75) 
 Other 6109 (14.3) 5178 (84.8) 931 (15.2) 0.85 (0.79–0.92) 0.89 (0.82–0.98) 
Triage level      
 ESI4 13886 (32.4) 13204 (95.1) 682 (4.9) (Reference) (Reference) 
 ESI3 22520 (52.6) 18756 (83.3) 3764 (16.7) 3.89 (3.57–4.23) 2.79 (2.53–3.07) 
 ESI2 6397 (14.9) 4402 (68.8) 1995 (31.2) 8.77 (7.99–9.63) 4.30 (3.84–4.83) 
Site      
 A 11010 (25.7) 8725 (79.2) 2285 (20.8) (Reference) (Reference) 
 B 10642 (24.9) 8418 (79.1) 2224 (20.9) 1.01 (0.94–1.08) 1.88 (1.72–2.05) 
 C 11713 (27.4) 10862 (92.7) 851 (7.3) 0.30 (0.28–0.33) 0.41 (0.37–0.45) 
 D 9438 (22.0) 8357 (88.5) 1081 (11.5) 0.49 (0.46–0.53) 0.97 (0.87–1.07) 
Highest pain score category      
 No pain 6390 (14.9) 5910 (92.5) 480 (7.5) (Reference) (Reference) 
 Mild pain 6579 (15.4) 5799 (88.1) 780 (11.9) 1.66 (1.47–1.87) 1.28 (1.13–1.46) 
 Moderate pain 12955 (30.3) 11099 (85.7) 1856 (14.3) 2.06 (1.85–2.29) 1.55 (1.38–1.74) 
 Severe pain 16879 (39.4) 13554 (80.3) 3325 (19.7) 3.02 (2.73–3.34) 2.16 (1.93–2.42) 
Procedural sedation      
 No 30027 (70.2) 27008 (89.9) 3019 (10.1) (Reference) (Reference) 
 Yes 12776 (29.8) 9354 (73.2) 3422 (26.8) 3.27 (3.10–3.46) 2.68 (2.51–2.87) 
Multitrauma      
 No 41380 (96.7) 35181 (85.0) 6199 (15.0) (Reference) (Reference) 
 Yes 1423 (3.3) 1181 (83.0) 242 (17.0) 1.16 (1.01–1.34) 0.83 (0.71–0.97) 

EM, emergency medicine; ESI, emergency severity index; NP, nurse practitioner; PA, physician associate; PEM, pediatric emergency medicine.

a

Adjusted for fixed effects of the variables in the table.

Opioid prescribing decreased over time; 26.6% received opioid prescriptions in 2012 compared with 4.9% in 2019 (P < .001). These decreases varied by race and/or ethnicity. For non-Hispanic White children, prescriptions decreased from 36.8% in 2012% to 5.9% in 2019 (RR 84.0%). Among non-Hispanic Black children, prescriptions decreased from 16.6% to 3.1% (RR 81.3%) and among Hispanic children, from 20.6% to 5.8% (RR 71.6%) (Fig 1). In Fig 1, we demonstrate convergence of racial and/or ethnic differences in opioid prescribing overall and across sites. In 2012, there were clear racial and/or ethnic differences in opiod prescription rates. In 2019, differences were no longer statistically significant overall (non-Hispanic Black versus non-Hispanic White children aOR 0.93; 95% CI 0.60–1.42) or within sites.

FIGURE 1

Rates of opioid prescription over time by race and/or ethnicity. Rates are the number of visits in which opioids were prescribed divided by the number of eligible visits for the race and/or ethnicity group for each year, without adjustment for other covariates. NH, non-Hispanic.

FIGURE 1

Rates of opioid prescription over time by race and/or ethnicity. Rates are the number of visits in which opioids were prescribed divided by the number of eligible visits for the race and/or ethnicity group for each year, without adjustment for other covariates. NH, non-Hispanic.

Close modal

This multicenter analysis of pediatric EDs reveals racial and/or ethnic differences with respect to opioid prescriptions for long bone fractures. Non-Hispanic White children were more likely to receive opioid prescriptions when compared with non-Hispanic Black and Hispanic children, even after adjustment for pain score and injury severity. We observed substantial reductions in opioid prescriptions overall and attenuation of racial and/or ethnic differences in opioid prescriptions over time. Baseline rates of opioid prescribing varied by site, although highest among non-Hispanic White children across all sites. As clinicians began prescribing fewer opioids, likely in response to the opioid epidemic, racial and/or ethnic disparities in prescribing rates diminished. Interestingly, however, sites continued to have racial and/or ethnic variability in opioid prescribing rates.

Our findings of racial and/or ethnic disparities in opioid prescriptions are similar to those found in previous studies of analgesia prescription at discharge among children with long bone fractures.1,79  In a more recent study of adults with long bone fractures, researchers found racial and/or ethnic differences in potency (morphine equivalents) but not rates of ED opioid prescriptions.10 

This study has several potential limitations. It is possible that patients of different racial and/or ethnic groups differentially declined opioid prescriptions; this information is not available. Also, patients may have been misclassified by race and/or ethnicity. In addition, our results may not be generalizable to general EDs in which rates of opioid prescriptions are higher and racial and/or ethnic differences in opioid prescriptions are larger.8  As noted in this study, there was substantial variability in opioid prescribing rates by site.

We found that as provision of opioid prescriptions declined over time, previously marked racial and/or ethnic disparities in opioid prescription rates at ED discharge attenuated. In future studies, researchers should seek to identify optimal outpatient pain management for children with fractures and ensure adequate postdischarge pain control for all children, regardless of race and/or ethnicity.

Dr Goyal conceptualized and designed the study and drafted the initial manuscript; Drs Drendel and Johnson helped conceptualize and design the study and reviewed and revised the manuscript; Drs Alpern, Chamberlain, and Cook helped conceptualize and design the study, coordinated and supervised data collection, and reviewed and revised the manuscript; Mr Wheeler and Mr Olsen performed data analysis and reviewed and revised the manuscript; Drs Babcock, Zorc, Bajaj, and Grundmeier coordinated and supervised data collection and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: Supported by the National Institute of Minority Health and Disparities grant R03MD011654; Agency for Healthcare Research and Quality grant R01HS020270. The Pediatric Emergency Care Applied Research Network infrastructure was supported by the Health Resources and Services Administration, the Maternal and Child Health Bureau, and the Emergency Medical Services for Children Network Development Demonstration Program under cooperative agreements U03MC00008, U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC22684, and U03MC22685. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by, Health Resources and Services Administration, Health and Human Services, or the US Government. No funding was secured for this study.

aOR

adjusted odds ratio

CI

confidence interval

ED

emergency department

RR

relative reduction

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have no conflicts of interest relevant to this article to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.