Advancing a National Agenda to Eliminate Disparities in Pain Care: Directions for Health Policy, Education, Practice, and Research

Meghani, Salimah H.; Polomano, Rosemary C.; Tait, Raymond C.; Vallerand, April Hazard; Anderson, Karen O.; Gallagher, Rollin M.

doi:10.1111/j.1526-4637.2011.01289.x

Cited by 109 publications

(79 citation statements)

References 115 publications

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“…5 There is also evidence of systematic variability in prescribers' choices of analgesics according to patient race or ethnicity. [7][8][9][10][11] In a recent meta-analysis 10 that synthesized data on analgesic treatment disparities…”

Section: Introductionmentioning

confidence: 99%

African Americans With Cancer Pain Are More Likely to Receive an Analgesic With Toxic Metabolite Despite Clinical Risks: A Mediation Analysis Study

Meghani

Kang

Chittams

et al. 2014

JCO

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A B S T R A C T PurposeRenal impairment is highly prevalent among patients with cancer, and many patients have undiagnosed chronic kidney disease (CKD) from underlying disease, treatment, or both. African American individuals have disproportionate risk factors (diabetes, hypertension) predisposing them to CKD. We investigated whether African American patients are more likely than white patients to receive morphine with 3-and 6-glucuronide metabolites, which are known to be neurotoxic and accumulate in CKD; whether insurance type mediates the relationship between race and the prescriber's opioid selection; and whether the chosen opioid has a resultant negative effect according to race. Patients and MethodsPatients (N ϭ 182) were recruited from oncology clinics within the University of Pennsylvania Health System. Inclusion was based on self-identified African American or white race, age older than 18 years, and the presence of cancer-related pain plus a prescription for morphine or oxycodone. Kidney function was estimated using the abbreviated Modification of Diet in Renal Disease formula. ResultsPatients with CKD who received morphine reported a greater severity of analgesic-related adverse effects than patients with CKD who received oxycodone (P ϭ .010). Controlling for health insurance type, African American patients had 71% lower odds of receiving a prescription of oxycodone than white patients (P Ͻ .001). Limiting analysis to those with CKD, the effect of private insurance became insignificant. However, race still remained a significant predictor of the prescribed opioid selection. Race was a strong predictor of adverse effect severity in the presence of CKD, and the type of opioid selection partially mediated this relationship. ConclusionReducing racial disparities in the type of opioid prescription and understanding mechanisms of disproportionate opioid-related adverse effects in African American patients might decrease the clinical disparities in cancer pain outcomes.

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Section: Introductionmentioning

confidence: 99%

African Americans With Cancer Pain Are More Likely to Receive an Analgesic With Toxic Metabolite Despite Clinical Risks: A Mediation Analysis Study

Meghani

Kang

Chittams

et al. 2014

JCO

Self Cite

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“…Our findings raise the broader question of whether efforts to address racial disparities in pain should focus on reducing disparities in opioid prescription, as has been suggested in prior policy recommendations [3]-at least in the case of patients with chronic noncancer pain. The use of race in decisions to prescribe opioids is clearly inconsistent with good medical practice and arguably constitutes racial bias.…”

Section: Discussionmentioning

confidence: 61%

“…Unfortunately, studies conducted in various settings, including the VA, have shown that primary care providers find chronic pain patients to be frustrating and difficult to treat and do not feel adequately prepared to provide care for them [42][43]. The growing movement toward "patient-centered medical homes," which are based on principles of accessibility, continuity, and care coordination, provides an opportunity for more effective and equitable chronic pain care [3,44]. However, because these models center on the role of primary care providers, it is critical that these providers have training in chronic pain treatment overall and in providing equitable care [3].…”

Section: Blacks Whites Blacksmentioning

confidence: 99%

“…The growing movement toward "patient-centered medical homes," which are based on principles of accessibility, continuity, and care coordination, provides an opportunity for more effective and equitable chronic pain care [3,44]. However, because these models center on the role of primary care providers, it is critical that these providers have training in chronic pain treatment overall and in providing equitable care [3]. Such training should also ensure that providers are aware of nonopioid-based treatments for chronic pain and be familiar with the biopsychosocial model of chronic pain that acknowledges the role of psychological and environmental factors in pain [45].…”

Section: Blacks Whites Blacksmentioning

confidence: 99%

“…These disparities have been viewed as especially problematic in light of evidence that blacks experience chronic pain that is more severe and more disabling than whites [2][3][4][5][6][7]. Although many factors contribute to these racial disparities in pain outcomes (e.g., racial differences in patients' beliefs about pain [4,[8][9][10], exposure to racial discrimination [11][12]), there is concern about the role of undertreatment of pain [1][2][3]13]. Consequently, recent position papers have highlighted the importance of reducing racial disparities in opioid prescription and proposed strategies to accomplish this goal [2][3].…”

Section: Introductionmentioning

confidence: 99%

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Association between pain outcomes and race and opioid treatment: Retrospective cohort study of Veterans

et al. 2016

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Abstract-We examined whether pain outcomes (pain interference, perceived pain treatment effectiveness) vary by race and then whether opioid use moderates these associations. These analyses are part of a retrospective cohort study among 3,505 black and 46,203 non-Hispanic, white Department of Veterans Affairs (VA) patients with diagnoses of chronic musculoskeletal pain who responded to the 2007 VA Survey of Healthcare Experiences of Patients (SHEP). We used electronic medical record data to identify prescriptions for pharmacologic pain treatments in the year after diagnosis (Pain Diagnosis index visit) and before the SHEP index visit (the visit that made one eligible to complete the SHEP); pain outcomes came from the SHEP. We found no significant associations between race and pain interference or perceived effectiveness of pain treatment. VA patients with opioid prescriptions between the Pain Diagnosis index visit and the SHEP index visit reported greater pain interference on the SHEP than those without opioid prescriptions during that period. Opioid prescriptions were not associated with perceived treatment effectiveness for most patients. Findings raise questions about benefits of opioids for musculoskeletal pain and point to the need for alternative treatments for addressing chronic noncancer pain.

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Pain and Ethnicity

Wyatt

2013

AMA Journal of Ethics

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Although pain is a widespread problem, studies have found that chronic disease, psychological distress, Medicaid insurance, and lower education levels are associated with higher incidences of severe pain [2]. Undertreating pain can lead to adverse outcomes, including elevated heart rates after surgery and increased risk of myocardial infarction, ischemic stroke, and bleeding events as a result of elevated systemic vascular resistance and elevated levels of catecholamines [2]. Other consequences of uncontrolled pain include reduced mobility, loss of strength, sleep disturbances, immune system impairment, increased susceptibility to disease, and medication dependence [3].Despite the availability of effective pharmacologic and nonpharmacologic interventions and methods to manage pain, there is a significant gap between the evaluation and treatment of pain in white people and its evaluation and treatment in African American and Hispanic people [4]. Differences in pain treatment may be due to differences in needs-e.g., resulting from genetic differences-or to inequitiesunfair differences in access or opportunity, e.g., unavailability of opioids in a neighborhood [2]. Another cause of differences in treatment may be a lack of awareness among clinicians and trainees of evidence-based guidelines. Defining PainThe American Academy of Pain Medicine classifies pain as acute or chronic. In acute pain, a "one-to-one relationship exists between injury and pain," and the "pain is frequently short-lived and self-limiting" [5]. However, the pain "can become persistent and intractable if the underlying disease process or injury is chronic or incurable, or if the activation of pain is unavoidable, as in pain caused by movement or weight bearing in injuries of the spine or in diseases such as arthritis" [5]. Chronic pain is defined as pain that persists longer than three months [5]. Pain can be managed with a range or combination of treatments such as nonsteroidal antiinflammatories (NSAIDs) and other nonopioid medications, physical therapy, psychological interventions, alternative medicine, referral to a specialist, or opioids. Pharmacogenomics and PainA review of the literature on the influence of race or ethnicity on the pharmacokinetics of analgesics found that there may be differences in bioavailability, hepatic metabolism, renal secretion, protein binding, and distribution

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Advancing a National Agenda to Eliminate Disparities in Pain Care: Directions for Health Policy, Education, Practice, and Research

Cited by 109 publications

References 115 publications

African Americans With Cancer Pain Are More Likely to Receive an Analgesic With Toxic Metabolite Despite Clinical Risks: A Mediation Analysis Study

African Americans With Cancer Pain Are More Likely to Receive an Analgesic With Toxic Metabolite Despite Clinical Risks: A Mediation Analysis Study

Association between pain outcomes and race and opioid treatment: Retrospective cohort study of Veterans

Pain and Ethnicity

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