|Racial and Ethnic Disparities in Pain Management: 2008
An Interview with Carmen R. Green, M.D.
|Carmen R. Green, M.D., is an Associate Professor and the Director of the Pain Medicine Research Division in the Department of Anesthesiology at the University of Michigan Health System and the Director of the Health Disparities Research Program at the Michigan Institute for Clinical and Health Research at the University of Michigan. She has written and lectured widely on the topic of disparities in pain care based upon race, ethnicity, gender, and age. PainEDU interviewed Dr. Green three years ago and this is a follow-up interview.
In 2004 you and a group of colleagues published an article in Pain Medicine that was a review of the literature on racial and ethnic disparities in pain management. Tell us about the further research and writing you and your colleagues have done on this topic.
Carmen R. Green, M.D.: The impetus for the article published in Pain Medicine in 2003, The Unequal Burden of Pain: Confronting Racial and Ethnic Disparities, was from a discussion with members of the American Pain Society's Special Interest Group on Pain and Disparities. We were concerned that a recent book published by the Institute of Medicine (IOM) on racial and ethnic disparities in medical treatment had only one page focused on analgesic care. Our article, a selective literature review, provided clear documentation in the literature of racial and ethnic disparities in pain perception, assessment and treatment. It was our response to the IOM report.
While my research continues to focus on pain, disparities, and policy, this article remains the most up-to-date review article. This work is important in the context that although pain is the second most common reason for a healthcare visit and a frequent cause of disability, there is continued significant disparity in the way pain is assessed and treated. Overall, our minority community has an increased burden.
EC: In your opinion, has progress been made with respect to the disparity in pain management since our last interview in 2004?
CG: There is more interest but the need for more research and funding continues. In fact, Pain Medicine published a special issue focusing on disparities in pain care. There continues to be a divide resulting in disparate pain assessment and treatment in the minority populations. In fact, in some instances it may even be worse. Beyond race and ethnicity, geography and socio-economic status play an important role, further complicating the picture. Obviously, this is quite significant as the socio-economic divide continues to grow in our increasingly diverse and aging country.
EC: Why are minorities at risk for inadequate pain treatment?
CG: Much of the research thus far has looked at African-Americans and Hispanics, but little is known about Native Americans. Other populations at risk include the very young and the very old, and those who do not speak English well. There are many reasons including unequal access to care, problematic assessment, clinician variability in decisions making, physician-patient communication, as well as patient education, knowledge, and attitudes. Minority patients also are more likely to have other co-morbid conditions, but are less likely to be referred to specialty care. These issues may be due to communication or economic barriers but there are also other clinical and patient related factors that must be explored.
Our individual values often come in to play when caring for patients. We feel more comfortable with someone who looks like us, and talks like us, comes from the same community or culture. However, to disentangle health disparities we have to be willing to listen to someone who tells their story in a different way.
EC: Is the problem of disparity of treatment different with respect to acute vs. chronic pain management in minority populations?
CG: The problem has been shown to exist across all types of pain, acute, cancer, and chronic, as well as in rural areas and inner cities. Recently, an article published in the Journal of the American Medical Association (JAMA) reported minority patients were less likely to receive an opioid for managing acute pain in the emergency department than non-minority patients. The problem continues to be far-reaching.
EC: What have you learned from your more recent research?
CG: In 2005, we published a paper that looked at socio-demographic differences in access to opioid pain medication at pharmacies across Michigan. We looked at race and income. My interest in doing this was the result of a discussion with a patient who told me she had to travel 30 miles from her home to buy her prescription pain medicine.
We surveyed pharmacists to see if their pharmacy carried sufficient opioid analgesic supplies, which we defined as stocking at least one long-acting, one short-acting, and one combination opioid analgesic. We labeled pharmacies as minority if more than 70% of the residents in the zip code were minority, and labeled them white if more than 70% of the residents in the zip code were white. We compared high-income zip codes to low-income zip codes.
Our research showed that both the racial composition and the income of the community were factors in access to medication, with significant differences related more to race than income. When comparing minority and white pharmacies, the pharmacies located in white zip codes stocked sufficient supplies of opioid analgesics more frequently (86.9%) than pharmacies in minority areas (54.2%). White pharmacies in zip codes with greater than median income were 13 times more likely than minority pharmacies in the same income range to have sufficient opioid supplies. In lower income zip codes, pharmacies in white areas were approximately 54 times as likely to have a sufficient opioid analgesic supply. Our conclusion was that Michigan pharmacies in minority zip codes were 52 times less likely to carry sufficient supplies, therefore, regardless of income people living in minority neighborhoods faced additional barriers to care. For the patient, this means facing barriers to obtaining their medication: a need to travel, and facing the risk of questions being raised about why the prescription was not filled closer to home.
EC: What do you think is the next step to solving the problem of racial and ethnic disparities in pain management?
CG: There are many different aspects of the problem that need to be addressed. First and foremost is the issue of educating healthcare providers about pain management -beginning with medical school and ending with continuing medical education. If the fundamentals of pain management are not instilled early in the medical education process, it makes it much more difficult to change attitudes and treatment approaches. When students start their training they are taught to explore and uncover as much information pertaining to the patient as a whole as possible. In many cases, when nearing the end of the educational process, this is reduced to just identifying the "chief complaint", and streamlining the process as much as possible. We must teach young clinicians to understand the importance of, and respect for one of the most important pieces of the puzzle of managing pain -the assessment. Only through better education and access to resources for all health care providers about pain and its appropriate management, can access to quality pain care begin to be more available to everyone, including patients receiving unequal levels of care now.
Currently, there are not enough pain medicine specialists. Thus, we all have to get better at assessing and treating the needs of all patients. Nurses and physicians who work in primary care and handle the majority of responsibility for the care of sick people in the United States, need to be educated and ready to confront these issues in their daily practice, as that is where these patients are most likely to present- regardless of their race and ethnicity. Primary care continues to be our front line in providing quality pain care.
Green CR, Tait RC (Editors): Disparities in Pain Care. Pain Medicine, Special Issue. 2005; 6:1-102.
Green CR, Tait RC, Gallagher RM: The unequal burden of pain: Disparities and differences. Pain Medicine. 2005;6:1-2.
Green CR, Ndao-Brumblay SK, West B, Washington T. Differences in prescription opioid analgesic availability: comparing minority and white pharmacies across Michigan. J Pain. 2005;6:689-699.
Green CR, Baker T, Ndao-Brumblay SK: Patient attitudes regarding healthcare utilization and referral: a descriptive comparison in African- and Caucasian Americans with chronic pain. Journal of the National Medical Association. 2004; 96(1):31-42.
Green CR: Racial disparities in access to pain treatment. Pain Clinical Updates. 2004; 12(6):4.