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10 Articles in this Series
Introduction
An AAPM 2019 Preview
APRNs/PAs in Pain Medicine SIG Gets Underway
Cannabis Has Entered Pain Management and Is Here to Stay: What Clinicians Need to Consider
Managing Pain in Marginalized Populations, including Ethnic Minorities, LGBTQ, and the Obese
Neuromodulation: A Roundtable on Current Best Practice & Key Questions
Pro/Con: CGRP Antibodies and Treatment Choice for Chronic Migraine
Pro/Con: Conservative Care is the Best Route for Chronic Pelvic Pain
Pro/Con: CRPS - Use Everything but Stimulation
Pro/Con: Ketamine for Complex Regional Pain Syndrome, Neuropathic Pain, and More
Pro/Con: Radiofrequency Denervation is Effective (The MINT Studies)

Managing Pain in Marginalized Populations, including Ethnic Minorities, LGBTQ, and the Obese

with Belinda L. Udeh, PhD, Sarah Rispinto, PhD, Marzena Buzanowska, MD, Danielle Weitzer, DO, and Samer Narouze, MD

 

In a targeted session at AAPM’s 35th annual meeting in Denver, clinicians from different disciplines provided perspectives on the barriers that remain to providing effective pain care to special population groups, including women, Hispanics, and members of the LGBTQ community. In a separate session, the links between chronic pain and individuals suffering from obesity were discussed, with highlights noted herein.

 

Economic Barriers

Belinda L. Udeh, PhD, a staff health economist at the Cleveland Clinic, used economic theory and the reality of healthcare in the US to point out barriers in providing pain care to vulnerable populations. For starters, she explained, the common practice of rational decision-making combined with DTC advertising often leads patients in these communities to develop preconceptions about medications and providers. Lack of insurance and/or coverage may also be an obstacle, for instance, when a surgery is approved more readily than a series of physical therapy sessions. Add to this the potential difficulties patients may have with finding transportation, making co-pays, and/or scheduling time to visit a doctor, and someone with chronic pain is more likely to seek a quick prescription over a longer-term complementary therapy.

In general, Dr. Udeh, noted, there is a lesser understanding of pain, care providers, and treatment options among lower socioeconomic status populations. This knowledge and access gap widens among populations that may have unique healthcare needs, such as transgender individuals. At the same time, vulnerable patient populations’ trust and respect for providers may be lower and they may be more skeptical of potential treatment outcomes.

 

Biases and barriers to optimal pain care lie on both the patient and provider side of the equation (Source: 123RF).

Language Barriers

These points were demonstrated by Sarah Rispinto, PhD, a pain psychologist at the Cleveland Clinic, who shared a model for an interdisciplinary, population-health program recently implemented at the clinic. The program was designed as a primary or secondary intervention, specifically for those experiencing low back pain, with adaptations made to address barriers, including language barriers for the Hispanic patient population. Called Back on Trek (Transform, Restore, Empower, Knowledge), the program started as a 12-week program and was later adapted to meet patients’ needs. It is now delivered as a four- to six-week LITE program or a 10-week program depending on patient needs. The focus of the program includes physical therapy and behavioral medicine groups. The Spanish-speaking group that was developed to meet the needs of the Hispanic population provides general psychoeducation along with helping to address language/reading barriers and sociocultural norms. For instance, Dr. Rispinto pointed out that many Hispanic populations presenting to the program relied on prayer and family support for their pain care.

The program includes using Spanish language materials and interpreters to lead patient conversations with context, the provision of Uber car rides for those lacking transportation access, and aftercare program refreshers to bolster proper PT exercises. Twenty Hispanic patients have gone through the program to date, primarily women.

“Empathy, compassion, and personal patient-provider experience ultimately helped to meet the patients’ needs to a fuller extent, including satisfaction with the program, adherence, and outcomes,” said Dr. Rispinto. “They felt heard and valued.” Clinical significance was found using the Oswestry Disability Index in sleep and depression improvement. The program is now being adapted to other populations with treatment barriers, and in addition to conducting a qualitative study of the program, Dr. Rispinto said she hopes that this type of patient-centered care will soon go beyond addressing language barriers to learn specific cultural norms for a wide variety of ethnic groups.

 

Provider Barriers

Sitting atop many of these barriers on the patient side are biases and misunderstandings on the provider side. Marzena Buzanowska, MD, a staff physician at the Center for Spine Health at the Cleveland Clinic, provided a physician’s perspective to the topic. Acknowledging the complexity of chronic pain pathology and treatment modalities, she pointed out how much more complicated pain care can become when working with special populations, often leading to frustration in clinicians and patients alike.

Dr. Buzanowska shared a number of studies and statistics as part of her discussion, all cited in her slide deck, which is available through the AAPM conference website. Below are a few highlights:

  • Racial/ethnic minorities are often linked with higher disability and higher prevalence of mental health conditions; the latter is also often true in women and LGBTQ groups.
  • Sexual minority adults are at greater risk of functional limitations due to pain and report more sites of pain.
  • In connection to the well-known historical dismissals of pain in women as being psychogenic or emotional, pain is undertreated across minority patients in both acute and chronic situations and across various settings.
  • Depression is underreported in racial/ethnic minorities compared to whites.
  • Mental health conditions are three times more likely to occur in LGBTQ individuals compared to those who identify as straight.
  • LGBTQ individuals are 2.5 more times likely to develop a substance abuse problem.

Reinforcing the stats, Dr. Buzanowska pointed out that surveys of minority group respondents have shown that more than half have experienced a type of discrimination in care. Some of this may stem from providers’ biases. She noted, for instance, one study demonstrating that nonwhite physicians achieved higher levels of pain reduction in minority patients.

At the same time, some research shows that ethnic groups may display sensitivity greater to experimental noxious stimuli; estrogen may influence some clinical pain conditions; and the research goes on and on describing differences in not only pain response but also in coping strategies and support levels among these special populations.

So, what can clinicians do? Advises Dr. Buzanowksi:

  • Believe your patient.
  • Establish an accurate diagnosis
  • Evaluate the degree of disability and mental health condition present, if applicable.
  • Evaluate your own biases to achieve positive interactions with your patients.
  • Refer patients to a chronic pain program when possible.

 

Community Barriers

Offering a personal perspective, final session speaker Danielle Weitzer, DO, a PGY-2 psychiatry resident at Rowan University, shared her journey as a transgender woman and the challenges she has faced not only in seeking medical care but also in pursuing a career in medicine. Presenting through middle school, high school, and the med school application process as a male, in order to avoid incessant bullying, it was not until after entering medical school that she began her transition and opened up about her true self. A lot of the delay and lack of seeking help came out of fear, she said.

There is no LGBTQ education provided in medical school, including the use of terminology and the health problems faced by the community, pointed out Dr. Weitzer. Pain in this population is often dismissed as mental illness or drug-seeking. This barrier, along with a lack of exposure to and understanding of the community can lead to provider bias, discomfort, and more, with the same feelings likely occurring on the patient side.

Further, not much research has been done on LGBTQ individuals and pain management. Yet, it is known that there is a bidirectional relationship between mental health and pain, said Dr. Weitzer, and this correlation must be considered moreso in the LGBTQ community, where suicide rates may be as high as 26%, so that patients can get the help they need. At the same time, pain alone cannot be dismissed. There is a lot of post-operative pain experienced by the transgender community, in particular, as these individuals may go through multiple body and facial surgeries to better align their appearance with their gender identification, she noted. And still, many transgender patients avoid seeing a doctor for fear of misunderstanding, judgment, or discrimination.

In terms of what has worked so far from her experience, Dr. Weitzer recommended that providers make their clinics and practices known as safe zones as this is very important to the transgender community. Clinicians can do this by reaching out to local diversity outreach programs and providing their practice phone number; adding diversity statements to their website; and making media statements about their clinic being a safe space for all communities.

 

Weight Barriers

In a separate but related AAPM session, Samer N. Narouze, MD, PhD, discussed the statistics and barriers around treating obese patients. Dr. Narouze is chair of the Center for Pain Medicine at Western Reserve Hospital and serves as a clinical professor at several universities in Ohio. He has been studying and publishing on obesity and chronic pain for the past six years.

A known public health concern, obesity was declared a disease in 2013 by the American Medical Association. It has been associated with level of education, age (middle age individuals are primarily affected), and race with a higher prevalence among African Americans and Hispanics compared to Caucasians, and lesser so, among women versus men, said Dr. Narouze. In the US, the total prevalence of obesity, defined by BMI as well as abdominal circumference and waist/hip ratio, among US adults is just under 40%.

So, does fat cause pain? The simple answer, said Dr. Narouze, is yes. In a survey of 1 million Americans, a BMI over 40 led to 254% more reported pain compared to a BMI of < 25 . What kind of pain? Back pain, osteoarthritis, peripheral neuropathy, and migraine are all common in those with the disease. “Obesity may not be associated with the onset of back pain but is more  associated with the chronicity of back pain,” Dr. Narouze clarified. Pain related to obesity stems from inflammatory effects, mechanical load, related accidental injuries, and metabolic syndrome.

In addition to diabetes, hypertension, and increased risk for certain cancers,  there are known neurological consequences of obesity as well, including increased risk of MCI, Alzheimer’s, polyneuropathy. When you add free fatty acids (FFAs) to the mix, Dr. Narouze explained, this causes inflammatory polyneuropathy and may also lead to DRG and C-fiber endings injury, as well as increased sympathetic tone, all leading to pain.

Overall, obesity is on the rise and chronic pain complaints mirror that trend, noted Dr. Narouze, but it is not necessarily clear what pain management providers can do to alleviate the challenge. Dmitri Souza, MD, PHD, also of Western Reserve Hospital, discussed some of research around standard treatments as part of the session. Often advised by PCPs and other specialists, these approaches include diet and nutrition interventions, exercise, certain pharmacotherapies, and behavioral modifications.  For morbidly obese individuals, there are additional specific interventional and pharmacological considerations which may help to provide better care for these patients. These are discussed in the speakers’ systematic review.

 

Next summary: Neuromodulation: A Roundtable on Current Best Practice & Key Questions
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