Minorities Not Prescribed Opioids As Frequently As Whites

If you’re black, Hispanic, or “Asian/other,” you might want to make sure your voice is heard loud and clear the next time you have to make a trip to the ER. Research published in the Journal of the American Medical Association shows that over the past 13 years, white patients were prescribed powerful opioid painkillers 31% of the time, versus 23% for blacks, 24% for Hisanics, and 28% for Asians and “others.”

According to Reuters, “the study found the largest racial disparity in providing stronger medications was found among patients in the most pain and those aged 12 or younger.”

“There is no evidence that nonwhites have less severe or different types of pain when they arrive in the emergency department,” Pletcher said. “We think our data indicate that opioids are being underprescribed to minority emergency department patients, especially black and Hispanic patients.”

A factor may be that white patients are more likely to expect and demand relief from pain and better convey their symptoms in comparison to minority patients, the report said. Whites — who are more likely to have health insurance — may also be overprescribed the drugs, it said.

From Scientific American:

The investigators acknowledge that it is conceivable that the disparity represents overprescribing to white patients, but they think it a more plausible explanation is true undertreatment of pain in minority patients. This may not be a result of physician bias but could reflect expectations and assertiveness of the patients.

“Racial gap in ER opioid use still persists” [Scientific American]
“Minorities less likely to get pain relief-US study” [Reuters]
(Photo: Getty)

Comments

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  1. nutrigm says:

    Those minors will take whatever we dish out! – bushism

  2. kublaconsumer says:

    Why bother with these studies? Final study: If you’re white, all your actions are nothing but pure racism.

  3. B says:

    I’d like to see this broken down by income level as opposed to race, because I think the most likely explanation is rich people buying prescription drugs for recreational use.

  4. This isn’t surprising given that there’s always some report about how women and/or minorities are more likely to die of X.

    For example, this article (a few years old): [www.americanheart.org]

  5. Project Thanatos says:

    I think there is truth in this study. I mean minorities are use to dealing with pain and such… usually caused by the white man!

    OH SNAP.

  6. Syd says:

    It’s only payback. White America introduced crack to minority neighborhoods and created a new batch of addicts. Now White America is trying to hook their own folk onto a more expensive habit.

    Can we just agree that rich White people aren’t doing any good for anybody?

    /wishes he was rich
    //already White

  7. lincolnparadox says:

    In my experience, with EMTs and Trauma Staff at two Iowa hospitals, no one is ever refused pain medication. Hospitals in Iowa will dole out the pain meds if you show any discomfort. Now, whether they give you extra strength Tylenol versus Tylenol-3 (with codeine) depends on your diagnosis. But here in the midwest I don’t think that race has anything to do with it.

    I also know that this fact is readily abused by many ER patients.

  8. Sonnymooks says:

    UM, I am going to ask the most obvious question here.

    What was the racial make up of the people of the people providing the painkillers?

    And then, how does it match up to the make up of the patients?

    Also with one race treatment to someone of the same race, does the care provided change? I.e. Black doctor to black patient, to white patient, etc?

    Without more data, this whole thing is crap that could be dismissed by simple geography (i.e. expensive hospital in the burbs versus an overwhelmed hospital near the projects).

    This was a shortcut study designed to get an answer that was wanted, instead of giving more data and information to form conclusions, and even, come up with solutions.

  9. canerican says:

    Oh brother this is pathetic.

    Of course the White Conservative Male is always wrong (unless its the Jews, right?)

    Well the Conservative Black Male is also wrong in the media’s eyes.

    Has anyone looked at average wages, unless you have done alot of work in black neighborhoods you will never understand the ethic. The idea in most black/hispanic ghettos is take as much as the government will give you, in the meantime try not to give any back, because the only people benefitting will be the white people.

    I have done lots of work in poor neighborhoods, I understand the mentality to say that the White people are guilty for everything wrong with minorities is absolutely ludicrous. There were certainly problems with the systemic repression of Blacks until about 1985, now, its ethic.

  10. DallasDMD says:

    So is the claim that minorities are being denied painkillers or merely that they’re not being prescribed them? Where does the blame lie exactly?

  11. dandd says:

    I agree that this study should be looked at in a socioeconomic sense, not a racial one.
    I work in health care and I think one of the biggest differences is how different races express pain and their idea of acceptable pain.
    EX: We’ve got two expectant mothers in the same room. One is of Italian descent and the other is of Asian descent. The Italian is very expressive and the whole floor knows when she has a contraction. The Asian is very reserved and silent.
    Guess which one started to deliver and caught us by surprise?

    If you are in pain, sometimes you need to be a squeaky wheel.

  12. youbastid says:

    No one else is gonna say it?

    Fine.

    It’s “opioid,” Chris.

  13. Mills says:

    This would mean something if they concluded something about the way that minorities use the American Health Care System (they’re statistically less likely to have health insurance and a Primary Care Physician because of that and more likely to use the emergency room in lieu of seeking the care of PCP.)

    It could also be because when you’re uninsured you’re less likely to demand palliatives-I certainly didn’t demand possibly expensive prescriptions when I didn’t have health insurance.

  14. pigeonpenelope says:

    The assertive hypothesis sounds plausible however there doesn’t seem to be enough data to really tell us why. I think there should have been more research done before making a report.

  15. timmus says:

    Save them poppy seeds.

  16. Antediluvian says:

    @youbastid: I was gonna say it, but was thinking maybe it was an annoucenment of Apple’s new foray into dyslexic Irish medical audio devices.

    But “opioid” is good too.

    And, I’ve got a new Scrabble word.

  17. Hitchcock says:

    This also need to broken down not by amount of pain, but reason they are in the emergency room. Different races have different health trends, and it may be in part that white people are coming in with different types of injuries that are more likely to use opiates to treat them.

    If I come in with a bad sore throat, I’m prescribed codeine. If I come in with a headache (which hurts more) I’ll walk out with two Asprin or possibly some Ibuprofen.

  18. techguy1138 says:

    You really need to know a lot about this study for it to be valid.

    Were the patients complaining of the same symptoms and expressing their pain in the same way?

    Were the same injuries being compared in the same physical locations?

    Who had insurance and who didn’t? Were doctors being racist or simply prescribing cheaper, non-opioid, pain medicines to people who had to pay more out of pocket?

  19. 92BuickLeSabre says:

    @canerican: Really? So recent case studies that show that in numerous geographic areas otherwise identical White Males with a Criminal Record are hired more often than Black Males with no Criminal Record (and that Black Males with a Criminal Record are rarely hired at all) are just lots o’ coincidence?

    And continued case studies showing that otherwise identical minorities are still rented apartments less often than their white counterparts are just fictitious even in liberal urban centers?

    I too have spent plenty of time working in “poor neighborhoods” and disagree wholeheartedly with your anecdotal perspective not only based on the studies, but from my own experiences as well.

  20. Sonnymooks says:

    @pigeonpenelope:

    Your absolutely right, I would also add, I would love to see the methodology, i.e how was this done, how many african americans, how many asians, how many whites, and also where or what type of locations was this study done at?

    I.E. Hospital in suburbs, in the inner city, etc.

  21. chili_dog says:

    I can statistically prove that the sky is orange. And yet it still tells us nothing, just like this report.

    But on the other hand, are the non-whites getting other classes of pain killers more?

  22. Boberto says:

    @canerican: Lots of comments like this one.

    Among some MD’s, the perception is: Urban/Minority=Diversion and or abuse.

    This is especially true in New York since July 1st 2007. This date was the start of electronic transmission of Narcotic prescription reporting. Basically, whenever a health care practitioner writes an RX for anything narcotic, it is electronically transmitted to Albany for review(other States have laws like this also). The law was intended to reduce diversion and abuse.

    July 2007 was also the beginning of a trend seen by myself and many colleagues where upon Hospital discharge, Patients were deemed magically cured of pain symptoms. Prescriptions for Narcotics among this observed group (minority/urban/recent inpatient discharge) virtually disappeared. I can also tell you that these were painful diagnoses(osteomyelitis, Bone fractures, bacterial pneumonia etc.) which had been treated with heavy doses of narcotics up until the day of discharge.

    In reality though, pain management has taken about 10 steps backwards. The people who are prone to substance abuse still end up doing so. The people who require pain management are hyper scrutinized and often times denied effective treatments.

    The Bush justice department’s targeted jailing of pain management MD’s has not inspired compassion among those treating chronic or even acute pain.

    Sad.

  23. pureobscure says:

    Scientific American is a political magazine masquerading as a science magazine. I believe exactly zero of what they publish. It’s a shame too, they used to be my favorite magazine.

  24. Invisobel says:

    I don’t think this has anything to do with racism, I think the researcher hit it on the nose. This is about many minorities inability to articulate their symptoms as well. It is also a measure of many minority’s assertiveness and sense of entitlement. It’s a cultural thing, many of the older people in my family (Puerto Rican) are used to mistrusting doctors and usually want to get out of a hospital of office as quickly at possible. If anything the study is placing the “blame” on the minority.

  25. cde says:

    @lincolnparadox: That’s part of what’s being said. Given the same pain level, if you are a minority, you are more likely to get prescribed strong over the counter meds (Ibu 800mg, Aspirin 1000mg, etc) instead of controlled meds (Morphine, Codine, Oxy).

    Better Article:
    [www.startribune.com]
    //The irony, she said, is that blacks are the least likely group to abuse prescription drugs. Hispanics are becoming as likely as whites to abuse prescription opioids and stimulants, according to her research. She was not involved in the current study.//

    //Patient behavior may play a role, Pletcher said. Minority patients “may be less likely to keep complaining about their pain or feel they deserve good pain control,” he said.//

    What that last one is saying is that minorities suck it up/walk it off while whities bitch and moan about every little last pain. Which if you look at it, is true.

  26. cde says:

    @cde:

    That article is a AP writeup of the information. And is more informative.

  27. Namilia says:

    Oh god I’m going to have to bite my tongue on this one. Just bite your tongue and walk away…

  28. UpsetPanda says:

    1) There are no obvious conclusions or implications of this article. White people get more painkillers…maybe they have more pain. Does this include pregnant women? Most of them want painkillers on arrival.

    2) In a country with so much cultural diversity, why didn’t the scientists look at how culture comes into play? We are obviously talking about a majority of American-born white and black people, yet a majority of Hispanics and Asians most likely were not born in the U.S. I know that the older generations of Asian people are more distrusting of Americans or white people, not necessarily because of race, but because they are transplants to another country and there is a significant language barrier for a lot of them, more so than for Hispanics.

    Really, just check out Chinatown. There are stores upon stores selling herbal remedies and roots of various kinds promising health benefits. Is it any wonder that a lot of Asian people who have been raised in Asia are suspect of Western medicine and perhaps may be less inclined to trust in it? When my grandfather got sick, heck yes we took him to the hospital. But I doubt he would’ve gone if it were just up to him. After every hospital visit, my grandma would whip up a batch of some herbal remedy, and he’d have that along with all of his doctor-prescribed medicines. I don’t know if it did any good, but when I was a kid, my mother would treat my coughs and sniffles with robitussin and some herbal drink, because her mom had done it, and whether it was actually helpful or not (I doubted it), it was what was taught.

  29. chili_dog says:

    @boberto: In reality though, pain management has taken about 10 steps backwards… The people who require pain management are hyper scrutinized and often times denied effective treatments.

    So True. I deal with chronic foot/leg pain from an injury 10 years ago. And while I barely use (by choice) narcotic pain meds, I have had 2 calls from the state regulators concerning the “frequency” that I fill a particular med. I guess 2 prescriptions of Dilaudid over a 10 year period is suspect. But no thanks on the big stuff. Just give me good ol Tylenol #3 and life is just grand.

  30. Womblebug says:

    @B: Because surely wealthy people have no better recourse for getting narcotics than the local public emergency room. =P

  31. bohemian says:

    There are too many missing factors. Gender of the doctor vs. the patient should be studied. There are some male doctors who will dismiss medical complaints by female patients. There are cultural differences vs. the doctor. If the doctor isn’t interpreting what the patient is telling them correctly they may think the patient is fine or totally over-reacting when that is not the case.

    Income and insurance should also be looked at. I know when I was in the hospital with extremely good insurance the staff was trying to milk the insurance for all it was worth. They kept offering me extra services I really didn’t want or need. This was the polar opposite of when I was in the hospital with crappy bare bones insurance.

    The concerns about patients abusing or diverting medications goes beyond race stereotypes. There have been ongoing issues in poor white rural areas of people selling their medications in the exact same manner that has been labeled a minority/urban problem.

  32. @canerican: You do realize that your comment has absolutely nothing to do with the article, right?

  33. Namilia says:

    I’ll say this much at least…I agree with all of you saying that there are too many missing factors, and I believe it should have been done by culture/nationality group rather than skin color. Example being, there are a lot of people who fall under the ‘Hispanic/Latino’ tag but are from widely varying tribal groups and locations. The same goes for White, Black, Asian, etc. I also agree with the gender factor, not only are male doctors more likely to dismiss complaints by female patients, but female patients may feel uncomfortable voicing their symptoms to someone of the opposite gender, and vice versa.

  34. LadyCarolineLamb says:

    Opiates are the more hard-core natural-based addictive meds (like Vicodin, Oxycodone, Percocet, etc), Opioids, also pain meds, but synthetic versions, and less likely to have the user form addictions (Tramadol, for example).

  35. Blowfish says:

    Why is this study so hard to believe? Most hospitals keep meticulous records for legal reasons. Its not a subjective survey. Blacks and other minorities were either prescribed the drugs or not. Not that this validates the article but I first hand experience two weeks ago. My wife and I were out of town visiting family. She began having severe abdominal pain. One ER provided minimal service and accused of doctor shopping when the Dilaudid dose failed to alleviate the pain. Of course we left after we raised a stink and they threatened to call the police. I was able to GPS another ER 15 miles away. Similar testing performed and this hospital was able to locate a badly infected cyst in one of the fallopian tubes. Potentially fatal condition had it burst. Yes, I had insurance. Yes, I am keeping my legal options open but since her life was saved there are really no damages to pursue.

    This African American has no reason to doubt this article.

  36. WTRickman says:

    Maybe minorities don’t complain as much about pain as white folks. Just a thought.

  37. bohemian says:

    The fear on the part of doctors that they might get in trouble and heightened suspicion of patients isn’t helping matters. You can start getting some wacked out results when doctors start making snap judgements about people and their potential to be trying to obtain narcotics for misuse.

    There has been some evidence of some doctors refusing to prescribe pain meds to patients with tattoos under the assumption that someone with a tattoos is more likely to abuse or sell drugs. If those kinds of random judgements are being made, race judgments are certainly not a stretch either. I still think the unequal care has more factors at play than just race.

  38. tazo says:

    Just keep my ass alive and don’t worry about getting me addicted to the latest goddamned designer drug.

  39. techguy1138 says:

    Blowfish- The article states number but provides no meaning or context.

    It doesn’t state if the patient complain more thus receive medicine. It doesn’t mention if like conditions were compared.

    It also doesn’t look to see if Whites and Asians are being over prescribed the medications.

    Your wife didn’t need pain killers she needed a better diagnosis. I am glad that you were clear headed enough to find another hospital and get her help.

  40. Sonnymooks says:

    @Blowfish:

    Actually, you just gave a very valid reason to doubt this article.

    One hospital would not serve you properly, while another one did.

    What isn’t explained here, is where the hospitals were located for this study.

  41. pigeonpenelope says:

    Thanks Sonnymooks!

    Also I wonder if doctors don’t prescribe pain killers to those they know have medical insurance. In this case, it is a matter of the insured and the uninsured. It can be possible that folks of certain minorities are not with medical insurance due to socio-economic reasons.

    Ugh. Too many possibilities.

  42. Sonnymooks says:

    @WTRickman:

    I highly doubt that african americans are meek and submissive when in pain, just another thought.

  43. pigeonpenelope says:

    Bohemian: I think you also have a good point.

  44. WTRickman says:

    @Sonnymooks:

    Good point.

  45. trollkiller says:

    It has more to do with percieved economic factors than color of skin.

    Most black people are poor, so the stereotype goes, if you are poor and need a fix you go to the ER. Doctors don’t want to feed your fix.

    Most white people are rich, so the stereotype goes, if you are rich and need a fix you call your dealer or your own doctor.

    If you think of the economic stereotypes wealth goes 1)Whites 2)Asian 3)Hispanic 4)Black.

  46. Pamoya says:

    Some of you are complaining that the article doesn’t look at some obvious demographic explanations. Well, the Scientific American summary doesn’t show the whole story, but this is from a study published in the Journal of the American Medical Association.

    Like they would for any serious, scholarly study, the researchers coded the cases for any obvious alternative explanations and included them in the analysis. I went and looked at the study description in JAMA and here are some of the factors they also analyzed: patient description of pain, doctor diagnosis, patient characteristics such as whether they had a chronic condition or were an alcoholic or drug user, age, gender, whether they had insurance, hospital characteristics such as urban or rural, hospital region, hospital regional type.

    These alternative explanations for the difference are included in the model– if the race explanation is too strongly correlated with one of the other factors it would not be statistically significant. But even with all these factors included, the different treatment for minorities holds up.

  47. Boberto says:

    @LadyCarolineLamb: Ultram/Tramadol is non narcotic, non opioid. It is an opiate agonist, and inhibits reuptake of seratonin and norepinephrine.

  48. faust1200 says:

    So the main point here is ?????? We’re not giving minorities enough addictive pain medication?? On top of the non-existent point of the article, the percentages aren’t very lopsided anyway. And as long as we’re picking apart typos: watch out for those “hisanics.”

  49. asherchang2 says:

    Jeez! Please! STFU people! You’re embarrassing all the actually reasonable laymen and average folk who comment on blogs!

    Everyone’s screaming for the raw data and for a look at the effects of socioeconomic status, type of injury, geography, etc, certain that they can find something wrong with the methodology that the authors of the study used. But I doubt that anyone in here would be nearly as proficient in statistics and data analysis as Dr. Mark J. Pletcher and his colleagues with their analysis of the National Hospital Ambulatory Medical Care Survey.

    Do you think that they would submit such a study if it had such gaping holes that even Consumerist commenters can spot? If it’s common practice for medical experts to ignore statistically relevant info and not control for them before making a conclusion, then we should never trust them at all.

    All these researchers said was that minorities are prescribed opioids less frequently, with the offered explanations of whites being more assertive and expecting painkillers more frequently. This isn’t even remotely related to racism or blame or any sort of class struggle.

  50. MercuryPDX says:

    @faust1200: Borrowing from Kanye here… “ER Docs hate black people.”

    @asherchang2: Figures don’t lie, but liars can figure. –
    Copy editors who deal with wire stories on research results should be especially wary. We pass along too much dubious information that serves only to frighten readers despite sketchy or nonexistent evidence.

  51. beavis88 says:

    @canerican: Yeah it’s been a tough run for the conservatives in this country of late. Sucks being in charge, eh?

  52. sonichghog says:

    @Blowfish: Because it may not have anything to do with skin color. It is possible that you can replace Blacks and Latinos with uninsured and have the same numbers. Or, inner city hospitals perscribe the drugs less, and you could have the same result.

    The article makes the hospitals sound racist, when that is probably not the case.

  53. ornj says:

    Doesn’t seem to me that the numbers prove anything. The % are all pretty close, I wonder what the margin for error is?

    I can’t stand these “studies” that cry racism at everything but that might be because I don’t really have to deal with it in the same way that others do. That and I wasn’t really exposed to it growing up.

  54. Wormfather says:

    Hey Chris, I know you mean well, but please guys, dont bother posting any articles like this, all it usually amounts to is a Racial Flame War (RaFlaWa FTW). Not an inteligent debate of the facts (or lack there of).

    I for one make a decent living, have health insurance and do not exhibit “drug seeking behavior” but I can remember a couple of times that I’ve went to the ER in some serious pain and been given a tylenol, after being asked and describing my pain as an 9 out of 10. I was just in too much pain to even argue (and nervous about how I’d look to the doctor). If it wasnt for the fact that my fiancee followed the doctor and gave him a what for then that probably would have been the end of it.

    But I dont think that counts because both he and I were black.

    But then again, another time I went with a sprained ankle, the doctor perscribed me percoset…I looked at her like “What?”, never even filled the perscription…just needed anti inflamitory pills.

    She was white.

    My point as always is…I dont have to have one.

  55. Wormfather says:

    In other news…why is it that whenever the race is thrown into an issue like this, the answer is either racist or not-racist.

    If a white guy snubs a black guy does that automatically make him racist? Maybe he’s just an ass hole, maybe he didnt see him, maybe he was in a rush.

    Even as a black guy, I think both sides run to their racial defense positions a bit to fast these days.

    I hate all of you equally.

  56. Wormfather says:

    @Invisobel:

    “It is also a measure of many minority’s assertiveness and sense of entitlement. It’s a cultural thing…”

    Nice touch.

    I know when I’m in pain, I typically have a sense of entitlement, I treat my doctors just like waiters at a high end dining establishment.

    “My opiods are cold, send them back and bring me a manager”

    Oh and that whole wanting to get out of the hospital, that transends all gender and race.

  57. topgun says:

    you know really there is nothing to this story. I mean really is there much of a variation on the pecentages?
    We’re only talking a few points.

  58. ppiddyp says:

    I have a feeling that there are a LOT of factors at play here, not just one. Sure, it’s probably mostly economics. However, ignoring the possibility of racial bias is stupid because we know it exists elsewhere in society. Ignoring the possibility of cultural differences in how people express pain is stupid as well.

    I know the tendency, especially as a white guy, is to totally blow off any study that implies that people are showing racial bias. Blowing it off doesn’t make it untrue, though, and it sure alienates everyone who isn’t white when people refuse to acknowledge the existence of racism.

    In any case, this study doesn’t tell us anything except that there’s a difference in the treatment people receive. Period. It’s one of those “warrants further study” studies.

    P.S. “hispanic” and “latino” are not races. You can be black, native american or white and be hispanic.

  59. Hambriq says:

    I’ve had to deal with a number of fake or stolen prescriptions (and an even larger number of ones I suspect to be fake but cannot conclusively prove). The decision to further investigate a prescription is generally one based on judgment; I look at the person, I look at the prescription, and if something seems funny, I’ll look into it.

    As it turns out, the VAST majority of the people bringing in phony prescriptions are African American or Mexican. Granted, the pharmacy I work at has a minority customer base of around 80%, so that could easily be the cause of it. Or, maybe I’m subconsciously profiling because somehow white people don’t set off my “spider sense” the way that minorities do, all other factors being equal.

    So I can certainly understand the dilemma of a doctor who may recognize signs of drug-seeking behavior and follow his instinct by not prescribing them a narcotic. At some point, the doctor has to look at the person and say, “From what I can tell of this person, would they be the type to divert, misuse, or abuse a prescription for a narcotic?”

    So where does that cross the line from “good judgment” to “profiling”?

  60. SingingMongoose says:

    It’s interesting that the study didn’t mention racial profiling as a possible cause of the disparity.

    It’s not just the pharmacists who have to make a judgement call, as Hambriq notes in his comment, but of course the prescriber as well. I have a hard time believing that racial profiling isn’t a factor here, especially as it’s (unfortunately) no longer taboo in this country.

  61. JMH says:

    I think this is just because we white people are pussies.

  62. vladthepaler says:

    This doesn’t seem to make any attempt to measure need for the opioids. Maybe people just have different needs. Maybe poor people, who are statistically likely to be minorities, come to the emergency room for more minor things than more well-off people, who have other avenues of treatment. If lots of white people went to the ER instead of to their regular doctor for relatively minor things, then the probability of white people being prescribed high-power painkillers would decrease.

  63. jwissick says:

    Where do I go to apologize for being white?

  64. ornj says:

    Jesse Jackson

  65. UpsetPanda says:

    I don’t have access to the full article (does anyone in college have access to the JAMA articles?) but I found this in their current issues – [jama.ama-assn.org] Might give more indication as to how they conducted their study. What stood out to me was:

    Opioid prescribing for patients making a pain-related visit to the emergency department increased after national quality improvement initiatives in the late 1990s, but differences in opioid prescribing by race/ethnicity have not diminished.

    Basically, they studied current numbers through study and compared them to past numbers…and there was no difference.

  66. techguy1138 says:

    @Wormfather:
    If you could in fact be nervous about what your doctor would think you most likely were not a 9 or a 10 on the pain scale.

    I have seen people get to that point they just sit there and scream or cry.

    They got strong pain killers in the ER and they were black. Their pain was rated “8.”

    @asherchang2: The consumerist write up had no conclusions. The article while statically relevant made no attempt to determine why. This is because their thesis was not on race disparity. It just turned up as an interesting trend given the data. I’m sure this will spur a future study.

  67. SexierThanJesus says:

    @canerican: “Of course the White Conservative Male is always wrong (unless its the Jews, right?)”

    Why hasn’t this been flagged yet?

    @techguy1138:

    Agreed. The writeup draws no conclusions, and that’s probably a good decision.