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The impact of neighborhood socioeconomic status and race on the prescribing of opioids in emergency departments throughout the United States
Open accessAbstract
Background Racial and ethnic disparities in opioid prescribing in the emergency department (ED) are well described, yet the influence of socioeconomic status (SES) remains unclear. Objectives (1) To examine the effect of neighborhood SES on the prescribing of opioids for moderate to severe pain; and (2) to determine if racial disparities in opioid prescribing persist after accounting for SES. Design We used cross-sectional data from the National Hospital Ambulatory Medical Care Survey between 2006 and 2009 to examine the prescribing of opioids to patients presenting with moderate to severe pain (184 million visits). We used logistic regression to examine the association between the prescribing of opioids, SES, and race. Models were adjusted for age, sex, pain-level, injury-status, frequency of emergency visits, hospital type, and region. Main measures Our primary outcome measure was whether an opioid was prescribed during a visit for moderate to severe pain. SES was determined based on income, percent poverty, and educational level within a patient's zip code. Results Opioids were prescribed more frequently at visits from patients of the highest SES quartile compared to patients in the lowest quartile, including percent poverty (49.0 % vs. 39.4 %, P<0.001), household income (47.3 % vs. 40.7 %, P<0.001), and educational level (46.3 % vs. 42.5 %, P=0.01). Black patients were prescribed opioids less frequently than white patients across all measures of SES. In adjusted models, black patients (AOR 0.73; 95 % CI 0.66–0.81) and patients from poorer areas (AOR 0.76; 95 % CI 0.68–0.86) were less likely to receive opioids after accounting for pain-level, age, injury-status, and other covariates. Conclusions Patients presenting to emergency departments from lower SES regions were less likely to receive opioids for equivalent levels of pain than those from more affluent areas. Black and Hispanic patients were also less likely to receive opioids for equivalent levels of pain than whites, independent of SES.
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TL;DR
In NHAMCS 2006–2009, ED patients with moderate-to-severe pain from lower-SES neighborhoods were less likely to receive opioids than those from more affluent neighborhoods. Black and Hispanic patients were also less likely to receive opioids than white and non-Hispanic patients, and these disparities persisted after adjustment for neighborhood SES.
Key findings
- Opioid prescribing was lower in the lowest vs highest SES quartiles: poverty 39.4% vs 49.0% (P<0.001), income 40.7% vs 47.3% (P<0.001), and education 42.5% vs 46.3% (P=0.01).
- In adjusted models, patients in high-poverty areas (>20% poverty) were less likely to receive opioids than those in low-poverty areas (<5%): AOR 0.76, 95% CI 0.68–0.84.
- Black patients received opioids less often than white patients (38.7% vs 46.4%, P<0.001); adjusted models accounting for SES showed lower odds (poverty AOR 0.73, 95% CI 0.67–0.80; income AOR 0.71, 95% CI 0.65–0.78; education AOR 0.69, 95% CI 0.63–0.76).
- Hispanic patients received opioids less often than non-Hispanic patients (40.4% vs 44.9%, P<0.001); adjusted AORs were 0.83 (0.75–0.91) for poverty, 0.83 (0.74–0.88) for income, and 0.80 (0.73–0.88) for education. No trend in opioid prescribing by race was found from 2006 to 2009.
Methods
- Cross-sectional analysis of National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2006–2009, including adults ≥18 presenting to EDs with moderate-to-severe pain; weighted to national estimates (abstract reports 184 million visits).
- Primary outcome: whether an opioid was prescribed. Neighborhood SES was measured by zip-code quartiles for poverty, median household income, and education; race was white/black/other and ethnicity Hispanic/non-Hispanic.
- Logistic regression models, weighted for complex sampling, with separate models for each SES measure and adjustment for age, sex, pain severity, injury status, prior ED visits, hospital type, region, and metropolitan status.
Limitations
- Stated: SES was defined only by five-digit zip code, so patient-level SES beyond neighborhood quartiles was unavailable; sample size did not allow examining Asian or other racial groups separately; quantity and strength of opioids were not available; clinician race/ethnicity, institutional/prescriber factors, and use of testing or prescription monitoring were not accounted for.
- Stated: SES was missing for approximately 5.7% of visits, and those visits were excluded.
- Evident: the cross-sectional observational design cannot establish causality and may leave residual confounding.
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“In adjusted models, black patients were less frequently prescribed opioids compared to white patients while accounting for percent poverty (AOR=0.81,0.68-0.97),median household income (AOR=0.80,0.66-0.96),and education level (AOR=0.79,0.66-0.95)(Table 2).”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Race and Ethnicity
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“Opioids were prescribed more frequently at visits from patients of the highest SES quartile compared to patients in the lowest quartile, including percent poverty (49.0 % vs. 39.4 %, P<0.001), household income (47.3 % vs. 40.7 %, P < 0.001), and educational level (46.3 % vs. 42.5 %, P=0.01).”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Abstract
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In the paper
“We also found that prescribing patterns varied according to geographic region”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > DISCUSSION
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In the paper
“In adjusted models, SES was an independent predictor of opioids being prescribed for moderate to severe pain.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Socioeconomic Status
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In the paper
“We did not find a trend between 2006 and 2009 in the frequency of prescriptions written for opioids for white patients (β=0.01;P=0.69), black patients (β=0.03;P=0.32), or patients of other racial groups (β=-0.03;P=0.63).”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Trend Over Study Period
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In the paper
“Opioids were prescribed less frequently to black patients for moderate to severe pain compared to white patients at all levels of SES (Fig. 1).”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Race and Ethnicity
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In the paper
“Adjusting for SES did not attenuate the influence of race on the prescribing of opioids for patients in the emergency department with moderate to severe pain (Table 2).”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Race and Ethnicity
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In the paper
“For instance, black patients from lower SES neighborhoods were approximately 6 % less likely to receive opioids for pain compared to white patients residing in similar neighborhoods, nearly 6 % less likely than black patients in more affluent neighborhoods, and nearly 14 % less likely than white patients residing in more affluent neighborhoods.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > DISCUSSION
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In the paper
“Similarly, opioids were prescribed less frequently to Hispanic patients for moderate to severe pain compared to non-Hispanic patients (40.4 % vs. 44.9%; P<0.001).”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Race and Ethnicity
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In the paper
“Opioids were prescribed more frequently at visits from patients of the highest SES quartile compared to patients in the lowest quartile, including percent poverty (49.0 % vs. 39.4 %, P<0.001), household income (47.3 % vs. 40.7 %, P < 0.001), and educational level (46.3 % vs. 42.5 %, P=0.01).”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Abstract
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In the paper
“The NCHS has established strict release standards for data based on the relative standard error of the point estimate and the absolute number of visits to ensure reliability of national estimates.8 All values reported meet the established release criteria for national estimates.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Data Analysis
What the sources say
- Not matchedcites [8] National Center for Health Statistics. NCHS public-use data files and documentation: National Hospital Ambulatory Medical Care Survey (NHAMCS)—2006, 2007, 2008, 2009. Available at: ftp://ftp.cdc.gov/pub/health_statistics/nchs/dataset_documentation/nhamcs .
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
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What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Models were adjusted for age, sex, pain-level, injury-status, frequency of emergency visits, hospital type, and region.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Abstract
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“All covariates were included based clinical significance and statistical significance in bivariate analyses.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Data Analysis
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“To control for whether a patient was a frequent visitor to the ED, we also included the frequency of prior visits to the ED within the past year and whether the patient had been seen in the ED within the past 72 hours.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Data Analysis
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“Field representatives from the U.S. Bureau of the Census performed checks for data completeness and, when necessary, missing data were imputed by the NCHS for race and ethnicity.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Data Completeness
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“Socioeconomic status (either poverty, income, or education) was missing for approximately 5.7 % of visits.Visits without SES were not included in our analysis.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Data Completeness
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In the paper
“Despite these limitations, it is clear that disparities in the prescribing of opioids in emergency departments exist, not only by race and neighborhood-level socioeconomic status, but along regional levels as well.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > DISCUSSION
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In the paper
“All Statistical tests were performed using SAS version 9.1 and SAS callable SUDAAN functions to appropriately weight visits and account for the complex sampling design.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Data Analysis
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“Third, information on the quantity and strength of opioids prescribed was not available.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > DISCUSSION
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In the paper
“To produce a common measure of pain across the years studied, we used the Clinical Practice Guidelines published by the Agency for Healthcare Research and Quality to categorize pain listed on a 10-point scale to none (0), mild (1-3), moderate (4-6), or severe (7-10).”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Other Key Covariates
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“To avoid colinearity, we developed separate models for each measure of socioeconomic status (poverty, income, and education).”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Data Analysis
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
In the paper
“NHAMCS is a national survey designed to collect data on the utilization and provision of emergency care throughout the United States.8”
- Also stated in: § Data Source · plain
“The survey uses a multistage probability design to select a stratified systematic sample of visits to EDs throughout the United States.The data are then weighted to produce national estimates of utilization of emergency medical care services in the United States.8”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Data Source
What the sources say
- Not matchedcites [8] National Center for Health Statistics. NCHS public-use data files and documentation: National Hospital Ambulatory Medical Care Survey (NHAMCS)—2006, 2007, 2008, 2009. Available at: ftp://ftp.cdc.gov/pub/health_statistics/nchs/dataset_documentation/nhamcs .
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plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
- Also stated in: § Data Source · plain
The paper relies on this without support.
The influence of neighborhood socioeconomic status on opioid prescribing for pain in the emergency department is unknown.
“Although racial and ethnic disparities in opioid prescribing in the emergency departments remains steady, the broader influence of socioeconomic status (SES) on the treatment of patients' pain is unknown.”
The paper relies on this without support.
Whether differences in socioeconomic status explain some of the racial and ethnic disparities in opioid prescribing in the emergency setting is unknown.
“Additionally, it is unknown whether differences in SES may explain some of the racial and ethnic disparities previously observed in opioid prescribing in the emergency setting.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In the citing paper
“The environment in which one resides is a known predictor of consumption behavior (39), thus behavioral economics is a conceptual system to understand how one's access and exposure will predict demand and subsequent intake (40–43).”
From A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health (2019) · cites this paper as [41]
In the citing paper
“Meanwhile, heroin use has significantly increased across most demographic groups (41).”
From A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health (2019) · cites this paper as [41]
In the citing paper
“Norwegian data suggests that individuals with a drug-related death had lower SES than the general population but overall SES situation prior to death was heterogenous (41).”
From A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health (2019) · cites this paper as [41]
In the citing paper
“In a rural part of Wisconsin (92.6% White, median income $46,333), a majority of overdose patients had private insurance (57) which is contrary to national data suggesting higher rates of overdose among the uninsured (41).”
From A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health (2019) · cites this paper as [41]
In the citing paper
“Non‐White and low income patients are more often undertreated for severe pain than White and high income patients in United States, even when pain is noted in their medical chart, with providers' beliefs of increased likelihood of opioid addiction cited as the primary reason to deny medication to Black patients (Joynt et al., 2013).”
From On race, human variation, and who gets and dies of sepsis (2022) · cites this paper as Joynt et al., 2013
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In the paper
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Abstract
“In adjusted models, black patients (AOR 0.73; 95 % CI 0.66-0.81)and patients from poorer areas (AOR 0.76; 95 % CI 0.68-0.86)were less likely to receive opioids after accounting for pain-level, age, injury-status, and other covariates.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > CONCLUSION
“| Race White Black Other | 46.4 † 38.7 † 42.2 † | 1.0 0.73 (0.66-0.81) 0.84 (0.72-0.99) | 1.0 0.73 (0.67-0.80) 0.81 (0.68-0.97) | 1.0 0.71 (0.65-0.78) 0.80 (0.66-0.96) | 1.0 0.69 (0.63-0.76) 0.79 (0.66-0.95) |”
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In the paper
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > RESULTS
“There were 50,264 visits in which opioids were prescribed for moderate or severe pain.Table 1 lists the weighted characteristics of these patient visits.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > CONCLUSION
“| *Total unweighted sample size was 50,236 patient visits; total | |”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > CONCLUSION
“| 16.67-31.68 % | 25.9 % |”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > CONCLUSION
“| 12.84-19.66 % | 22.3 % |”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Race and Ethnicity
“In adjusted models, black patients were less frequently prescribed opioids compared to white patients while accounting for percent poverty (AOR=0.81,0.68-0.97),median household income (AOR=0.80,0.66-0.96),and education level (AOR=0.79,0.66-0.95)(Table 2).”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > CONCLUSION
“| Race White Black Other | 46.4 † 38.7 † 42.2 † | 1.0 0.73 (0.66-0.81) 0.84 (0.72-0.99) | 1.0 0.73 (0.67-0.80) 0.81 (0.68-0.97) | 1.0 0.71 (0.65-0.78) 0.80 (0.66-0.96) | 1.0 0.69 (0.63-0.76) 0.79 (0.66-0.95) |”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Abstract
“In adjusted models, black patients (AOR 0.73; 95 % CI 0.66-0.81)and patients from poorer areas (AOR 0.76; 95 % CI 0.68-0.86)were less likely to receive opioids after accounting for pain-level, age, injury-status, and other covariates.”
§ The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States > Socioeconomic Status
“Compared to patients in low poverty areas (< 5 % poverty), those residing in high poverty areas (> 20 % poverty) were less likely to receive opioids for moderate to severe pain (39.4 % vs. 49.0 %; AOR 0.76, CI 0.68-0.84).”
Citations
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Metadata
- Authors
- Joynt, M., Train, M. K., Robbins, B. W., Halterman, J. S., Caiola, E., & Fortuna, R. J.
- Affiliations
- University of Rochester Medicine (US)
- Corresponding author
- Fortuna, Robert J.
- Venue
- Journal of General Internal Medicine
- Published
- 2013-06-25
- Volume
- 28
- Issue
- 12
- Pages
- 1604-1610
- ISSN
- 0884-8734 (ISSN-L)
- 1525-1497
- PMC
- PMC3832731
- OpenAlex
- W2147530350
- Semantic Scholar
- f1c6bf89669f7fc82a96b622e64387231b365a70
- Cited by
- 152
- References
- 28
- Citations by year
- 2026: 4 · 2025: 10 · 2024: 15 · 2023: 16 · 2022: 15 · 2021: 16 · 2020: 21 · 2019: 18 · 2018: 13 · 2017: 8 · 2016: 3 · 2015: 7 · 2014: 3 · 2013: 3
- FWCI
- 5.06
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Journal of General Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (submittedVersion)
- Deep Blue (University of Michigan) (submittedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
- Social Sciences › Health › Health disparities and outcomes
- Keywords
- opioid prescribing, neighborhood socioeconomic status, racial disparities, emergency department visits, moderate to severe pain, Black patients, Hispanic patients, poverty, household income, educational attainment, pain management
- MeSH terms
- Adolescent, Adult, Aged, Analgesics, Opioid, Cross-Sectional Studies, Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Pain, Practice Patterns, Physicians', Poverty, Residence Characteristics, Social Class, United States, Racial Groups, Young Adult
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-10-14, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-14 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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