Treatment Disparities in Pain Management

2. 2
Treatment Disparities in Pain
Management
Sylvia Malcore, Ph.D.
Antú Segal, Psy.D.
10/3/18

3. Disclosures
None
3

4. 4
Objectives
1. Describe why it is important to discuss
pain & treatment disparities within pain
management
2. Discuss the treatment disparities in
pain management

5. 5
Objectives
3. Describe how providers’ biases affect
pain treatment
4. What is our role in recognizing &
advocating for equal treatment for all who
have pain

6. 6
1. Describe why it is important
to discuss pain & treatment
disparities within pain
management

7. Why Consider?
• Widespread health care treatment
disparities for individuals of non-
dominant culture (Institute of Medicine, 2002)
7

8. Who does pain affect?
• 100 million Americans experience
chronic pain (Institute of Medicine, 2011)
• Affects multiple domains of life
8

9. Pain is…
• “An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage” (IASP, 2011)
• What about the context?
9

10. Multiple factors involved in pain
• Physical
• Social
• Behavior
• Psychological
• Environment
10

11. 11
2. Discuss the treatment
disparities in pain management

12. Why discuss disparities in a pain population?
• Important to realize the potential bias against individual who
have pain:
• Report of pain versus _________________
• Consider measurement
• Vital Signs
12

13. Why discuss for pain population?
• The public knows…
• The doctor doesn’t listen to her. But the media is
starting to:
• Article in The Atlantic (Fetters, 2018)
• We need to address concerns!
13

14. Socio-Cultural
• Cultural & socioeconomic factors impact on
pain and management (Interagency Pain Research
Coordinating Committee, 2015)
14

15. Disparities in Treatment
• Ethnicity
• Gender
• Age
• Substance misuse history
• Weight
• And more…
15

16. Ethnicity
• Evidence of under treatment of pain for
people of color (Bonham, 2001)
• Screening (Burgess et al., 2013)
16

17. Ethnicity
• Did not appear related to utilization of
treatment or prevalence of pain (Meghani & Cho,
2009)
• Primary care physicians and pain
perception (Staton et al., 2007)
17

18. Ethnicity
• Emergency Department:
• Wait-time (Wheeler et al., 2010)
• Wait-times and ethnicity (Ware, Epps, Clark, & Chatterjee,
2012)
• Analgesics administered (Epps, Ware, & Packard, 2008)
18

19. Ethnicity
• Substance Monitoring:
• Higher rates urine drug screen (Hausmann, Gao, Lee,
& Kwoh, 2013)
• Referrals more likely to substance use specialty
versus pain management specialty (Hausmann, et
al., 2013)
19

20. Ethnicity
• Results have been inconsistent.
• How does this occur?
• “discrepancy and inconsistency in the definition
and subsequent measurement of the terms
race, ethnicity, and minority” (Ezenwa, Ameringer,
Ward, & Serline, 2006, p.226)
20

21. Gender
• Literature also suggests evidence of
disparities in women (Institute of Medicine, 2014)
• Inconsistent findings
• Why?
21

22. Gender
• Higher rates of pain in woman
• Why?
• Complex & multifaceted which likely
includes sociocultural and biological
factors (LeResche, 2011)
22

23. Gender
• Referrals:
• Types of referrals made were different by
gender (e.g., Hamberg, Kisberg, Johansson, & Westman,
2002; Hirsh et al., 2014)
23

24. Gender
• Treatment:
• Less optimal treatment recommendations
(Green, Wheeler, & LaPorte, 2003)
• Inconsistent findings on opioid prescribing
24

25. Age
• Emergency Department Care (Hwang, Richardson,
Harris, & Morrison, 2010)
• Reduction of pain scores appeared lower
in older adults
25

26. Substance Misuse History
• The perception of patients’ ‘drug-seeking’ was
critical in shaping the social context of hospital care
• Delegitimized the very real pain & suffering
• Dosage
• “Just another junkie addict looking for free drugs”
(McNeil, Small, Wood, & Kerr, 2014)
26

27. Substance Misuse History
• Ambiguity in decision making when providers have
individual who were substance abusers in the past
• Providers made decisions based on two frameworks
(Berg, Arnsten, Sacajiu, & Karasz, 2009)
27

28. Substance Misuse History
• Providers are more hesitant to treat pain and
prescribe pain medications to patients with
substance misuse
• Physicians did not clearly identify patient’s primary
addiction as a medical condition
(Merrill, Rhodes, Deyo, Marlatt, & Bradley, 2002)
28

29. Weight
• More negative stereotyping, less anticipated patient
adherence, worse perceived health, & more
responsibility attributed for weight-related concerns.
• No clear evidence of bias in clinical
recommendations made for the patient's care
(Persky & Eccleston, 2011)
29

30. Weight
• Bias against overweight people (Puhl & Brownell, 2001)
• Negative attitudes (Puhl & Brownell, 2001)
• Implicit measures show significant bias, even in
health professionals who specialize in the treatment
of obese persons (Teachman & Brownell, 2001)
30

31. Non-English Language
• Use of interpreter
• Conclusion: insufficient evidence to determine the
effectiveness of using interpreter services or bilingual providers
for clients with limited English proficiency
(Anderson, Scrimshaw, Fullilove, Fielding, Normand, & Task Force on
Community Preventive Services, 2003)
31

32. Others
What have others encountered?
32

33. 33
3. Describe how providers’
biases affect pain treatment

34. How do these disparities occur?
Huge Question…
• Providers unintentionally contribute to treatment disparities
Why?
• Biomedical culture
• Inaccurate beliefs about racial differences
• Implicit versus explicit bias
• Stereotype-based bias
• Provider preference and patient likability34

35. Biomedical Culture
• Pain does not fit into the model:
• Mind-body dualism
• Focus on disease versus illness
• Bias toward curing disease versus care for patients within
their context
• These variables play a role in how a clinician
communicates, assesses, and manages pain
(Crowley‐Matoka, Saha, Dobscha, & Burgess, 2009)35

36. Inaccurate Beliefs
• Inaccurate beliefs about “biological
differences” and treatment
recommendations (Hoffman, Trawalter, Axt, & Oliver,
2016).
36

37. Implicit versus Explicit Biases
• Implicit versus Explicit Biases (Mathur, Richeson,
Paice, Muzyka, & Chiao, 2014)
• Implicit Biases in healthcare providers (Maina,
Belton, Ginzberg, Singh, & Johnson, 2018)
37

38. Stereotype-based Bias
• Vignette study asked 111 primary care physicians
to treat three hypothetical patients with pain
(Weisse, Sorum, Sanders, & Syat, 2001)
• Results: Male physicians provided more pain
relief to white patients & female physicians
provided more pain relief to black patients
38

39. Stereotype-based Bias
• Vignette study with a national sample of emergency
physicians recommended whether to prescribe opioid
analgesics for three different presenting pain conditions
(Tamayo‐Sarver et al., 2003)
• Results: Physicians were more likely to prescribe opioids
for patients with socially desirable characteristics
• Suggests that racial/ethnic disparities in pain treatment
may be due to providers’ beliefs that white patients
possess more socially desirable characteristics than non-
white patients
39

40. 40
Patient characteristics that
physicians find desirable
Patient characteristics that
physicians find undesirable
Promote efficiency of the medical
encounter
Abrasive/hostile/angry
Likable/physically attractive Non–English-speaking
Lacking excessive demands Excessive complaining
Cooperative/good response to tx Borderline personality
Good communication Suicidal tendencies/self-destructive
behavior
Competent Poor personal hygiene
Limited psychological problems Vague problems or high clinical
uncertainty
Compliant/adherent Drug-seeking behavior
Higher SES Immaturity
(Aberegg & Terry, 2004)

41. 41
4. What is our role in
recognizing & advocating for
equal treatment for all who have
pain

42. What is our role?
• What can we do? Help educate!
• Teach others about racial and ethnic disparities in health &
health care
• Provide cultural competence training in medical education
• Focus on common group membership (i.e., shared identities)
• Recognizing the potential influence of implicit responses
(Dovidio & Fiske, 2012)
42

43. Interventions
• Medical educators:
• Help identify, model & cultivate attitudes that can help to
eliminate health care disparities (i.e., egalitarian views)
• Adopt & model communication skills considerate of diverse
patient cultures & languages
• Demonstrate self-reflection & openness
• Urge educational institutions to adapt their curricula to include
guidelines for teaching about health disparities
(Smith et al., 2007)
43

44. Interventions
44
Bennett, 1986
A developmental
approach to training for
intercultural sensitivity

45. Interventions
45
Simple steps for fighting healthcare disparities
(Paulson & Dekker, 2005)

46. Interventions
• Empathy for patients (Drwecki et al., 2011)
• When asked to imagine patient’s experience of
pain, significant reduction in racial disparities for
pain management
46

47. Interventions
•What’s our role…
•Call it out
•Be aware of our own biases (Chapman, Kaataz,
Carnes, 2013)
47

48. In conclusion…
• The literature on treatment disparities is complicated with
multiple variables to consider
• Important to acknowledge and discuss potential variables
impacting disparities
• We need to examine our own biases
48

49. Questions?
49

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