Social determinants of health play ‘an important role’ in end-of-life pain strategies
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Patients with gastrointestinal cancers face ongoing racial/ethnicity-based disparities in end-of-life pain management, specifically in terms of access to and utilization of opioids, study results showed.
“I’m very interested in cancer, but also in end-of-life goal setting,” Timothy M. Pawlik, MD, PhD, MPH, the Urban Meyer III and Shelley Meyer Chair for Cancer Research and the chair of the department of surgery at The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, told Healio.
“Our previous work had shown social vulnerability and race/ethnicity-based disparities around access to palliative care consults and referrals,” he added. “This was the next step — to look at access to end-of-life care, like medication for the alleviation of pain and suffering.”
In the study, published in the Annals of Surgical Oncology, Pawlik and colleagues evaluated data on 48,631 Medicare beneficiaries from 2008 to 2016. Individuals included in the analysis had life-limiting liver, pancreatic, gastric, biliary, colon or rectal cancer, defined as 30 days before death or hospice enrollment. Pawlik spoke with Healio about his study’s findings, their implications and what needs to be done to correct this disparity.
Healio: What motivated you to conduct this study?
Pawlik: We’ve done a fair amount of work around social determinants of health and social vulnerability — how one’s lived environment impacts their access to health care. Even after accessing health care, social determinants of health can still have very important implications in terms of patient outcomes. That’s part of the reason we chose to look into this — we’ve had an arc or a theme in our research around studying social determinants of health.
Healio: How did you conduct the study?
Pawlik: We wanted to look at persistent poverty, which refers to an area where more than 20% of the population in that county are at the poverty level. Then we used SEER Medicare data of patients who are 65 years and older who have Medicare coverage. We merged the SEER Medicare data with data from the American Community Survey and some U.S. agricultural data that looked at poverty.
We then looked at trends of not only opioid prescriptions, but also fill rates and dosages when pain medication was prescribed.
Healio: What did you find?
Pawlik: Among about 50,000 Medicare beneficiaries with a wide range of gastrointestinal cancers, there was a steady decrease in opioid prescriptions near the end of life over the duration of our study. That’s not surprising because, as physicians, we are prescribing fewer and fewer opioids because of the epidemic. Perhaps more interesting was that Black, Asian, Hispanic and other racial groups had more markedly decreased rates and odds of filling a prescription for an opioid near the end of life compared with white patients. Even if they filled the prescription, patients who were non-white received lower daily doses of opioid pain medications compared with white patients. This disparity in opioid access and average daily doses was somewhat attenuated in poor areas, but it was still quite predominant among Black patients regardless of poverty status. Black patients had lower opioid access and utilization compared with white patients at the end of life.
Healio: What do you think accounts for this disparity?
Pawlik: The overall decrease trend in opioid utilization reflects national trends of using less opioids. Also, there’s a body of literature from our group and other groups that show a wide-ranging impact of race, ethnicity and other social determinants of health like poverty that affect access to care. Some of this may be due to inability to access care. Previous studies have found that non-white patients were less likely to have a palliative care consult. If a patient is less likely to have a consult or be put in touch with a palliative care physician, then it makes sense that it may be the mediating reason why these patients are less likely to get some of these palliative care interventions, like pain medications.
The cause is probably multifaceted. It may have to do with transportation or some mistrust of the medical system. There may be elements of implicit bias on the part of some providers with regard to their prescription practices. There may also be different beliefs around pain sensitivity and addiction in different populations that may not be justified by data.
Healio: What do you think needs to be done to eliminate this gap in care?
Pawlik: The findings of our paper have several implications for health care institutions, payers, policymakers and professional organizations. For example, the data provide some evidence for community policies and other related initiatives to encourage hospitals and local governments to examine their role in promoting structural equity in their community. This might include access to care, transportation, education and reducing financial toxicity associated with cancer care.
There needs to be a balance between the need for opioids among patients who are suffering with terminal cancer and require pain relief with the real need to curb opioid proliferation in light of the opioid crisis.
Patients with cancer represent a unique population because many are terminal and may be in significant pain, especially at the end of life. So, considerations around addiction are probably not very prominent. I think having more guideline-mandated opioid therapy to manage severe pain, and to follow those guidelines, would be important. It’s also important for clinicians to take time to think about socially vulnerable communities and non-white communities who may face barriers that preclude them from gaining access to the medications they need at the end of life. We need to have some focused effort and introspection around some of the implicit bias or systematic racism that may still exist in our health care system and in our society. The biggest danger is not being aware of it. If we don’t think social determinants of health have an important role, then we’re sadly mistaken, because they do. We need to recognize that, because the first step in developing targeted interventions is to recognize the different social determinants that are in play.
To that end, my co-editor, Samila Obeng-Gyasi, MD, MPH, and I have recently published a book with national and international experts on social determinants of health and how they affect surgery.
Healio: Is there anything else you’d like to mention?
Pawlik: I encourage all providers to screen for social determinants of health. When we see patients, we frequently ask if they have diabetes or hypertension. We less frequently ask them if they have adequate transportation, sufficient food supply or whether they feel safe at home. We’re finding that diabetes and hypertension are very important, but so is access to food and transportation. We have to holistically think of patients and their care not only in terms of their illness, which is important, but also their entire universe of care that can help them achieve optimal health care outcomes.
References:
- Munir MM, et al. Ann Surg Oncol. 2023;doi:10.1245/s10434-023-14218-4.
- Obeng-Gyasi, Pawlik TM, eds. Social Determinants of Health in Surgery: A Primer for the Practicing Surgeon. Elsevier; 2023.
For more information:
Timothy M. Pawlik, MD, PhD, MPH, can be reached at The Ohio State University, 2050 Kenny Road, Columbus, OH 43221; email: tim.pawlik@osumc.edu.
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