Is There a Gender Bias in Pain Management?



Keith Wesley, MD, FACEP | | Tuesday, August 11, 2009

Review of:Lord B, Cui J, Kelly A: "The impact of patient sex on paramedic pain management in the prehospital setting." American Journal of Emergency Medicine. 27(5):525-529, 2009.

The Science

The Metropolitan Ambulance Service of Melbourne, Australia undertook the task of determining whether there was a difference in the administration of analgesia to patients based on gender. For a one-week period, cases were reviewed. This retrospective cohort study of paramedic patient care records included all adult patients with a Glasgow Coma Score higher than 12 transported by ambulance in a major metropolitan area over a seven-day period in 2005. Data collected included demographics, patient report of pain and its type and severity, provision of analgesia by paramedics, and type of analgesia provided. Their protocol allowed morphine or methoxyflurane (similar to nitrous oxide) or a combination of both.

They transported 1,766 who reported pain. Of those, 52% percent were female with a median age of 61 and median initial pain score (on a 0-10 verbal numeric rating scale) of 6. The researchers stated that 45% of patients reporting pain didn't receive analgesia (791/1,766) (95% confidence interval [CI], 43%-47%), with no significant difference between sexes (P = .93).

There were, however, significant sex differences in the type of analgesia administered, with males more likely to receive morphine (17%; 95% CI, 15%-20%) than females (13%; 95% CI, 11%-15%) (P = .01). The difference remained significant when controlled for type of pain, age and pain severity (odds ratio, 0.61, 95% CI, 0.44-0.84).

The Street

This is yet another study examining the biases that exist regarding aggressive treatment of pain. Other papers have shown that prehospital and hospital treatment of pain is biased against blacks, the poor, children and women. The question these studies fail to answer is why. Perhaps the answers lie in sociology and psychology journals instead of our own professional journals.

But let's examine this paper a little more closely. In it, the authors note that 11% of patients refused any analgesia. However, they don't note the sex of those who refuse analgesia. So the actual number of the study group is 1,572. Additionally, more women than men reported severe pain (level 8-10) but were significantly less likely to be given morphine. However, the authors combined both trauma and medical cases, including cardiac calls, into the data. This could significantly alter the data. For instance, if during the study week there was a predominance of male cardiac patients, then it wouldn't be surprising to see more use of morphine.Regardless, both sexes were equally provided some form of analgesia.Are the authors suggesting that morphine is preferred over methoxyflurane? If so, then that's a protocol and education issue.

Although I agree there's a gender bias to pain management, I'm not convinced this study proved the point. If the authors had segregated the medical cases from the trauma ones and excluded those that refused analgesia altogether, then perhaps the data would be more compelling.

One final note is that in the paper, the authors state that they consider a drop in pain score by 2 points to be statistically significant. This is debatable, as going from 10-8 is certainly different than going from 4-2.Regardless, the authors report deep in the article that both males and females reported an equally significant relief in pain.If that's true, then does it really matter whether they got morphine or methoxyflurane?

Confused yet? Join the club.

Related article

"PCRF Abstracts"from March, 2007 JEMS.

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Related Topics: Medical Emergencies, Pain Management

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