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16 Articles in Volume 20, Issue #5
20/20 with Drs. Carmen R. Green and Johnathan Goree: Racial Disparities in Pain Care
A Kratom Primer: Miracle Medicine or Herb of Abuse?
A Pilot Study: Incidence and Prediction of Diversion among Opioid Therapy Patients
Analgesics of the Future: G-Protein Biased Mu-Opioid Receptor Ligands
Application Note: Decellularized Human Placenta in the Treatment of Infracalcaneal Heel Pain
Are Clinicians Effectively Counseling Patients on Safe Opioid Storage and Disposal? Survey Results
Ask the PharmD: How to Manage Pain Meds During Pregnancy?
Behavioral Medicine: Managing Anxiety and Maladaptive Behaviors
Case Report: Spinal Cord Stimulation for the Treatment of Pain Associated with Chronic Pancreatitis
Differential Diagnoses: Inflammatory or Non-inflammatory Chronic Back Pain?
Pelvic Inflammatory Disease: Diagnosis, Education, and Treatment Options
Product Review: Non-Invasive Neuromodulation for the Treatment of the Most Difficult Pain Conditions
Provider Perspective: Carpal Tunnel's Association with Hypothyroidism
Research Insights: Opioid Use During the Peripartum Period – What to Expect
Special Report: Race, Pain Management, and the System
When Patients Become Pregnant: How to Maintain Chronic Pain Management

Special Report: Race, Pain Management, and the System

Racial disparities continue to exist in chronic pain management – and throughout the healthcare system. Collaborative cross-cultural education and sensitivity training as part of clinical practice can help to eradicate them.

Chronic pain is one of the most common conditions, affecting an estimated 116 million Americans, but it is not treated equally in this country – inside the data and perspectives from Michael Schatman, PhD, Terri Lewis, PhD, Sherra M. Watkins, PhD.

Racial bias and discrimination have contributed – and continue to contribute – to inequities in pain experiences and pain care for Black, Indigenous, and People of Color (BIPOC) compared to White individuals.1,2

In fact, studies indicate that BIPOC patients in diverse practice settings (including primary care, emergency, surgical, and tertiary care centers) are significantly undertreated for pain.1 According to the CDC, systemic inequities in the social determinants of health, including healthcare access, racial discrimination, and economic security, increase barriers and lead to poorer health outcomes and quality of life for underrepresented groups.3

Clinicians, health systems, and policymakers need to recognize and mitigate influences that lead to unequal pain management for more unbiased care going forward.

 

The Data on Race and the Pain Experience Say it All

Studies show Black and Hispanic American patients report greater chronic pain severity but lower quality of care.4 Here are just a few additional examples uncovered in research to date:

  • Black patients receive less analgesics for fractures in emergency rooms than White patients (57% to 74%).
  • When facing metastatic or recurrent cancer (35% vs 50%), BIPOC patients receive inadequate pain management medications compared to White patients.5
  • Black women have been historically underdiagnosed and treated for endometriosis due to persistent stereotypes that the condition is more common in White women.6 (To date, little research has been conducted on the impact of undertreated endometriosis in BIPOC women even though it is a debilitating chronic condition causing significant pain, infertility, and negatively impacts quality of life.6)
  • Black individuals experience greater pain sensitivity and burdens, including functional limitations, in comparison to White patients, for many chronic non-cancer pain conditions such as arthritis and migraine.7
  • Hispanic Americans with chronic pain face more stigma, greater cost barriers due to lack of insurance, and less access to pain treatment compared to other individuals living with chronic pain.4
  • Indigenous Peoples in rural and tribal regions feel underserved by the healthcare system, lack access to pain management providers, and report that providers ignore, undertreat, or overlook their pain.8
  • Native Americans report feeling frustrated and betrayed by their providers for failing to hear their pain stories.9
  • In addition to undertreatment, racial discrimination can lead to chronic stress and increase immune mediated inflammatory responses in patients, all of which heighten these individuals’ risks for developing other chronic conditions (eg, depression, heart disease, obesity, behavioral health disorders) and lead to poor health outcomes.9,10

Eliminating long existing racial disparities in healthcare access and treatment within health systems, medical institutions, and with individual clinicians requires comprehensive interventions at individual, community, and national levels. (Image: iStock)

 

Individual and Societal Factors that Impact Access and Treatment

Many of the existing gaps in care go back to a historical lack of research focused on the pain experiences of and treatment of many racial and ethnic groups, including Black, Middle Eastern Americans, Indigenous Peoples, Latinx, and Asian Americans.Collectivization of diverse races and ethnicities under group nomenclatures such as “Asian” or “Hispanic” can compound implicit bias and stereotyping (more on this below).

The medical community currently lacks data to determine the impact of labels on perceived bias and stereotypes. According to the American Psychological Association (APA), cultural and ethnic group categorizations are imperfect, challenged, and continually shifting.11

A 2019 review study by Meints et al, attempted to get at this by discussing the disparities in pain experiences and treatment among racial and ethnic groups that stem from the complex interplay of patient and clinician factors.Compared to their White counterparts, the review found that patients of racially diverse backgrounds:

  • have their pain underestimated by providers
  • receive less comprehensive diagnoses
  • have less access to analgesic medications –  in particular opioids for pain management.

Individual Patient Factors

Pain is inherently subjective and personal, which can make diagnosis, assessment, and treatment challenging.12 Pain behavior and expression are also tied to cultural norms; different types of behavior, including verbal and non-verbal expressions of pain, are rooted in cultural context.13 Personal patient factors that can affect pain management include beliefs, perceptions of bias and discrimination in their care, and expectations of pain management.1,2

A 2018 study by Brown and colleagues from the University of California, Berkeley School of Public Health, found that perceptions of discrimination among BIPOC patient groups contributed to their own psychological stress, which in turn amped up their negative chronic pain experience.14 Black individuals indicated the highest level of perceived discrimination due to race.14 Pain sensitivity, beliefs, and coping also appear to influence pain severity differently among racial groups.1

Other factors that serve as barriers stem from health literacy, language, and communication gaps between patients and providers.12 For instance, coping mechanisms and accessing treatment varies among races based on cultural and social norms.15 Studies show Black and Hispanic patients use prayer to cope more often and that they are more stoic with pain in comparison to White patients.Asian Americans are reported to use exercise and positive thinking as coping strategies for pain, which have been shown to increase function and improve pain tolerance.1

The ongoing coronavirus pandemic in the US is highlighting long existing systemic racial disparities in healthcare access, diagnosis, and care that increasingly impact Black individuals. Recent 2020 data shows that although Black individuals represent 13% of the US population, they make up 33% of hospitalized patients with COVID-19.16 Evidence indicates that chronic stress and disparities in healthcare access from racism can lead to changes in biological factors over time, such as immune function and metabolic shifts. These changes increase comorbidities such as asthma, diabetes, and hypertension making Black individuals more vulnerable to the virus.16

Provider Factors

Clinician interactions with patients during assessment and treatment influence patient health outcomes.17 Studies show that implicit bias and racial stereotypes among health professionals can affect their decision-making, which adversely impact BIPOC patients. Clinician attitudes and behavior during interactions can perpetuate unequal treatment.18 Examples of provider implicit bias may be expressed with subtle shifts in behavior toward BIPOC patients, such as:

  • using a condescending tone
  • making assumptions about treatment adherence
  • keeping patients waiting longer
  • failing to provide interpreters.19

Terri Lewis, PhD, a nationally certified counselor and clinical educator told PPM, “There are several layers … linked to disparities, including lack of awareness of patient socioenvironmental community context, inadequate cultural competency training, and operating in silos rather than in a collaborative community partnership model.”

A 2016 study by Hoffman and colleagues at the University of Virginia found that White laypersons, medical residents, and medical students all held false beliefs regarding Black individuals’ biological differences, which led to incorrect perceptions and treatment recommendations for pain.Research has also uncovered differences in facial expression processing of one’s own race versus other race.20 For example, studies using the Implicit Association Test (IAT) for implicit bias among providers have demonstrated pro-White bias in numerous treatment settings with provider application of more stringent pain thresholds, failure to recognize facial pain expressions, and providing suboptimal pain management.19,20

Cultural knowledge gaps among providers further negatively affect racially diverse patients’ pain management. Gaps range from a lack of cultural sensitivity and language barriers to perceived patient financial barriers and provider bias toward BIPOC patients’ propensity for “drug seeking behavior.”21,22 Clinicians often undertreat pain in BIPOC patients due to continuing stereotypes about their pain management needs.23

Numerous studies have shown that implicit bias among providers influences opioid prescribing for underrepresented groups, in particular Hispanic and Black Americans, including children. Racial disparities are starker with non-objective pain conditions such as back pain and migraine. For example, Black patients visiting emergency rooms were significantly less likely to receive opioids in the ER or post discharge for abdominal or back pain compared to White patients.24

In a 2019 study by Friedman and colleagues, review of data from state prescription drug monitoring program of adults in California from 2011 to 2015 found substantial (300%) differences in prescription opioid prescribing prevalence rates among diverse races with higher rates among lower socioeconomic White patients, with a corresponding increase in prevalence of opioid overdose deaths in White individuals.25 (More on overdose follow-up disparities.)

Social Factors

Data indicates Black and Hispanic Americans face challenges with access to pain management providers, pain clinics, and pharmacies more so than Whites.1One study found 16% of Black patients and 22% of Hispanic American patients, compared to only 8% of White patients, reported obstacles in accessing pain specialists. In addition, neighborhood pharmacies in underrepresented locations have been known to stock significantly fewer opioid medications, creating greater access issues.1

Without proper access to pain treatment and medication, broader socioeconomic barriers grow. These include economic status, geographic location of patients, lack of transportation, inadequate health insurance, lack of childcare, and inability to take time off from work.26,27

Carmen R. Green, MD, a professor of anesthesiology at the University of Michigan’s (UM) School of Medicine, and of health management and policy at UM’s School of Public Health, has studied racial disparities in pain management for more than a decade – listen to her take in PPM's Side Chat podcast on this topic.

 

Many of the existing gaps in care go back to a historical lack of research focused on pain experiences and treatment of many racial and ethnic groups, including Black, Middle Eastern Americans, Indigenous Peoples, Latinx, and Asian Americans. (Image: iStock/PPM Cover collection)

 

 

How to Create to a Practice that Cares For a Racially Diverse Population

Bolster Training

Effective assessment and treatment of pain in BIPOC patients hinges on improved patient–provider communication and provider recognition of the effect of social and environmental factors that characterize personal pain experiences.1

Michael Schatman, PhD, adjunct clinical assistant professor of Public Health and Community Medicine at Tufts University School of Medicine, and Editor in Chief of Journal of Pain Research, told PPM, “Clinicians don’t have enough training on the cultural implications of pain.” He suggested that one way to bridge the knowledge gaps around race and ethnicity would be to “require mandatory continuing education for all healthcare providers around diversity and cultural competency as part of licensure.”

According to the Institute for Healthcare Improvement (IHI), equitable pain management across racial groups requires health professionals to recognize and address implicit bias, discrimination, and stereotypes.28

Eliminating long existing racial disparities in healthcare access and treatment within health systems, medical institutions, and with individual clinicians requires comprehensive interventions at individual, community, and national levels.

Overall, suggested interventions include improving delivery of clinical care by using evidence-based care, collecting quality metrics for process improvement, and recognizing and mitigating bias through cultural competency training. Researchers also suggest engaging in collaborative research initiatives on the sociocultural factors that shape pain experiences among BIPOC patients.1,29,30

Additionally, the IHI’s guide, Achieving Health Equity: A Guide for Health Care Organizations, provides a framework with five key elements to improve health equity:31

  • Create a strategic priority for health equity
  • Build the processes and structures necessary to support a program
  • Use specific strategies to address the determinants of health
  • Reduce racism within the organization
  • Develop community partnerships to increase health equity

Use Broader Care Models

Research further shows health professionals who apply the biopsychosocial model of care are more successful because they employ individualized approaches to pain management that account for biological, psychological, as well as socioeconomic factors to improve communication and pain outcomes.32 This integrative model allows for greater understanding of cultural differences in coping and pain expression among racial and ethnic groups to reduce disparities in pain management.12

For example, in surveys of Indigenous Peoples, study participants offered suggestions for providers that included the need for individualized care, respectful communication that is culturally sensitive, and care coordination that accepts prayer and traditional therapies along with pain management to improve pain outcomes.9

Dr. Lewis added, “Clinicians need to work beyond the walls of their practice and form relationships with community groups to address disparities and deliver value-based, outcome-oriented care.” They can do this by developing collaborative working agreements and networks within communities with social services, healthcare groups, and public officials – particularly in resource poor areas.

Dr. Lewis noted that US states have varying regulations on establishment of collaborative practice agreements so it is important to check the laws where you practice. She has used collaborative practice agreements to deliver healthcare to underrepresented patients in her own practice. She started a health clinic staffed with a physician, nurse practitioner, and pharmacy support by partnering with the regional area hospital. The clinic served both employees (350) and more than 3,000 persons with disabilities to divert patients from emergency rooms.

“Typically, these individuals were significantly marginalized by conditions of economic insufficiency, disability, age, race, and gender,” she said. The organization served 14 counties in the rural Upper Cumberland region of middle Tennessee, and the program’s outcomes demonstrated lowered healthcare costs and increased health equity in the community it served.

Johnathan Goree, MD, at the University of Arkansas for Medical Sciences, further recommends that clinicians provide safe spaces for patients – listen to his recommendations and experience as a minitory physician leader in PPM's Side Chat podcast on racial disparities in pain care.

Be Self-Aware

It is also important for providers to increase self-awareness of inherent bias, perceived negative stereotypes regarding race, and ethnicity. Providers need to improve cultural sensitivity, which they can achieve by developing patient quality assurance metrics in their practices to overcome inequities in assessment and treatment of pain.

Clinical psychotherapist Sherrá M. Watkins, PhD, recommends that clinicians take Harvard’s Implicit Bias Assessment to help individuals become aware of their own implicit biases that may lead to unequal treatment of racially diverse individuals, and it will allow clinicians to take steps to mitigate any bias.

In addition, Dr. Watkins recommends that providers make eye contact with patients and not assume they know or understand their situation. “Ask what their needs, worries, concerns, and fears are, listen to the patient and treat each person as an individual and not a disease,” she advises. “Do your best to put your patient at ease and help them feel safe, use non-medical language, have charts or pictures to help demonstrate information, be caring and show empathy.”

Dr. Watkins went on to say, “Be aware of and challenge your own bias. Don’t be afraid to have hard conversations about race, fears, false beliefs. Use a calm, soothing voice, remember hypervigilance −you can change the atmosphere with your voice. Your fear and apprehension is off putting and can further the patient’s fears. Don’t take it personally. Acknowledge the patient’s strength.”

Another area in need of work by both individual clinicians and practices is that of the nomenclature used when grouping people by race and ethnicity. The terminology itself can contribute to stereotypes and bias.

Dr. Schatman pointed out, “Tragically, the issue of nomenclature grouping commonly used in pain medicine has been widely ignored in the research. For example, studies have ‘clumped’ Latinx patients together, referring to them as ‘Hispanic.’ This represents a failure of investigators to understand the vast differences between various cultures and their responses to pain, and, as a result, their findings actually detract from our understanding of cultural differences rather than contribute in a meaningful way.”

He added, “Clinicians should avoid grouping people under broad labels by race, or ethnicity and instead focus on assessing and treating pain on an individualized basis.”

Take a Stand in Your Healthcare Systems, Educational Institutions, and Professional Organizations

Healthcare institutions also have a top-down role to play in improving health equity and outcomes in patient care. Adding BIPOC clinicians to leadership roles is one important step in recognizing the value of cultural competency. In addition, increasing enrollment of BIPOC students in educational programs and by supporting further research to address gaps in underrepresented groups will help to increase culturally sensitive care and improve equity.

Curricula that is culturally sensitive can support greater understanding of racial and ethnic disparities, and evidence indicates health professional cultural training increases cultural competence and patient satisfaction.33 These measures can assist in eliminating negative stereotypes, racial discrimination, and bias.34 As of 2020, several states require cultural competency training for health professionals, including: California, Connecticut, New Jersey, New Mexico, and Washington. New Jersey also requires cultural competency training of medical and dental professionals.35

Meharry Medical College, founded in 1876 at Central Tennessee College, a historically Black College, is one example of such a program. Meharry’s goal is to reduce health disparities among underrepresented individuals by offering a culturally competent curricula for its students.

The Association of American Medical Colleges (AAMC) has developed programs and recommendations for culturally sensitive curriculum. Recommendations include going beyond education of medical students to include faculty at medical institutions, focusing on concrete measurable cultural competency goals around knowledge, skills, and attitudes.36

AAMC offers a Tool for Assessing Cultural Competence Training (TACCT) and an education portal MedEDPortal dedicated to publications on bias and racial disparities in healthcare.

It’s important to note that BIPOC providers also face bias and discrimination within academic and health system environments.37 According to the IHI, less than 9% of physicians, and less than 15% of nurses and nurse practitioners in the US, are People of Color.28 Bias and discrimination in healthcare settings toward BIPOC clinicians can negatively impact trust, communication, generate stress, and diminish patient–provider and health system relationships, often before providers even enter into practice.

There are also legal and ethical concerns raised in patient–provider interactions stemming from patient denial of treatment consent or withholding crucial information. Commitment from organization leadership toward addressing systemic racism, creating opportunities for feedback, and developing support systems for BIPOC clinicians is crucial to improving foundations of trust and achieving healthy workplaces. 

 

A Complex but Possible Path Forward 

Overall, strategies to increase equitable pain management require integrative approaches to address barriers with outcome-oriented care delivery. This means incorporating considerations of social, environmental, familial, and cultural context into the overarching healthcare system – both from the ground up and the top down.

Historic data has shown systemic racism is interconnected to several structural or institutional factors and is influenced by political, legal, and economic practices and policies that negatively impact underrepresented communities.34

A 2019 report by Williams and Cooper suggests three strategies to address systemic issues that lead to racial disparities including access to quality healthcare services.

First, create broad “communities of opportunity” to address fundamental gaps in early childhood education, poverty, housing, and employment.38

Next, reduce health inequities through improved access to quality care and the use of preventive care approaches (eg, more health screenings). Provide social support by using programs such as the Health Leads model, which uses undergraduate student volunteers to assess patients’ food, housing, and other social needs at health clinics or health centers. Work to build healthcare workforce diversity and increase patient-provider empathy to stem bias and discrimination.

Finally, develop strategies aimed at increasing public awareness, which may ideally guide national policies toward more empathetic and equal healthcare.38

There is still a long way to go to deliver equitable healthcare for all pain patients, but evidence indicates recognizing barriers, increasing cultural competency training of healthcare providers, and utilizing integrative approaches to stem racial disparities will increase equality in pain management.

 

Terminology Note

The author used the American Psychological Association guide for racial and ethnic identity and used the terms BIPOC or underrepresented groups rather than “minority.” Some specific group nomenclature (eg, Hispanic, Latinx, Native American, Indigenous Peoples) used is based on reference sources for studies cited:

American Psychological Association guidelines for psychological practice with transgender and gender nonconforming people.

Publication Manual of the American Psychological Association, Seventh Edition, 2020 

American Medical Association style 

 

Clinical Educational & Cultural Competency Resources

APA GUIDELINES on Race and Ethnicity in Psychology: Promoting Responsiveness and Equity

Cultural Complications Curriculum

Proceedings of the Diversity and Inclusion Innovation Forum: Unconscious Bias in Academic Medicine

How to Reduce Implicit Bias

Achieving Health Equity: A Guide for Health Care Organizations

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care

Advancing Health Equity

American Hospital Association Equity Campaign

 

Additional Resources, as recommended by Dr. Sherrá M. Watkins:

Black Man in a White Coat: A Doctor's Reflections on Race and Medicine

Just Medicine

How to Be an Antiracist

Caring for Patients from Different Cultures

Racism, Inequality, and Healthcare for African Americans

Improving Cultural Competence to Reduce Health Disparities

Black and Blue: The Consequences and Origins of Medical Racism

 

Last updated on: October 1, 2020
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