Friday, December 11, 2009

Racial, Ethnic Disparities in Pain Care Examined

According to a recent research review, racial and ethnic inequities persist in the treatment of all pain conditions, across all age groups, and in all treatment settings throughout the United States. Barriers to optimal pain management for minority-group patients include factors related to patients themselves, healthcare providers, and the healthcare system. What should be done?

In the most comprehensive literature review to date, the authors examined peer-reviewed articles published between 1990 and early 2009 focusing on racial and ethnic disparities in pain and its management in the U.S. [Anderson et al. 2009]. Writing in the December 2009 edition of The Journal of Pain, they observe that many inequities persist in acute, chronic, cancer, and palliative pain care settings, with minorities clearly receiving lesser quality care than non-Hispanic whites. Here are several examples:
  • Multiple studies have shown that in emergency departments acute pain in minority patients is undertreated. In one study of long-bone fractures, Hispanic patients were twice as likely as non-Hispanic whites to receive no analgesics at all. Black (African American) patients were two-thirds more likely to receive no analgesics for their pain.

  • Although opioid analgesic prescribing for pain-related emergency department visits has generally increased, white patients with pain are significantly more likely to receive an opioid analgesic than black, Hispanic, or Asian/other patients. This has been evident in children as well as adults.

  • Postoperatively, white patients receive significantly higher total opioid doses than minority (black, Hispanic, Asian American) patients.

  • In a study of childbirth labor and delivery, researchers found that black, Hispanic, and Asian women were less likely to receive epidural analgesia than white women.

  • In the treatment of osteoarthritis, a nationwide study of veterans found that minority-group patients were less likely to receive adequate medication and the number of days’ supply of medication provided was less than for white patients.

  • Treatment inequities for minority-group patients also have been evident in studies of cancer pain. In most cases, black and Hispanic patients did not receive appropriate or adequate analgesics for their cancer-related pain.

  • In one study, minority-group patients were twice as likely as whites to be disabled 6 months after occupational back injuries.
There have been some inconsistencies across studies, with most finding egregious disparities in pain care but some finding improvements during more recent years. And, most research has examined non-Hispanic white populations in comparison with Hispanic/Latino and/or black/African American minority groups. Few studies have included Asian American, Arab American, Native Hawaiian, Pacific Islander, Native American, Alaskan Native, or other racial or ethnic groups that might be of concern.

The barriers to optimal pain management for minority-group patients include factors related to patients themselves, healthcare providers, and the healthcare system. Patient-related barriers may include differences in pain thresholds and tolerances, genetic factors, and attitudes or beliefs related to pain and suffering. Provider-related barriers often include lack of knowledge and training regarding pain management, inadequate assessment and treatment of pain, and inaccurate beliefs and expectations regarding minority patients. Minority patients also face barriers in the healthcare system, including limited access to care, lack of insurance or underinsurance, and limited availability of community resources needed for optimal pain management. For example, in some communities pharmacies do not stock certain potent analgesics, particularly opioids, that might be prescribed.

In their review, Anderson and colleagues [2009] contend that education on pain assessment and treatment is still a neglected topic during medical training, leaving physicians and healthcare providers ill-equipped to manage pain. Along with that, numerous studies document that clinicians are not satisfied with the pain care they provide or with their ability to provide culturally competent care for an increasingly diverse society. Although there is some legislative activity focused on healthcare disparities, proposed legislation has just begun to focus on pain and pain care inequities, in particular the National Pain Care Policy Act [more information here].

As Anderson et al. suggest, “Because the increasing prevalence of pain has significant and potentially devastating socioeconomic and health ramifications for the individual and society, a robust pain research program must be developed, funded, and more successfully translated into practices and policies specifically designed to reduce and eliminate disparities in care.” They further recommend that culturally and linguistically appropriate interventions must be developed to ensure quality pain assessment and management for minority-group patients, along with extensive efforts to transform health-professional education and healthcare institutions to overcome the inequities.

Comment: It is important to recognize that reform programs currently being debated in the U.S. Congress seem primarily concerned with access to healthcare insurance, which would expectedly increase access to the healthcare system for persons who have been underserved. However, this will not necessarily result in access to better healthcare or improved pain management practices that minority groups often have been denied.

Reference: Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009(Dec);10(12):1187-1204 [access abstract].