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16 Articles in Volume 20, Issue #5
20/20 with Drs. Carmen R. Green and Johnathan Goree: Racial Disparities in Pain Care
A Kratom Primer: Miracle Medicine or Herb of Abuse?
A Pilot Study: Incidence and Prediction of Diversion among Opioid Therapy Patients
Analgesics of the Future: G-Protein Biased Mu-Opioid Receptor Ligands
Application Note: Decellularized Human Placenta in the Treatment of Infracalcaneal Heel Pain
Are Clinicians Effectively Counseling Patients on Safe Opioid Storage and Disposal? Survey Results
Ask the PharmD: How to Manage Pain Meds During Pregnancy?
Behavioral Medicine: Managing Anxiety and Maladaptive Behaviors
Case Report: Spinal Cord Stimulation for the Treatment of Pain Associated with Chronic Pancreatitis
Differential Diagnoses: Inflammatory or Non-inflammatory Chronic Back Pain?
Pelvic Inflammatory Disease: Diagnosis, Education, and Treatment Options
Product Review: Non-Invasive Neuromodulation for the Treatment of the Most Difficult Pain Conditions
Provider Perspective: Carpal Tunnel's Association with Hypothyroidism
Research Insights: Opioid Use During the Peripartum Period – What to Expect
Special Report: Race, Pain Management, and the System
When Patients Become Pregnant: How to Maintain Chronic Pain Management

20/20 with Drs. Carmen R. Green and Johnathan Goree: Racial Disparities in Pain Care

A conversation on provider bias, suboptimal care, and why telemedicine may be further hindering healthcare access for minority patients.

This discussion is part of a conversation series led by Editors-at-Large Jeff Gudin, MD, and Jeffrey Fudin, PharmD, in honor of PPM’s 20th anniversary of publication. A condensed transcript follows. Access the full conversation audio file.

Dr. Gudin: Events of the past year, and beyond, have brought inequalities to the forefront of politics, education, culture, and healthcare – and pain care is no exception. Our goal with this Side Chat is to have a frank conversation about racial disparities in pain management and pain practice. We want to dive into what’s at stake here – the patients who need us – and talk about why racial disparities continue to exist in pain assessment, prescribing, and follow-up care. We want clinicians to take time to understand the current environment’s full impact and to take steps to move things forward.

Dr. Green, the literature shows clear racial disparities in the way we assess and manage pain care. Can you share a little bit about how you got into pain management and what drove your research in this area?

Dr. Green: When I was a House Officer Fellow, I wondered why it was that certain people received care and had access to care as opposed to others. I found that women and minorities in general did not receive the same quality of care. Someone who came in with their suit and tie had access to any and every type of pain care that we had available. Yet, those people who were minorities, and particularly women of color, had less access and had to actually prove that they had pain.

It was a question of who gets pain care, how, and why – and it was really the patients’ experiences and stories that got me interested in doing this particular type of research.

Dr. Fudin. I have experienced similar issues in my career at the VA but of a different sort, such as disparities on the part of patients who may be very reluctant to work with Asian doctors and pharmacists, because perhaps they served in the Korean War or were in Vietnam. I’ve also seen a lot of these variations with women.

Dr. Green: So what you’re referring to is that variability in how patients’ attitudes and perceptions, at some level, get in the way of care. Clearly, there’s a historical record of discrimination from both the patient perspective and from the medical/professional society perspective as it relates to racial minority positions, particularly as it relates to African American physicians… It wasn’t until recently – 2008 – that the AMA apologized for their discrimination as it relates to minority physicians. That discrimination goes back 100-plus years in regard to not allowing them to participate in professional societies and relegating them to the same type of segregated conditions that other people of color experienced.

Dr. Goree: My journey into pain management was very similar to Dr. Green’s, and it was really born out of my personal experiences. When I was 20, I had oral surgery and after that surgery, I had 10 out of 10 pain. I was given fentanyl, which caused me to become apneic or unresponsive and then I was given Narcan. At the time, I would have given anything, paid anything, to get rid of that pain. I was lucky that Narcan only lasted for about 30 minutes but I took two things from that experience.

One was that there’s a group of people who live with that level of pain every single day of their life. As physicians, we’re taught to diagnose and treat pathology, but there’s this large subset of people who we don’t have any treatments for no matter what pathology they have and we just kind of discard them. I wanted to be an advocate for them.

Second, there are a lot of people that I’ve encountered in my medical training, as Dr. Green alluded to, that looked a lot like me. I am a Black American and these individuals either weren’t believed or they didn’t have the access to resources to have their pain treated. That motivated a lot of my interests in research and advocacy because I wanted to make sure that, while there is this small subset of patients who have chronic pain that we need to focus on, there are even smaller subsets that may not have the resources, or to be frank, may not be heard.

Dr. Fudin: Thank you both for sharing these pertinent experiences. It is unfortunate that while papers are published on these occurrences, I think a lot of the time, they are not at the forefront. Dr. Green, you have an extensive body of research under your belt in this area – could you share what has struck you the most?

Dr. Green: Fundamentally, our work [at UM] is focused on unequal burdens and unheard voices as it relates to women, minorities, and really looking at the social determinants of health across the life course.

First of all, we have identified the failure to assess pain as it relates to racial and ethnic minorities. Even when the pain is assessed, they receive lesser treatment for the same type of pain as compared to Caucasians. And when they do get a prescription for their pain, they have worse outcomes, and they are less likely to have their prescriptions filled in their pharmacies.

We further showed that, when you look at women, and women of color, and compare them to men, they report more disability but actually function at a higher level. And we’ve been concerned about why that is. Why is it that a woman comes in with her kids – with the same pain complaint as that of a man, and she receives lesser quality care? Some of this has been reported before in primary care and medicine literature. But overall, we have a body of literature that shows that racial-ethnic minorities, particularly African Americans, have suboptimal pain care compared to Whites.

Dr. Gudin: I know, too, that from teaching residents, medical students, and nurses, sometimes it seems like they make a decision whether the patient deserves to be given certain access to pain medications or not based on stereotypical qualities, whether that’s gender or race or sexual orientation or age or ethnic background, which is really incredible – and unacceptable.

In addition to these challenges, we’re in a time right now that’s unprecedented – the COVID pandemic – and I’d like to hear your opinions on whether this healthcare crisis has further highlighted racial disparities or facilitated treatment at all. Dr. Goree, what do you think COVID has done to the pain treatment landscape?

Dr. Goree: One of the things that COVID has done is introduce telemedicine, which I think many have argued has increased access. But I come from a different perspective because I live in the rural south. So when COVID first started, I had a conversation with one of my colleagues from Chicago and we were talking about what we’re going to do with pain care when we aren’t actually able to see patients. He said, ‘Don’t worry about it. We have telemedicine, everyone has an iPhone.’ But I can tell you that where I live, not all of my patients have an iPhone, especially my older minority patients.

So with COVID-19 precautions in place, telemedicine has actually created this dichotomy where those with means that have technology, broadband access, and computer literacy have even more access to specialty care than they ever had before. Some of these patients are getting visits once a week with telemedicine. Then we have those patients who don’t have that technology, don’t have those means, and don’t have health literacy – who are also at the highest risk of dying due to pre-existing conditions and they have less access to specialty care. They have fewer visits and when they do come for visits, they have to come alone because we have these pandemic restrictions that don’t allow family members or advocates to come in.

For example, grandmother can’t read or write, and the thought of her having to go into a doctor’s visit alone…. I know that her care is not going to be as good as my care where I have a higher level of health literacy and I live in a city where I have more access. So, while there have been some things we’ve learned from COVID that will improve care in the future, we have to be very intentional about how we use these tools and make sure that we don’t accidentally restrict access with them.

Dr. Green: I agree. The social determinants of health influence a lot of the cure that we get. So, just because we can do Zoom or telemedicine doesn’t mean that we should. There is something that occurs with patient interaction, with the ability to look someone eyeball to eyeball. To reach out and touch them. You know, we failed to remember that we are also the patient’s advocate. If you can’t read, or write then who advocates for you?

As physicians, we are in the top 10% of educated people and income earners in this country and this alone makes us often disconnected from our patients. So, Zoom care access may be giving some people a lesser quality of care and we need to explore that.

Dr. Gudin: This extends to many facets of what we do. I recall rotating on the pediatric pain service where adolescents of color with certain painful conditions like sickle cell were treated differently – often provided with suboptimal analgesia. This is a travesty and as clinicians we need to educate our clinicians of the future to level the playing field.  Looking ahead, I think we have the ability to change practice. We always ask our guests, What advice would you give to your medical students, your residents, your fellows, to level the playing field and to extend theses message to the greater community?

Dr. Goree: It’s interesting because this is a conversation that we’ve actually had recently about how we can include this in our residency education. My piece of advice is always to make sure your spaces are welcoming – that includes your clinics, your hospital, your office – welcoming of all backgrounds, all genders, all sexes, all religions. I often make a point of walking into the front door of our clinic rather than the back door, because I want to see what our patients see.

I think it’s easy for our spaces and our clinic encounters to become littered with bias. I use this example: Whenever I see a patient, I remember that there are probably four people that see that patient before I do. There’s my front desk person, a nurse, and normally a fellow, resident, or nurse practitioner. I get a lot of information from those people and I get a lot of information from the chart as well. We can see past medical history, we can see payer status, and all that’s right in front of our face – we have to remember that our mind is very powerful and we can create these entire worlds of who someone is and what their intentions are and how much health literacy they have before we even walk in the room.

And so, we have to make sure that, first, our patients feel welcome, and second, we have to make sure that all this information at our fingertips doesn’t bias the visit and that we don’t use it as a shortcut to the in-person, face to face, eye to eye physician-patient relationship.

Dr. Fudin: And Dr. Green, what’s your take?

Dr. Green: You know, first of all, perceptions are valid until tested. I actually think there are challenges with the electronic medical record. We have more information at our fingertips than our physician forefathers, but some of that information may not be valid. I’m very concerned about what the electronic medical record says and what it doesn’t say. What questions did we ask, and what questions didn’t we ask? Were we actively listening? I think we need to go back to that process we started in medical school of listening intently to the patient and asking, what does this mean to you?

Second, we need to think about how we trust our patient, and asking, do we like the patient, because the role of conscious and unconscious as well as explicit and implicit bias plays a role. I have this conversation with my interns – do you like the patient? I tell them, you may not always like the patient. But you have to acknowledge where you are to provide the patient with good quality care.

Safe clinical spaces are also an issue. We wrote a paper a couple of years ago that focused on the fact that African American patients and their visitors were more likely to have security called on them than Whites. That suggests that some of our patient spaces are not safe for all patients. There’s a robust history of patients, particularly African American patients, being mistreated and not receiving treatment. We need to actually address that fact.

We need to address how we have used pain to control behaviors in patients of color, and how this has gotten us to some of our hypotheses that currently drive how we deliver pain care. Think about the issue of addiction and opioids; there is no data to suggest that African Americans are more at risk for addiction than Caucasians, but they are consistently undertreated for pain. People have rationalized that because African Americans were less likely to receive opioids for pain care that it actually protected them from suicides and overdoses. (More on disparities in overdose follow-up.)

Dr. Fudin: I’ve actually written on some of this and, as a clinical pharmacist, I have to be painfully aware of the disparities that do exist in pharmacy access across socioeconomic groups, in pharmacy stock, and whether they are making naloxone easy to access based on their location for example. There have been a number of reports on this, including the paper where you, Dr. Green, compared minority and white pharmacies in Michigan. We could clearly continue this conversation.

Dr. Green: Yes, and I would just end by saying that we have failed to implement what we know. There’s a need for more research, but the bottom line is we failed to implement what we know.

 

 

Dr. Carmen R. GreenDr. Carmen R. Green

Carmen R. Green is a professor of anesthesiology and of obstetrics and gynecology at the University of Michigan’s (UM) School of Medicine, and of health management and policy at UM’s School of Public Health. She serves as the attending physician at the UM Back and Pain Center and is a faculty associate for a number of UM’s specialized institutes and programs, including: Research on Black Americans; Group Dynamics; Research on Ethnicity, Culture, and Health, Health Behavior, and Health Education; and Health Policy and Innovation. Dr. Green’sresearch has addressed healthcare policy and reform and disparities in healthcare access, and she is considered an expert in learning diversity, education equity, and inclusion science.

Dr. Johnathan GoreeDr. Johnathan Goree

Johnathan Goree, MD, is an associate professor of Anesthesiology at the University of Arkansas for Medical Sciences where he serves as director of the Chronic Pain Division, Program Director of the Pain Medicine Fellowship, and Chair of the Opioid Stewardship Committee.  Dr. Goree considers himself a quality of life physician who is focused on improving function through opioid-sparing interventional care.  His research interests include complex regional pain syndrome, racial disparities in chronic pain care, implementation science, and studying efforts to increase diversity, equity, and inclusion in our field.  

 

Throughout 2020, we will be featuring more dialogues on the evolution of pain management over the past two decades and what the future may hold. To get involved, email the editorial team. See Episode 1 with Lynn Webster, MD, Episode 2 with Peter Staats, MD, Episode 3 with Suzanne Amato Nesbit, PharmD, Episode 4 with Nathanial Katz, MD.
 
Last updated on: October 1, 2020
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