Each month, Lynette Menefee, Ph.D. tackles pressing issues in pain management with one of the nation's leading practitioners. This month Dr. Menefee speaks with Carmen Green, M.D. about a review of racial and ethnic disparities found in the field of pain management. Dr. Green is an Associate Professor of Anesthesiology and a pain specialist at the University of Michigan's Health System.

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Questions

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Dr. Lynette Menefee: Dr. Green, thank you for joining us today. We are pleased to be speaking with you.

Please tell us about your recent review of the literature on racial and ethnic disparities in pain management.

Dr. Carmen Green: The idea for the review came from the American Pain Society’s Special Interest Group on Pain and Disparities. Although I’m the lead author, many people were involved with part of it and are listed as co-authors. We noted that a recent book published by the Institute of Medicine on racial and ethnic disparities in medical treatment only had one page focused on differences in analgesic care. We wanted to respond.

LM: And you were quite comprehensive in your response!

CG: The article is a selective review of the literature, with emphasis on the empirical studies over anecdotal reports. There are 182 citations and we covered the literature in all types of pain, including experimental pain, acute postoperative pain, cancer pain and chronic nonmalignant pain. We also covered different settings, such as emergency departments.

LM: What were some of the overall findings?

CG: It appears that the literature is clear that there are racial and ethnic disparities in pain perception, assessment, and treatment. In emergency medicine, Hispanics were found to be twice as likely as non-Hispanic Whites to receive no pain medication when they presented to the emergency department with similar injuries. Ethnic disparities have also been found between African Americans and non-Hispanic Whites. In one study, African Americans had a 1.66 relative risk of receiving no analgesics compared with non-Hispanic White patients.

LM: Wow, that’s really appalling. Are the results of other studies similar?

CG: We found the literature shows something a little bit different in the cancer population. One large national study showed that 42% of patients with pain were prescribed analgesics that were lower than those recommended by the World Health Organization (WHO) guidelines. However, in settings where racial and ethnic minorities make up the majority of the patient population, the percentage ranges of inadequate analgesia are higher – from 60% to 74%.

LM: What about age differences, do they come into play as well?

CG: Unfortunately, we have limited evidence about older adults, especially racial and ethnic minorities. We do know that older African Americans report pain less often than non-Hispanic Whites. More valid information will need to come from studies that are designed to include a large percentage of racial and ethnic minorities.

LM: What are some of the reasons for these disparities?

CG: Well, there are probably a number of reasons. When physicians and nurses in primarily nonminority clinics and minority clinics were asked to rank the barriers to cancer treatment, for example, they listed inadequate pain assessment, inadequate staff knowledge, and patients’ difficulty reporting pain. However, only physicians and nurses in minority clinics rated lack of staff time and inadequate access to a wide range of analgesics as barriers.

LM: What are other barriers?

CG: We can’t discount the fact that Caucasian Americans are more likely than minorities to present to health care practitioners. For African Americans, some researchers have attributed this to a higher ability to cope with pain that may be present in African Americans – sort of a John Henryism. African Americans may have learned through the years to have lower expectations of care and to expect that they need to “handle” pain without complaining. This theory is consistent with research that shows that pain-related physical and psychosocial disability among African Americans is greater than among non-Hispanic Whites.

Another hypothesis is the lack of trust in health care providers by minorities. Yet another is one of social learning – that pain complaints of racial and ethnic minorities are often discounted. My research has shown that psychological disturbances, such as depression, panic, anxiety and posttraumatic stress disorder (PTSD) are often not noticed in racial and ethnic minority patients.

LM: Your article also talks about the subject of Worker’s Compensation. There are stereotypes about persons who are injured in their occupations and have Worker’s Compensation. There must be even more for non-Hispanic Whites than for Whites.

CG: Yes, the literature shows that African Americans do not return to work within 6 months at about twice the rate as non-Hispanic Whites. Some of this has been attributed to limited vocational opportunities. However, other findings show that African Americans without legal representation receive significantly less treatment than non-Hispanic Whites and African Americans with legal representation. So disparities in the system also affect treatment.

LM: What can practitioners do to be more aware of these differences?

CG: Well, first, recognize that we all make judgments about patients (and people) all the time. It’s inevitable. So it is important to recognize and be aware that while we all want to feel that we treat everyone similarly, sometimes we don’t. Check yourself. And be aware of the literature. Ethnic and racial minorities may be depressed, but not look depressed. They may not report pain and present later because of perceptions that they can’t fully trust the health care system. The advice given to many physicians in evaluating pain applies to racial and ethnic minorities as well: listen to the patient and believe him or her.

LM: What about perceptions of higher rates of addiction in ethnic and racial minorities?

CG: We are all a product of our socialization – including what the media has fed us. The truth is that we are more likely to believe people who are like us, and that includes people who look more like us. We might give the benefit of the doubt to patients if they are more like us. Be aware of how you treat people who have a darker hue, who may not be as affluent as you are, who may speak in terms that are not familiar, or have different experiences than you.

LM: Apart from being aware of proper treatments, you and your colleagues propose a number of other solutions.

CG: We propose an agenda that covers all aspects of diversity. We propose more study of the various factors that produce inequities and ways to overcome them. These areas include communication between physicians and patients, physician decision-making, and pain assessment and treatment. We are engaged in some exciting research on some of these topics. At a larger level, we need health care policy to change in order to increase access to pain management. We need to advocate for increased education and reimbursement for pain management. Pain is the number one reason that patients seek help from their doctors. We want everyone to receive the care they need and deserve.

LM: Thank you for talking with us today, Dr. Green. You are obviously doing important work and we wish you well.

The article refered to in this interview can be found in the journal Pain Medicine, Volume 4 Issue 3.