Disparities in Pain Care: Descriptive Epidemiology-Potential for Primary Prevention

Background to this Chapter

This chapter is being written at an unprecedented time in the history of the United States. The coronavirus (SARS-CoV2) pandemic has swept across the country. COVID-19 case numbers, hospitalizations, and deaths show non-Hispanic Blacks, American Indians, and Hispanics to have been disproportionately affected. ^, The Centers for Disease Control (CDC) has reported age adjusted mortality rates for non-Hispanic Blacks and American Indians are over twice that of non-Hispanic Whites, and age adjusted hospitalization rates for Hispanic, and non-Hispanic Blacks are almost five times greater than that for non-Hispanic Whites. These large disparities in COVID-19 mortality and hospitalization are attributed to the long term detrimental effects of systemic/structural racism, manifest in persistent discrimination and unequal opportunity, poverty, segregated crowded residential neighborhoods, and current employment in “essential” low paying jobs that require the use of public transportation.

On March 25, 2020, the horrifying death of George Floyd, an unarmed non-Hispanic Black male, was televised. Mr. Floyd’s death has stimulated a widespread and continuing resurgence of and support for the “Black Lives Matter” movement. These two events have made it virtually impossible for most individuals to continue to believe that “racism” in the United States ended in the 1960s or to deny that non-Hispanic Blacks, in particular, continue to be impacted by discriminatory racial biases. Currently, the difference between “not racism” and “antiracism” is being discussed widely, and actions necessary to be an “anti-racist” are being disseminated through news and social media. ^, Coincident with this, healthcare professionals are acknowledging the influence of systemic/structural racism on the healthcare system and, consequently, the health of disadvantaged minority populations. In a recent issue of the Journal of the American Medical Association (JAMA), Hooper et al. wrote, “ The pandemic presents a window of opportunity for achieving greater equity in the healthcare of all vulnerable populations.” In mid-July, an editorial in the New England Journal of Medicine by Evans and his colleagues stated: ‘‘ Now, amid an acute public health crisis that is transforming medicine, perhaps we have an opportunity to reset our priorities to face this deeper, more chronic crisis as well…..Even if we can’t change the social determinants of health for any individual patient in any given encounter, we can think more seriously about how they affect what the patient can and can’t do, tailor the patient’s care accordingly, and show that we are invested.” These sentiments suggest healthcare providers may be ready to accept the challenge of moving beyond a healthcare system constrained by the influences of systematic/structural racism to one in which health care is equitably delivered and universally accessible.

In addition to the above secular events, two recent developments provide additional impetus for specific change in pain management. Consequent to the opioid epidemic, the CDC has issued restrictive guidelines that substantially limit opioid prescriptions for acute and chronic pain care. Practitioners and patients are faced with new challenges regarding which medication regimens and/or nonpharmacologic treatment approaches will work best. ^, The opportunities for doctor/patient decision making with regards to non-opioid treatment options can result in patient empowerment and increased treatment adherence. A second important change in pain management is the recognition that optimal care requires a multi-disciplinary group of pain practitioners (e.g. pain psychologists, physical therapists, and complementary medicine specialists) who join the physician and the patient in the planning and implementation of pain treatment plans. ^, With less reliance on opioid analgesics, this is a promising development. When fully operational, providers and patients will need to work creatively to ensure that patients who will benefit from important nonpharmacologic interventions will be able to access and pay for them.

Part I: Introduction

For most of the past 25 years, low back pain has been the number one cause of “years lived with disability” (YLD) worldwide. As such, low back pain accounts for more disability burden across the globe and in the United States than any other disease or injury. Acute and chronic pain are highly prevalent. Drawing on CDC data for 2016, Dalhamer et al. indicate that 20.4% of the United States adult population (~50 million individuals) suffered from chronic pain. Total overall annual treatment costs associated with pain have been estimated to exceed 600 billion dollars. Treatment costs represent only a small part of total pain costs. The physical and emotional suffering, loss in life quality, work productivity, and creativity experienced by individuals in pain and that experienced by family and friends are major additional costs. Both the World Health Organization statement on health as a human right, and the National Pain Strategy endorse the goals of equal access to health and health care for all individuals and reduction or prevention of the burden of pain across the life span.

In 1993, Todd et al. reported that Hispanics seen in the emergency department (ED) with a long bone fracture received inferior pain care compared to that received by non-Hispanic Whites. The Hispanics received no analgesic or a lower strength non-opioid analgesic, while non-Hispanic White patients received opioid analgesics. In 2000, Todd et al. reported similar disparate care received by non-Hispanic Blacks treated for acute pain in the ED. Over the past 27 years, many research papers, review articles, and government reports have documented racial/ethnic disparities in pain care, and pain care providers and educators have been challenged to find solutions to the problem. ^, Despite their efforts, unequal pain care to minority groups continues as a pernicious and troubling aspect of contemporary pain management. This chapter addresses the questions: “Is the primary prevention of disparate pain care to minority groups a possibility?”; and “If thought to be possible, what can pain care practitioners do to diminish or prevent the delivery of unequal pain care?” To develop answers to these questions, Part I addresses the epidemiology of pain care disparities. An operational definition of disparate care with the selected process and outcome indicators is presented. The populations at risk of such care are identified, findings from research studies pertinent to the identified indicators are summarized, and the consequences of suboptimal pain care are discussed. Part II presents contributing causes of inadequate pain care. In Part III, the potential for the primary prevention of disparate pain care is addressed, and actions pain care practitioners may take to diminish or eliminate their contributions to disparate care and to ensure optimal pain care for ALL are identified.

Part I: Epidemiology of Disparities in Pain Care

Definition of Disparities and Indicators of “Suboptimal” Pain Care

The Oxford Dictionary defines the term “disparities” as “a difference especially one connected with unfair treatment.” While helpful, a clinical definition of “unequal or disparate treatment” is missing. From an epidemiologic perspective, an operational definition of unequal or suboptimal pain care is important. However, no comprehensive definition has been identified. Because of the privileged status of most non-Hispanic Whites, researchers have used the pain care received by them as a metric against which to compare that received by other racial, ethnic, or marginalized groups. Since most of the published studies preceded recommendations to restrict opioid prescribing, less frequent or lower dose administration of opioid analgesics was most often the study variable that indicated suboptimal or optimal care. ^, Selected process and outcome indicators of suboptimal pain care reported in the literature or deemed critical to evaluating pain care are presented in Table 80.1 . As researchers, clinicians, and patients gain a greater understanding of the effective pain care strategies that supplement or replace those specific to a prescription of opioid analgesics, it will be important to identify new process and outcome indicators for both optimal and suboptimal pain.

TABLE 80.1

Selected Process and Outcome Indicators of Suboptimal Care for Acute and

Chronic Pain

Indicators	Citation Numbers
Patient’s pain level was not assessed by the treating provider	^, ^, ^,
Provider’s assessment of patient’s pain level is lower than patient’s self-report	^, ^, ^, ^, ^,
Provider failed to prescribe any analgesic to a patient with pain compared to a similar White patient treated for pain	^, ^,
Provider failed to prescribe opioid analgesic to patients with substantial pain compared to a similar White patient treated for pain	^, ^, ^,
Excessive time delay from emergency department (ED) arrival to administration of appropriate analgesic	^,
At ED, hospital, primary care physician (PCP) office discharge, provider prescribed no opioid analgesic or an opioid analgesic of inadequate strength for the patient’s pain level and disease status	^, ^,
At ED, hospital, PCP office discharge, provider required return visits for a patient prescribed an opioid analgesic at a shorter interval than for typical patients	^,
Patient/provider visit is shorter than provider’s average patient visit time
Provider diminished or dismissed patient’s self-reported pain and discharged patient from ED or outpatient office without thorough evaluation	^, ^,
Acute pain patient seen in ED or surgery transitioned into post-surgical chronic pain
Acute or chronic pain patient developed post-traumatic stress disorder or post-traumatic stress syndrome following treatment	^,
Acute or chronic pain patient developed misuse or abuse of prescribed narcotic analgesic	^,

Indicators are drafted based on a single patient. Evidence of disparities in pain care exists if the rate of suboptimal pain delivered to race/ethnic or other marginalized groups exceeds the comparable rate of suboptimal pain delivered to the comparison group.

Population Groups at Risk of Disparities in Pain Care

Many contemporary scientists, this author included, view “race” as a socio-political construct instead of a complete biologic phenomena informed only by a group’s genetic makeup. The conclusion that “race” is predominantly contrived rather than entirely determined by genetics remains controversial given population based genome studies and the interest in the identification of gene disease markers. While results of the Human Genome Project have shown that humans have 99.9% of their genetic material in common, ^, the differences remain unresolved between 1) the view that race is genetic and 2) the view that the effects of social and environmental exposures have contributed to the development of intergroup phenotypic differences such as skin color, hair texture, and eye color. Although no credible evidence supports the theory that non-Hispanic Whites represent a superior racial group and all other population groups are genetically inferior, White Nationalists explicitly support this racist theory. Other non-Hispanic Whites may have implicit biases they are not consciously aware of that support the supremacy of non-Hispanic Whites. Beginning with the practice of slavery, the racist viewpoint has had a longstanding history in the United States. Currently, the population is hierarchically organized, with non-Hispanic Whites the privileged holders of wealth and power; non-Hispanic Blacks, Hispanics, and other groups are devalued and limited in their access to power, wealth, opportunity, and material goods. ^, Although considered arbitrary, the race/ethnic classification established by the United States Office of Management and Budget that includes non-Hispanic Whites, non-Hispanic Blacks, Hispanics, American Indians or Alaska Natives, Asians, and Native Hawaiian or other Pacific Islander has become a principal classification variable used for the organization of Census Statistics and most health related research. It is used throughout this chapter. Following an informal scientific convention, non-Hispanic Whites are typically considered the “reference” or ‘comparison” group. In addition to race/ethnicity, other population groups have been classified, some or all of the time, as “minority” or “marginalized.” Such groups include American Indian/Native Alaskans, Asians, Native Hawaiian/other Pacific Islander, individuals who are poor, individuals with intellectual, physical, or emotional disabilities, older adults, women, persons who do not self-identify as heterosexual male or female, and those who ever have been incarcerated. ^, Collectively, these groups comprise the population at risk for disparate pain care.

Disparities in Pain Care: Summary of Recent Evidence

The substantive conclusions from previous research specific to the indicators listed in Table 80.1 have changed very little from the findings presented in earlier review papers published by Green et al., Anderson et al., Mossey, and Meghani et al. Consequently, updated findings reported in more recently published research papers are only very briefly summarized below.

Acute Pain Care: Emergency Department, Primary Care Settings

A cute pain is often treated in the ED, primary care outpatient offices or clinics, and the hospital pre- and post-surgery units. Typically, the treatment process includes 1) the identification of the patient’s self-reported pain level; 2) the development of a clinical pain level assessment based on the provider’s interpretation of the patient’s self-reported pain and other relevant clinical information; and 3) selection and administration of an analgesic that is deemed safe for the patient and commensurate with the patient’s reported pain level. Until the recent CDC guidelines in opioid prescribing for acute and chronic pain, the prescription of an opioid analgesic has differentiated suboptimal pain care from optimal pain care. While some studies have reported no racial/ethnic disparities in analgesic prescribing, the most consistent findings showed non-Hispanic Black and Hispanic pain patients, compared to non-Hispanic Whites, have received suboptimal pain care in the ED, outpatient offices, and the hospital.

Recognized as a critical driver of the providers’ analgesic prescribing, studies show self-reported pain levels of child and adult patients seen in the ED and other outpatient settings were not assessed as frequently for non-Hispanic Blacks and Hispanics as for non-Hispanic Whites. This disparity occurred during Emergency Medicine Service (EMS) transit to the ED and after admission to the ED, ^, ^, or attendance at primary care offices. There is considerable evidence that when non-Hispanic Blacks and Hispanics self-report their pain level, their report is an underestimation of the pain they actually feel. ^, Researchers have speculated that such under-reporting may reflect the patients’ internal pressures to maintain their self-image, cultural expectations, or fear that they will be perceived by healthcare providers as “complainers.” ^, Strong evidence explaining their tendency to under-report pain is not available. Simultaneous to the recognition that non-Hispanic Black and Hispanic patients underestimate their pain, clinical and experimental studies report that many providers believe these patients exaggerate their pain. ^, As a result of the patients’ and providers’ misrepresentations, compared to non-Hispanic Whites, non-Hispanic Black, and Hispanic children and adults are more likely to receive no analgesic during EMS transport to the ED and during an ED visit for a painful condition. ^, When analgesics are prescribed, non-Hispanic Black and Hispanic children, ^, and adult pain patients ^, seen in the ED consistently are less likely to be administered an opioid analgesic than non-Hispanic Whites. For example, in a study of the treatments and outcomes of children seen in the ED for a long bone fracture, non-Hispanic Blacks and Hispanics were more likely than non-Hispanic Whites to receive any analgesic [non-Hispanic Black adjusted odds ratio (aOR) 1.72 (95% confidence interval [CI] 1.51–1.95), Hispanics AOR 1.32 (1.16–1.51)]. However, they were less likely than non-Hispanic Whites to be prescribed an opioid analgesic [non-Hispanic Black AOR 0.86 (0.77–0.95) Hispanic AOR 0.86 (0.76–0.96)] or to achieve optimum pain reduction [non-Hispanic Black AOR 0.78 (0.67–0.90); Hispanic AOR 0.80 (0.67–0.95)]. Comparable to the experience of children, for adults with moderate to severe pain, the adjusted risk of receiving an opioid analgesic was 17% to 30% lower for non-Hispanic Blacks and Hispanics than for non-Hispanic Whites.

Pre- and Post-Op and Postpartum Acute Pain Care to Ethnic/Racial Minorities

Recent studies indicate persistent ethnic/racial disparities in pre- and post-op pain care to children and adults. Compared to non-Hispanic White children, Hispanic, Pacific Islander, or Asian children were at lower odds [AOR 0.87 (95% CI 0.74–0,97); AOR 0.53 (0.33–0.84); AOR 0.83 CI 0.70–0.97], respectively, of receiving important post-op non-opioid analgesics. Baldreldin et al. reported that while Hispanic and non-Hispanic Black postpartum women reported higher pain scores than non-Hispanic Whites, they received significantly fewer inpatient MMEs and were less likely to receive a prescription for an opioid analgesic [Hispanic AOR 0.80 (95% CI 0.67–0.96), non-Hispanic Blacks AOR 0.78 (0.62–0.98)].

Chronic Non-cancer Pain

Chronic pain is one of the most difficult pain diagnoses for the provider and patient to manage. Suffering can be extreme, and patients often feel desperate for relief. Studies indicate the prevalence of chronic pain is lower in non-Hispanic Whites; the intensity of the pain and the level of pain interference is greater among non-Hispanic Blacks and Hispanics. Recently divided into high impact chronic pain (HICP), pain with activity limitations, and low impact chronic pain (CPWL), pain without limitations, Dahlhamer et al. reported 8.0% of the adult population in 2016 suffered from HICP, and 20.4% experienced CPWL. Studies show non-Hispanic Blacks and Hispanics continue to receive suboptimal chronic pain care more frequently than non-Hispanic Whites. ^, In outpatient settings, studies indicate the percentage of non-Hispanic Blacks and Hispanics receiving opioid analgesics was smaller than for non-Hispanic Whites. Non-Hispanic Blacks were prescribed fewer opioid pills and required to return for urine testing more frequently than non-Hispanic Whites. Prescription of fewer drugs and more frequent monitoring for opioid misuse suggest pain providers are more likely to distrust non-Hispanic Black patients than non-Hispanic White patients, even though there is no evidence that non-Hispanic Blacks are more likely to misuse or divert prescribed medications for chronic pain. ^,

Other non-minority groups, including females and older adults, experience disparate chronic pain care. Compared to males, physicians tend to withhold giving females opioid analgesics, female pain levels are dismissed more frequently, and women are referred to pain specialists less often than males. ^, The experience of women whose physician diminishes their pain is particularly difficult and, very likely, demeaning to the patient. Comments of a Black female quoted in a qualitative study indicated: “You could just tell that he just didn’t believe me that I was in as much pain as I was. He was just very unsympathetic. He would literally walk away while I was in the middle of a sentence.”

Ethnic/racial disparities in Cancer Pain Care

Non-Hispanic Blacks are at increased risk of presenting for medical care with advanced cancer than non-Hispanic Whites. They have poorer outcomes for many cancer diagnoses and are less likely than non-Hispanic Whites to receive advanced cancer treatments or, when transferred to a nursing home, to have their pain level assessed. In a study of Medicaid cancer patients, Halpern et al. reported non-Hispanic Blacks and Hispanics were half as likely as non-Hispanic Whites to receive interventional pain treatments for breast cancer. In a study of racial disparities in the treatment of metastatic spine disease, non-Hispanic Blacks were less likely than non-Hispanic Whites to undergo surgery; they had longer hospital lengths of stay and were more likely to experience a complication.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here