Morton, N. S. and Errera, A. (2010). APA national audit of pediatric opioid infusions. Paediatr Anaesth , 20 , 119 \200\223125 . Niscola, P., Romani, C., Scaramucci, L., Dentamaro, T., Cupelli, L., Tendas, A., et al . (2 008). Pain syndromes in the setting of haematopoietic stem cell transplantation for hematol ogical malignancies. Bone Marrow Transplant , 41 , 757 \200\223764 . Yaster, M., Kost-Byerly, S., and Maxwell, L. (2003). Opioid agonists and antagonists. In N. L. Schechter (ed) Pain in infants, children, and adolescents (2nd edn), pp. 181 \200\22322 4 . Philadelphia, PA : Lippincott, Williams & Wilkins . Olmstead, D. L., Scott, S. D. and Austin, W. J. (2010). Unresolved pain in children: a relational ethics perspective. Nurs Ethics , 17 , 695 \200\223704 . Zalon, M. L., Constantino, R. E., and Andrews, K. L. (2008). Th e right to pain treatment: a reminder for nurses. Dimens Crit Care Nurs , 27 , 93 \200\223101 . Prince v Massachusetts . (1944). 321 U.S. 158, 64 S. Ct. 438, 88 L. Ed. 645 edn, US. CHAPTER 65 Sociodemographic disparities in pediatric pain management: relationships and pre dictors Miriam O. Ezenwa and Anna Huguet Summary Th e purpose of this chapter is to present a narrative review of research studies e xamining sociodemographic predictors of dispari- ties in pain management in children and ad olescents. Findings from this review are confl icting. In the majority of the studies, soci odemo- graphic variables were not statistically signifi cant predictors of dis- parities in pain management. However, some gaps remain. For the studies in which evidence of sociodemo graphic disparities exist, it is: (1) not clear whether the statistically signifi cant soci odemographic disparities were also clinically meaningful and (2) in all of the stud- ies re viewed, the goal was to determine predictors of disparities in pain management. Future stud ies need to focus on determining the clinical meaningfulness of other fi ndings and systema tically testing explanatory models for possible sociodemographic disparities in pediatric p ain management. Adequately addressing these gaps will help to move forward the science of s ociodemographic disparities in pediatric pain management. disparities in pain research, there are important sociodemographic factors, other than race /ethnicity, that could be potential predic- tors of disparities in pain management both ind ependently and in combination. Th ese factors include age, sex, educational level, geo- gra phic location, and income level. Most of the studies reviewed in the IOM report on racial a nd ethnic disparities in health care were conducted with adults (Smedley et al., 2003). Th e pioneering work of scholars on pain experiences in children reporting inadequacy of pain control in children (Beyer et al., 1984; Eland and Anderson 1977; Schechter et al., 1986) s et the stage for more studies focus- ing on pediatric pain management, including studies fo cused on sociodemographic disparities in pediatric pain management. However, there is still limited research. In this chapter, a non-systematic review aimed to explore several sociodemographic factors (including age, sex, race/ethnicity, insur- ance status, and residential area) as potential predictors of disparities in pain management in children and adolescents is presented. Pai n management is a multidimensional and global construct encom- passing concepts such as pai n intensity, prescription for pain medi- cation, pain medication used, and satisfaction wit h pain control. For the purpose of this chapter, we defi ne pain management as receiving pa in medications or prescriptions for pain medications. Included in the review were original studies conducted in the US and Europe, in which investigators compared groups on dispariti es in pain man- agement based on the following sociodemographic factors: age, sex, race/eth nicity, health insurance status, and residential region. Th e database searched was Medline (PubMed and Ovid Medline). We identifi ed 12 studies that met our inclusion criteria and a nalyzed them using a descriptive analytic approach (see Table 65.1 ). Introduction Over two decades of research in adults with pain show evidence of racial dispa rities in pain management. Racial and ethnic minor- ity patients are more likely to receive poor pain management than Caucasians (Cintron and Morrison, 2006; Ezenwa and Fleming, 2012 ; Ezenwa et al., 2006; Meghani et al., 2012). Much research on the health disparities liter ature has focused on race/ethnicity as the explanatory factors for the health disparities i n pain management. Th is focus is underscored by the defi nition of health care dispari- ti es provided by the Institute of Medicine (IOM). Th e IOM defi ned health disparities as \200\230Racial or ethnic diff erences in the quality of health care that are not due to acc ess-related factors or clinical needs, preferences, and appropriateness of intervention \200\231 (Smedley et al., 2003, p. 3). While this defi nition is pertinent and has pro- vid ed a springboard for honing in on explanatory factors for racial Age-related factors We identifi ed six studies that examined age-related dispari- ties in p ain management. Th e fi ndings are confl icting. In three SECTION 9 special topics 670 Table 65.1 Summary of \201 ndings on sociodemographic disparities in pediatric pain manag ement Authors Design Sample Setting Major \201 ndings Statistics used Age-related factors Zuppa et al. (2005) Retrospective chart review 2348 children aged between 1-month and 16 years old hospitalized at the PICU in 2002 USA, pediatric intensive care unit (PICU) Th e utilization of the most frequently administered drugs (e.g. nalbuphine, morphine, vanc omycin, and cefotaxime) di \200 ered by age Univariate (Chi-square) analysis VanderBeek et al. (2006) Retrospective cohort study 503 patients 18 years of age or younger with a diagnosis of fractured radius or ulna USA, tertiary care children \200\231s hospital No statistical age di \200 erences were found between those who use conscious sedation and those who didn \200\231t; however, younger age of the patient was a signi \201 cant predi ctor of conscious sedation use Univariate (t-test) and multivariate statistical (logistic regression) analysis Stevens et al. (2010) Retrospective survey 847 children aged between 3 and 17 years old that receive an headache diagnosis USA, outpatient setting (including primary and secondary care) Age was not found to be related with the likelihood of being prescribed an evidence- based medication once a diagnosis is given Univariate logistic regression Boyd et al. (2006) Survey 1017 students in 5th \200\22310th grades (ages ranged from 10 to 18 years) USA, Detroit-area public school district No signi \201 cant age di \200 erences in were found in the reporting of use of medical u se of pain medications Univariate (Chi-square) analysis Ellis et al. (2002) Survey and chart review 273 children ranging in age from 10 days to 17 years who were on the inpatient unit during the 8-h study period (patients on the psychiatric and the intensive care unit were excluded ) Canada, pediatric teaching hospital Th ere was no signi \201 cant correlation between age and the amount of opioid or non-opio id analgesia administered Correlations Univariate (Chi-square) analysis Fein et al. (2010) Retrospective chart review 363 children younger than 21 years that had lumbar punctures performed in 2003 USA, children \200\231s tertiary care hospital Younger patients received pain management less often than did older patients: \227\206 16 (6.5%) of 246 neonates (0 \200\2232 months), 4 (14.3%) of 28 infants (3 \200 \22318 months), 9 (60%) of 15 preschoolers (19 \200\22359 months), and 55 (85.9%) of 64 old er children (60 months to 21 years). \227\206 7.2% of children younger than 18 months; 82% of children 19 months or older. Gender-related factors Logan and Rose (2004) Survey and chart review 102 adolescents aged between 12 and 18 years undergoing surgeries with overnight hospital s tay that are typically associated with moderate to severe postoperative pain USA, large urban pediatric hospital Patterns of controlled analgesic (PCA) usage, PCA demands or PCA injections did not vary by sex on postoperative days Univariate analysis (t-test) VanderBeek et al. (2006) Retrospective cohort study 503 patients 18 years of age or younger with a diagnosis of fractured radius or ulna USA, tertiary care children \200\231s hospital Gender was not found to be associated with use of conscious sedation Univariate (Chi- square analysis) and multivariate (logistic regression) analysis Boyd et al. (2006) Survey 1017 students in 5th \200\22310th grades (ages ranged from 10 to 18 years) USA, Detroit-area public school district Signi \201 cant gender di \200 erences were found in reporting medical use of prescriptio n pain medication. Girls (17%) were more likely to report medical use of prescription pain medication in the past year than boys (7%) Univariate (Chi- square) analysis (Continued) CHAPTER 65 sociodemographic disparities in pediatric pain management 671 Table 65.1 (Continued) Authors Design Sample Setting Major \201 ndings Statistics used Ellis et al. (2002) Survey and chart review 273 children ranging in age from 10 days to 17 years who were on the inpatient unit during the 8-h study period (patients on the psychiatric and the intensive care unit were excluded ) Canada, pediatric teaching hospital Th ere was no signi \201 cant correlation between sex and the amount of opioid or non-opio id analgesia administered Correlations Taylor et al. (2008) Survey and chart review 241 medical and surgical patients hospitalized on the day of the audit (no age limits, mean age for boys = 5.9 years, mean age for girls = 4.2 years) Canada, tertiary and quaternary pediatric hospital Th ere was no sex di \200 erence in the analgesia received Univariate (Chi- square) analysis Race/ethnicity-related factors Jimenez et al. (2010) Retrospective cohort study 94 children younger than 18 years old admitted for ambulatory surgery, 47 = Caucasians, mea n age = 8.30; 47 = Latinos, mean age = 8.59 USA, ambulatory surgical pediatric hospital Th ere were racial di \200 erences in the receipt of postoperative opioids after tonsillec tomy and adenoidectomy surgery Mann-Whitney U tests, Univariate (Chi- square) and Fisher \200\231s exact tests Sabin and Greenwald (2012) Online survey 86 academic pediatricians who are faculty, residents, or fellows USA, large urban research university \200\231s primary care, ambulatory, and acute care Pediatricians \200\231 implicit bias was related to prescribing less opioid pain medication for African American children than for Caucasian children after surgery Pearson \200\231s correlations, hierarchical linear regression analysis Retrospective chart review 1030 records representing 3.9 million children younger than 19 years old who presented to e mergency department for isolated long bone fracture, 792 records = Caucasians, 111 records = African Americans, 127 records = Hispanics USA, emergency department Race did not predict use of analgesics and opioid analgesics Multivariate logistic regression analysis Yen et al. (2003) a Retrospective cohort study 503 patients 18 years of age or younger with a diagnosis of fractured radius or ulna, 418 = Caucasians, 85 = African Americans USA, Tertiary care children \200\231s hospital Race was not associated with receiving conscious sedation Univariate (t-test) and multivariate statistical (logistic regression) analysis VanderBeek et al., (2006) .a Taylor et al. (2008) Survey and chart review 241 medical and surgical patients hospitalized on the day of the audit (no age limits, mean age for boys = 5.9 years, mean age for girls = 4.2 years) Canada, tertiary and quaternary pediatric hospital Th ere was no racial di \200 erence in the analgesia received by children Univariate (Chi- square) analysis Retrospective survey 847 children aged between 3 and 17 years old that receive a headache diagnosis. Sample size for racial groups not provided USA, outpatient setting (including primary and secondary care) Race was not related to the likelihood of being prescribed an evidence-based medication onc e a diagnosis is given Univariate logistic regression Stevens et al. (2010) a (Continued) SECTION 9 special topics 672 Table 65.1 (Continued) Authors Design Sample Setting Major \201 ndings Statistics used Retrospective chart review 3554 children who underwent laceration repair, mean age = 6.7 years, 2128 = Caucasian, and 1428 = Minority Brodzinski et al. (2010) a USA, urban tertiary- care children \200\231s hospital emergency department Race was not associated with receiving pharmacological procedural sedation Fisher \200\231s exact tests, multivariate logistic regression analysis Health insurance-related factors Retrospective chart review 3554 children who underwent laceration repair, mean age = 6.7 years USA, urban tertiary- care children \200\231s hospital emergency department Health insurance status was not associated with receiving pharmacological procedural sedati on Brodzinski et al. (2010) a Fisher \200\231s exact tests, multivariate logistic regression analysis Stevens (2010) a Retrospective survey 847 children aged between 3 and 17 years old that receive an headache diagnosis USA, outpatient setting (including primary and secondary care) Health insurance status was not related to the likelihood of being prescribed an evidence-b ased medication once a diagnosis is given Univariate logistic regression Residential region-related factors Retrospective chart review 1030 records representing 3.9 million children younger than 19 years old who presented to e mergency department for isolated long-bone fracture, 792 records = Caucasians, 111 records = African Americans, 127 records = Hispanics USA, emergency department Residential region did not predict use of analgesics and opioid analgesics Multivariate logistic regression analysis Yen et al. (2003) a a Th e same study. A study can \201 t into more than one category. n/a = not available fr om original study. Th ey retrospectively reviewed the records of all patients younger than 21 years who had re ceived this procedure during the year 2003 at a large urban children \200\231s hospital. Th eir sample included 363 children. Th ey found that younger patients received pain manage- ment less oft en than did older patients: 16 (6.5%) of 246 neonates (0 \200\2232 months), 4 (14.3%) of 28 infants (3 \200\22318 months), 9 (60%) of 15 pre-schoolers (19 \200\22359 mo nths), and 55 (85.9%) of 64 older children (60 months to 21 years) (Fein et al., 2010). studies, results support age as a predictor of disparities in pain management. In three stu dies, investigators did not report similar fi ndings. Studies where age was related to disparities in pain management Zuppa et al. (2005) examine d whether age was associated with trends in prescription for pain medication in children in the inten- sive care unit (ICU). All children hospitalized to Child \200\231s Hospital of Philadelphia pediatric ICU during the 2002 year were consid- ered (n = 2348); data was obta ined from the drugstore database of the hospital. Age was signifi cantly associated with pr escription for morphine for children in the ICU (Zuppa et al., 2005). Morphine was prescrib ed less oft en for infants (1 month to <2 year) than for older children (2 to <12 years) an d adolescents (12 to 16 years) (Zuppa et al., 2005). Similarly, VanderBeek et al. (2006) in vestigated whether age was associated with the receipt of conscious sedation for pain contr ol for fracture reduction surgery in 503 patients aged 18 years and under. Th ese patients were recruited from a univer- sity-affi liated tertiary care children \200\231s hospital em ergency depart- ment (ED). In a multivariate statistical analysis, younger age of the patie nt was a statistically signifi cant predictor of use of conscious sedation for pain managem ent for forearm fracture reduction (VanderBeek et al., 2006). Likewise, Fein et al. (2010) examined the relationship between age and pain management (local anaesthet- ics and sedatio n) received during the lumbar puncture procedure. Studies where age was not related to disparities in pain management Ellis et al. (2002) exa mined the relationship between age and analgesic when surveying all children and their pare nts who were hospitalized in a pediatric teaching hospital in eastern Ontario during the 8- h data collection period. Children hospitalized on the psychiatric unit and the intensive c are units were excluded. Th eir sample included 273 children aged between 10 days and 17 ye ars old. Th ey found that there was no statistically signifi cant correlation between age a nd the amount of opioid or non-opioid analgesia administered to the children (Ellis et al., 2002). Similarly, Boyd et al. (2006) in a study conducted with 1017 students in fi ft h to tenth grade (ages ranged from 10 years to 18 years) examined the use of pain medication fo r medical and non-medical pur- poses. Th ey found that as grade level increased so too did preva- lence rates of medical use of pain medications, but the diff erences were not statis tically diff erent (Boyd et al., 2006). Finally, Stevens CHAPTER 65 sociodemographic disparities in pediatric pain management 673 Study where sex was related to disparities in pain management We have earlier described in more details Boyd et al. \200\231s (2006) study. Boyd and colleagues also found that sex wa s related to inadequate pain management. Th ey found that there was a statistically signifi - cant sex disparity in the report of medical use of prescription pain medication. Girls ( 17%) were more likely to report medical use of prescription pain medication in the past yea r than boys (7%) (Boyd et al., 2006). Boyd and colleagues when surveying the 1071 middle an d high school students did not ask them for their levels of pain, so they could not control for pain levels when comparing both sex groups. et al. (2010), in a retrospective study including 847 children aged between 3 and 17 years old, explored whether there were sociode- mographic diff erences in the management of child ren \200\231s headache. Th ey found that age was not related to the likelihood of being pre scribed an evidence-based medication for headache (Stevens et al., 2010). Taken together, the fi ndings of the studies that examined age- related disparities in pedi atric pain management are inconsist- ent. Reasons for this inconsistency could be multiface ted. Th e wide range of age of children included within individual studies could be problem atic because developmentally, these children dif- fer in their ability to communicate prese nce of pain. It was not clear whether age-appropriate pain assessment measures were used fo r the diverse age range of the sample. Another probable explanation for the inconsistent fi ndings could be related to type of pain. Studies have been conducted with patients with va ried types of pain (headache, menstrual cramps, urological, surgical, and other unspecifi e d types of pain). Also, the context where the pain is experienced may explain these inconsi stent fi ndings. Studies are focused on outpatients, patients undergoing a surgical proce- dure, or in an ICU setting located in diff erent institutions. Hence, the decision to admin ister a particular dose of pain management resides with the provider as well as the culture of the institution. Provider variables such as opioidphobia and inadequate knowl- edge and training about pain management or lack of supporting pain management polices contributes t o poor pain management (Bashayreh 2011). Consequently, the 2011 IOM report Relieving Pain i n America recommends more training and education of both current and future health care pro viders on pain management skills (Institute of Medicine, 2011). Patient and caregiver train ing are also needed to overcome misconceptions about use of opioids, which have been report ed as barriers to adequate pain manage- ment in the adult pain populations (Ward and Hernan dez 1994; Ward et al., 1993). Studies where sex was not related to disparities in pain management Reporting on the sex-re lated fi ndings in the Ellis et al. (2002) study described earlier, fi ndings show that the re was no statistically sig- nifi cant correlation between sex and the amount of opioid or non- opioid analgesia administered (Ellis et al., 2002). No sex diff erences in pain levels were reported, but fi ndings show no signifi cant cor- relations between pain intensity ra ting provided by children or pro- fessional and amount of opioid or non-opioid analgesia pr escribed and administered (Ellis et al., 2002). In another study, Logan et al. (2004) condu cted a study with 102 adolescents aged 12 to 18 years who were undergoing surgeries to exam ine sex diff erences in post- operative use of patient-controlled analgesia (PCA). Although girls reported statistically signifi cant higher low and average pain scores than boys, bo ys and girls did not diff er signifi cantly on total PCA usage, PCA demands, or PCA injecti ons aft er surgery (Logan and Rose, 2004). Further, in the VanderBeek et al. study describe d ear- lier, in a univariate statistical analysis, sex was not associated with use of consc ious sedation for pain control (VanderBeek et al., 2006). Multivariate results also show th at sex was not a signifi cant pre- dictor of conscious sedation use (VanderBeek et al., 200 6). Finally, Taylor et al. (2008) in a study with 241 medical and surgical inpa- tients to determine the adequacy of pain management in a sample of hospitalized children found no sex diff erence in the analgesia received (Taylor et al., 2008). Th e age groups likely to receive disparate pain management diff er. For instance, VanderBe ek et al. (2006) found that younger children were more likely to receive prescription pain medication. On the other hand, in Fein et al. \200\231s (2006) study, younger children were less likely to receive prescription pain medication. Th e pain management goal must be to administer or provide prescriptions for pain medications that are appropriate for patients \200\231 pain level and age. To reduce and/or prevent age-related disparities in pae- diatr ic pain management, it is necessary to use age appropriate tools, such as the Poker Chip To ol for children from age 3 to 4 by Hester et al. (1990), the Faces Pain Scale- Revised for children from age 4 to 12 by Hicks et al. (2001), or the Numerical Rating Scale for childre n aged 8 years or older (von Baeyer et al., 2009). See McGrath et al. (2008) for evidence-b ased recommendations for the use of measures and assessment strategies for pain for dif- fe rent age groups. It is also important to use evidence-based pain management guidelines and protocols to adequately assess and treat children \200\231s pain. In sum, although sex-based disparities have often been reported in prevalence of pain and t he adjustment to the pain especially around puberty with more girls reporting more pain and its impact on daily activities (Huguet and Miro 2008; King et al., 2011; Kroner-Herwig et al., 2007; Mattila et al., 2005), sex disparities tend to be observed in use of prescribed medication. Th e fact that girls may be more prone to develop more frequent and severe pain but use less prescribed pain medication than boys may suggest sex diff erences in the resp onse to pain management as suggested by Fillingim et al. (2009) or sex diff erences in atti - tudes to drug use. Racial- and ethnic-related factors We identifi ed seven studies in which investigators exam ined race/ ethnicity as predictors of disparities in pain management. Th e studies reported mixed results. We have categorized them into two rubrics: studies supporting racial dispar ities in pain manage- ment and studies not in support of racial/ethnic disparities in pain management. Sex-related factors In fi ve studies, investigators examined sex diff erences in pain man- agement of pediatric patients. One study supports sex as a predic- tor of disparities in pe diatric pain management. Th e other four studies did not support this fi nding. SECTION 9 special topics 674 Health insurance-related factors In two studies, investigators examined patients \200\231 h ealth insurance status as a predictor of disparities in pain management. In both studies, p atients \200\231 health insurance status was not related to dispari- ties in pain managemen t. Study where race/ethnicity was related to disparities in pain management Jimenez et al. (20 08) in a retrospective cohort study of 94 children, 47 Caucasian and 47 and Latino patients presenting to the ambula- tory surgical unit in a children \200\231s hospital, examined wh ether racial disparities exist in use of postoperative opioids. Latino children received 30 % less postoperative opioids than Caucasian children presenting for tonsillectomy and adeno idectomy (Jimenez et al., 2010). Similarly, Sabin and Greenwald examined the role of pae- d iatricians \200\231 implicit bias on pain management recommendation for children \200\231s surgical pain with 86 academic pediatricians who are faculty, residents, or fellows in larg e urban research university \200\231s pri- mary care, ambulatory, and acute care settings. Race/ethnicity was a statistically signifi cant predictor of narcotic prescriptions (Sabin and Greenwald, 2012). Pediatricians prescribed less opioid pain medication for African Amer icans than for Caucasians aft er sur- gery (Sabin and Greenwald, 2012). Brodzinski and colleagues, in the study described earlier, included 3554 children in resear ch to examine health insurance sta- tus, as a predictor socioeconomic disparities in pain m anagement of children who presented to the emergency department for lacera- tion repair in an urban tertiary-care children \200\231s hospital emergency department. Th ere were 1946 c hildren with private health insur- ance and 1608 with public or no health insurance. Aft er controlling for sociodemographic (age, gender, and SES) and clinical (triage acuity, physi cian type, length of laceration, complexity of repair, time of day, body site of laceration , and use of topical anesthetics) variables, there was no statistically signifi cant associ ation between health insurance status and receiving procedural sedation in these children ( Brodzinski et al., 2010). Similarly, Stevens et al. \200\231s retro- spective study, descri bed earlier, used two nationally representative samples to examine whether there were dispa rities in management of children \200\231s headache based on health insurance status. Th e authors did not provide the breakdown of children represented in their four insurance statu s categories: private, Medicaid, self-pay, and other. Th ey found that health insurance sta tus was not statistically related to receiving evidence-based medication for the management of headache (Stevens et al., 2010). Study where race/ethnicity was not related to disparities in pain management Yen et al. (20 03) with a nationally representative sample of chil- dren \200\231s records who presented i n the ED, Caucasian, n = 792, African American, n = 111, Hispanic, n = 127, determined whet her race was associated with receiving analgesics to control pain related to isolated long- bone fracture. Aft er controlling for confounding variables (health insurance type, hospita l owner type, geographic region, and survey year), there was no statistically signifi cant dif- ference between African Americans, Hispanics, and Caucasian for using analgesics and o pioid analgesics for isolated long-bone fracture (Yen et al., 2003). Likewise, VanderBeek e t al. (2006) in a retrospective cohort study of children presenting in a tertiary care chil dren \200\231s hospital, Caucasian, n = 418 and African American, n = 85, found that race/e thnicity was not associated with receiv- ing sedation for pain management for forearm fract ure reduction (VanderBeek et al., 2006). In the Taylor et al. study described ear- lier, th ere is no racial/ethnic diff erence in the analgesia received (Taylor et al., 2008). In the same way, Stevens et al. in a retrospec- tive study used two nationally representative sam ples of 847 chil- dren from outpatient setting, including primary and secondary care settin gs to examine whether there were race/ethnic disparities in management of children \200\231 s headache. Th e authors did not pro- vide the racial breakdown of their sample. Race/ethni city was not signifi cantly related to receiving evidence-based medication for the manageme nt of headache (Stevens et al., 2010). Finally, Brodzinski et al. examined race/ethnic disp arities in pain management of Caucasian, n = 2128, Minority, n = 1426 children who presente d to the emergency department for laceration repair. Aft er control- ling for other sociode mographic (age, gender, and socioeconomic status (SES)) and clinical (triage acuity, physic ian type, length of laceration, complexity of repair, time of day, body site of laceration, and use of topical anesthetics) variables, there was no signifi cant association between r ace/ethnicity and receipt of pharmacological procedural sedation in children who underwent laceration repair (Brodzinski et al., 2010). In summary, health insurance status was not found to predict disparities in pain management . Th ese results support the ethical standards and acceptability that all children in pain receive man- agement regardless of health insurance status. Residential-related factors In only one study did investigators examine the relationship be tween residential region and disparities in pediatric pain man- agement. Yen et al. (2003), with a nationally representative sample of 1030 children \200\231s records, examined dispa rities in the receipt of analgesics for isolated long-bone fracture pain based on residenti al region of children who presented in EDs. Aft er controlling for con- founding variables including age, payment method, hospital type, survey year, and metropolitan statistical are a status of the hospi- tal, children from the South and West region of the United States we re signifi cantly more likely to receive opioid analgesics than chil- dren from the Northea st for isolated long-bone fracture (Yen et al., 2003). Although there was a diff erence in pediatric pain manage- ment based on residential region, it \200\231s not clear what this f i nding from one single study represents. We cannot put any emphasis on this one study unti l more evidence emerges in this area. Conclusion Th ere is accumulating evidence about the contribution of sociode- mographic fac tors to disparities in pediatric pain management. However, the results are inconsistent (se e Table 65.1). Unlike the fi ndings in the adult population, in the majority of the studies that focused on children, evidence did not support sociodemographic factors as predictors of disparities in pediatric pain management. For the studies in which evidence supports soc iodemographic In summary, although the fi ndings related to race/ethnic dispari- ties in pediatric pain m anagement studies were inconsistent, the majority found no statistically signifi cant racia l or ethnic diff er- ences in the pain management of children. CHAPTER 65 sociodemographic disparities in pediatric pain management 675 factors as predictors of disparities in pain management, we have confi dence in the interpr etations of the results. Investigators con- trolled for several confounding variables that could have obscured the interpretation of fi ndings, e.g. age, gender, SES, triage acu- ity (Brodzinski et al., 2010); health insurance type, hospital owner type, geographic region, and survey year (Yen et al., 2003). However, some gaps remain. Future studies should provid e evidence of clini- cal signifi cance of the sociodemographic disparities in pediatric pai n management. Although, the disparities might be statistically signifi cant, they may not b e clinically meaningful. Th is knowledge is critical because evidence of clinically meaning ful sociodemographic disparities in pediatric pain management have practice implica- tions. For example, it could suggest medical errors on the part of the providers that require ser ious action. Pain relief is a fundamental human right (Brennan et al., 2007). Consequently, inadequate pain management induced by sociodemographic diff erences is a medical error tha t leads to unnecessary pain and suff ering (McNeill et al., 2004). Further, all of the stud ies have focused simply on exploring potential sociodemographic disparities in pediatric pa in manage- ment without suggesting explanations for those disparities when reported. Based on these fi ndings, we make some recommendations that will help move forward the science of sociodemographic dis- parities in pain pediatric pain management. We recommend that invest igators should: (1) systematically and prospectively exam- ine factors that explain sociode mographic disparities in pediatric pain management, (2) determine whether the sociodemograp hic disparities in pediatric pain management are clinically meaning- ful, and (3) examine d iff erences using a theoretical model that may provide information on the cause of any disp arities. Th is approach will provide evidence to develop interventions that address both pa tient-related and provider-related factors that contribute to socio- demographic disparitie s in pediatric pain management. a typical tomboy who enjoys playing soccer with her brothers. Her love for soccer helped he r to secure a position as the team captain of the girls \200\231 soccer team in her middle school. Around thanksgiving holiday, BJ started complaining of headaches that eventually in creased in frequency and intensity. Currently, BJ suff ers numerous headaches per month and rates them as 7 or 8 on a scale of 0 to 10, where 0 is no pain and 10 is pain as bad as it can be. Over-the-counter (OTC) pain medications do not abate her frequent headaches. Her m other feels frustrated because of loss of work days when BJ is sent home from school or she needs to take BJ to the ED, which is now increasing in frequency. She asked BJ \200\231s d octors why nothing much is done to help BJ. She learned that her public health insurance do es not provide coverage for a wide range of eff ective interventions. BJ \200\231s prescrip tions for pain medications consist of only OTC and weak opioids such as codeine. Th ese pai n medications are not strong enough to relieve the severe headaches that BJ oft en suff ers and treatments options other than medication are not available for her. Consequently, BJ s uff ered in pain, became depressed, and dropped out of school and the soccer team she loved . BJ was beside herself in anger and frustration aft er a visit from her friend, KC, a 14-y ear-old Caucasian boy. KC told BJ how well triptans and biofeedback were able to reduce his migraines. His father gave him strong opioid pain medica- tion that greatly relieved his p ain. BJ wonders if the poor pain management she receives was because she is a poor African American girl who lives in a poor housing unit and her mother cannot aff ord better pain ma nagement resources. She thought it was unfair but at the same time feels helpless to change her situation. Our fi ndings have education, research, and policy implications. In order to improve pediat ric pain management, there needs to be more education and training for health professionals who care for children and adolescents in pain. Provider training could focus on how to inc orporate pharmacological and non-pharmacological interventions and on the invaluable skills of assessing the eff ective- ness of the intervention to improve pain management in childr en. Researchers should develop interventions that focus on eliminat- ing sociodemographic d isparities in pediatric pain management. Research that examine patient-provider variables s uch as commu- nication skills, racial or sex concordance, and trust that could be barriers to adequate pain treatment are desperately needed. Th ese patient-provider factors could mo derate the relationship between sociodemographic variables and pain outcomes in this popula tion. Finally, engaging policymakers during several aspects of research in pediatric pain m anagement has a merit. It will serve as an impetus to policymakers to advocate for more res earch funding for paedi- atric pain management to reduce pain severity and improve quality of life for these patients. References Bashayreh, A. (2011). Opioidphobia and cancer pain management. J Pediatr Hematol Oncol , 33 (Suppl 1), S60 \200\22361 . Beyer, J. E., Ashley, L. C., Russell, G. A., and DeGood, D. E. (1984). Pediatric pain aft e r cardiac surgery: pharmacologic management. Dimens Crit Care Nurs , 3 (6), 326 \200\223334 . Boyd, C. J., Esteban McCabe, S., and Teter, C. J. (2006). Medical and nonmedical use of pre scription pain medication by youth in a Detroit- area public school district. Drug Alcohol Depend, 81 (1), 37 \200\22345 . Brennan, F., Carr, D. B., and Cousins, M. (2007). Pain management: a fundamental human right. Anesth Analg , 105 (1), 205 \200\223221 . Brodzinski, H., Iyer, S., and Grupp-Phelan, J. (2010). Assessment of disparities in the use of anxiolysis and sedation among children undergoing laceration repair. Acad Pediatr , 10 (3), 194 \200\223199 . Cintron, A. and Morrison, R. S. (2006). Pain and ethnicity in the United States: a systematic review. J Palliat Med , 9 (6), 1454 \200\2231473 . Eland, J. M. and Anderson, J. E. (1977). Th e experience of pain in children. In A. Jacox ( ed.) Pain: a source book for nurses and other health professionals , pp. 453 \200\223473 . Boston, MA : LittleBrown . Ellis, J. A., O \200\231Connor, B. V., Cappelli, M., Goodman, J. T., Blouin, R., and Reid, C. W. (2002). Pain in hospitalized pediatric patients: how are we doing? Clinical J Pain , 18 (4), 262 \200\223269 . Case example: sociodemographic issues related to pediatric pain management Ezenwa, M. O., Ameringer, S., Ward, S. E., and Serlin, R. C. (2006). Racial and ethnic disp arities in pain management in the United States. J Nurs Scholarsh , 38 (3), 225 \200\223233 . BJ is a happy 13-year-old African American girl whose person- ality is larger than life. Sh e lives in a subsided housing apart- ment in Texas with her single mother and two brothers. BJ is Ezenwa, M. O. and Fleming, M.F. (2012). Racial disparities in pain management in primary ca re. J Health Disparities Res Pract , 5 (3), 1. Fein, D., Avner, J. R., and Khine, H. (2010) . Pattern of pain management during lumbar puncture in children. Pediatr Emerg Care , 26 (5 ), 357 \200\223360 . SECTION 9 special topics 676 Sabin, J. A. and Greenwald, A.G. (2012). Th e infl uence of implicit bias on treatment reco mmendations for 4 common pediatric conditions: pain, urinary tract infection, attention def i cit hyperactivity disorder, and asthma. Am J Public Health , 102 , 988 \200\223995 . Fillingim, R. B., King, C. D., Ribeiro-Dasilva, M. C., Rahim-Williams, B., and Riley, J. L. 3rd. (2009). Sex, gender, and pain: a review of recent clinical and experimental fi ndings . J Pain , 10 (5), 447 \200\223485 . Hester, N., Foster, R., and Kristensen, K. (1990). Measurement of pain in children: general izability and validity of the pain ladder and poker chip tool. Adv Pain Res Th er , 15 , 79 \200\22384 .