Support patients by eliminating disparities in pain care
LAS VEGAS — Research has shown that racial and ethnic differences in pain management exist, and clinicians need to work to mitigate these disparities, according to a speaker at PAINWeek 2022.
Kevin L. Zacharoff, MD, a clinical instructor at the Renaissance School of Medicine, said these differences exist even in children.
A 2020 study published in Pediatrics showed that among 21,069 pediatric ED visits involving patients aged 18 years and younger with long bone fractures, children from underrepresented groups were less likely than non-Hispanic white children to receive satisfactory treatment for their pain (Goyal et al.).
Biases exist in how pain assessment is performed and how treatment is developed and implemented, Zacharoff said.
A paper in the Proceedings of the National Academy of Sciences (PNAS) in 2016 pointed to false beliefs regarding people of color and race-based decision-making in pain treatment (Hoffman et al.).
“Possibly it’s related to concerns about appearance, access to health care, ability to follow up, other judgments,” Zacharoff said.
The PNAS report stated that Black patients are less likely to receive analgesics for extremity fractures in the ED than white patients, and when pain medications are administered, lower dosages and quantities are used.
The report also indicated that in a study of nearly 1 million children with appendicitis, Black patients were less likely than white patients to receive any pain medication for moderate pain and were less likely to receive opioids for severe pain. Similar findings were reported from a study of patients with metastatic cancer pain.
The PNAS report cited a survey of medical students where many indicated that they believed the skin of Black people is thicker than that of white people, and that Black people have denser and stronger bones.
“It’s possible that clinicians do not recognize pain in the first place and don’t seek to treat it,” Zacharoff said. “It could be perception of other people’s pain. Clinicians might frequently assume that Black patients feel less pain than white patients or underestimate the impact of pain in Black patients.
“Even if we looked at clinicians of color, they were less likely to prescribe opioids to people of color,” he added. “This isn’t racist individuals taking opportunity to act on their racism.”
The authors of the PNAS study concluded: “Beliefs about biological differences between Blacks and whites are associated with the perception that Black people feel less pain than white people and, consequently, this often results in providing inadequate treatment recommendations for Black patients’ pain.”
Zacharoff said restraint in pain management may be thought of as protective against drug overdose.
“If you’re not being prescribed an opioid, you can’t overdose on it,” he said. “But we’re actually seeing Black males experiencing overdose fatalities five times more than people who are white.”
Zacharoff said sickle cell disease occurs most commonly in those with origins in Africa, the Middle East, the Indian subcontinent, Southern Europe, South or Central America, or the Caribbean.
“Sickle cell disease pain is unpredictable,” he said. “It spans their entire life. It’s intermittent. It can be very difficult to be productive.”
The PNAS report cited discrimination in health care encounters even among patients seeking treatment for sickle cell disease.
A 2020 study in the Annals of Emergency Medicine concluded that, “Guideline adherence for timeliness of sickle cell disease pain treatment is poor.”
Brousseau and colleagues said that only half of the visits were adherent to guidelines for time to first opioid, and only one-seventh were adherent regarding second dose.
“The answers are hiding in plain sight,” Zacharoff said. “I let my medical students know the situation. We need to support our patients better."
“Think about that invisible patient and figure out how to make their care better and diminish their disparities,” he added. “Willingness is not enough. Mitigate the risks of being invisible.”
References:
- Brousseau DC, et al. Ann Emerg Med. 2020;doi.org/10.1016/j.annemergmed.2020.08.006.
- Goyal MK, et al. Pediatrics. 2020;doi:10.1542/peds.2019-3370.
- Hoffman KM, et al. Proc Natl Acad Sci. 2016;doi:org/10.1073/pnas.151604711.