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Disparities in Pain Medicine: A Psychological Perspective

Disparities in Pain Medicine: A Psychological Perspective. Raymond C. Tait, PhD Saint Louis University. Disclosures. Spouse is on the Speaker’s Bureau for Lilly Center for World Health & Medicine (direct report) has a project jointly funded by Lilly and J&J No discussion of unapproved uses.

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Disparities in Pain Medicine: A Psychological Perspective

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  1. Disparities in Pain Medicine:A Psychological Perspective Raymond C. Tait, PhD Saint Louis University

  2. Disclosures • Spouse is on the Speaker’s Bureau for Lilly • Center for World Health & Medicine (direct report) has a project jointly funded by Lilly and J&J • No discussion of unapproved uses

  3. The study of error is not only in the highest degree prophylactic, but it serves as a stimulating introduction to the study of truth. --Walter Lippmann (1922)

  4. Organization of Comments • Review general evidence on disparities in pain care • Primary focus = race/ethnicity • Race/ethnicity and SES • The clinical encounter • Pain as subjective phenomenon • Variability in provider assessments • Provider as a social judge • Patient influences (reported pain severity, race/ethnicity) • Is high pain severity a condition for context-mediated judgments? • Situational (medical evidence) • Provider (specialty) • Imputed response cost – a common pathway?

  5. Disparities in Pain Care • Race/ethnicity • Todd et al., 1993; Green et al., 2003; IOM, 2003; Chibnall et al., 2005; Anderson et al., 2009; IOM, 2003, 2011; Meghani et al., 2012 • Gender • Martin & Lemos, 2002; Taylor et al., 2005 • Age • Old (Hadjistravropoulos et al., 2007; Weiner et al, 2002) • Young (Howard, 2003; Anthony & Schanberg, 2005) • Socioeconomic status • Morrison et al., 2000; Mayberry et al., 2000 • Conditions • Low back pain (Tait et al., 2004) • Acute pain (Salmon & Manyande, 1996) • Recurrent pain (Elander et al., 2006) • Cancer pain (Cleeland et al., 1997)

  6. Disparities in Pain Care • Race/ethnicity • Todd et al., 1993; Green et al., 2003; IOM, 2003; Chibnall et al., 2005; Anderson et al., 2009; IOM, 2011; Meghani et al., 2012 • Gender • Martin & Lemos, 2002; Taylor et al., 2005 • Age • Old (Hadjistravropoulos et al., 2007; Weiner et al, 2002) • Young (Howard, 2003; Anthony & Schanberg, 2005) • Socioeconomic status • Morrison et al., 2000; Mayberry et al., 2000 • Conditions • Low back pain (Tait et al., 2004) • Acute pain (Salmon & Manyande, 1996) • Recurrent pain (Elander et al., 2006) • Cancer pain (Cleeland et al., 1997)

  7. Patient Factors in Racial Disparities: Experimental Studies of Pain Perception • African Americans demonstrate lower pain thresholds and tolerances than nHw’s • Zborowski, 1969; Zatzick & Dimsdale, 1990 • Negative affect may mediate findings • Sheffield et al., 2000; Campbell et al., 2008 • Higher vigilance may mediate findings • Campbell et al., 2005 • Cautionary notes • Experimental data may not predict response to clinical pain (Edwards et al., 2001) • Experimenter-subject effects (e.g., ↑ pain behavior in ethnically concordant pairs; Hsieh et al., 2011)

  8. Patient Factors in Racial Disparities: Clinical Studies of Pain Perception • Acute pain • ↑ AA relative to nHw (Faucett et al., 1994) • No diffs (Barak & Weisenberg, 1988) • Chronic pain • ↑ AA relative to nHw (McCracken et al., 2001; Selim et al., 2001; White et al., 1999) • No diffs (Thomason et al., 1998; Jordan et al., 1998; Tait & Chibnall, 2001) • Methodologic challenges • Control over prior treatment, sampling (most patients come from single clinic), social reactivity

  9. Patient Factors in Racial Disparities: Pain-Related Coping and Adjustment • ↑ post-treatment disability for AA vsnHw • Chronic LBP (Selim et al., 2001; Chibnall et al., 2005), osteoarthritis (Allen et al., 2010), general chronic pain (Edwards et al., 2001) • ↑ distress for AA vsnHw • Allen et al., 2010; McCracken et al., 2001 • Coping • ↑ passive coping (Jordan et al., 1998; Clark et al., 1999) • ↑ catastrophizing (Fabian et al., 2011) • Distrust of medical professionals • Lillie-Blanton et al., 2000 • Expectations of benefit • LaVeist et al., 2000; Ibrahim et al., 2002

  10. Racial Disparities: Situational/Public Health Factors • Racism • Long-term implications for health (Clark et al., 1999) • Socioeconomic factors co-vary with minority status (Mayberry et al., 2000; Meghani et al., 2012) • Access • Analgesics (Morrison et al., 2000; Green et al., ) • Medical care (Meghani et al., 2012) • Insurance (Zuvekas and Taliaferro, 2003) • Resources (Tait & Chibnall, 2012)

  11. Relative Contributions ofRace and Socioeconomic Status

  12. Disparities in Occupational Lumbar Injury Outcomes Research (DOLOR)(Agency for Healthcare Research and Quality, R01 HS13087-01) • Missouri cases of LB injuries that were settled between 1/01 and 6/02 • St. Louis city, St. Louis county, Jackson county • 90% of African Americans in the state • 2,934 cases • 50.3% completed survey • 14.7% refused survey • 35.0% could not be traced • Data sources • WC database • Telephone survey instruments

  13. Demographics(N = 1,475) • Age  43.6 years • Education = 13.07 years • Gender = 896 males, 533 females • Race (self-identified) = 889 Caucasian, 540 African Americans, 43 mixed, 3 refused • Working full-time at time of injury = 95.2% • Working full-time now = 62.8%

  14. WC Database: Surgical vs. Non-Surgical Treatment(Chibnall et al., Spine, 2006) 2(1) = 106.1, P < 0.0001 OR = 4.0; 95% CI = 2.9 – 5.4

  15. WC Management Database by Race

  16. Predictors of WC Management:Demographics, SES, and Injury*(Tait et al., Pain, 2004) * Simultaneous entry multiple hierarchical regression: R2 change (all P’s < 0.001)

  17. Clinical Outcomes: 2 Years Post-Settlement (Chibnall et al., Pain, 2005) * P < 0.0001

  18. 6-Year Follow-Up: High Levels of Pain, Catastrophizing, and Disability(Chibnall & Tait, Pain Medicine, 2011) * 1 = high (pain ≥ 7; PCS ≥ 30; PDI ≥ 45) vs. 0 = less than high

  19. 0.29 0.29 0.29 0.32 0.32 0.32 0.37 0.37 0.37 0.66 0.66 0.66 Race Race 0.23 0.23 - - 0.29 0.29 - - 0.27 0.27 0.60 0.60 Gender Gender SES SES WC Factor WC Factor PDD PDD - - 1 1 PDD PDD - - 2 2 - - 0.25 0.25 - - 0.14 0.14 Age Age 0.16 0.16 Time Time 0 +1.75 0 +1.75 years +6 years +6 years years Settlement Baseline Long Settlement Baseline Long - - Term Term Path Analysis for Predicting Adjustment (pain/distress/disability: PDD) Circled values indicate Multiple R at that stage of the model, P < 0.001

  20. 10 * 9.5 Caucasian 9 African American 8.5 8 7.5 7 6.5 6 5.5 Pct. Change from Baseline 5 * 4.5 * 4 * 3.5 * 3 2.5 * * 2 1.5 1 0.5 0 Baseline Year 1 Year 2 Year 3 Year 4 Year 5 Post-Settlement Years Race Effects on Financial Court Actions: 5 Years Post-Settlement(Tait & Chibnall, Spine, 2012)

  21. Implications for Race & SES • Race/ethnicity and SES are associated with differences in patient/provider approach to treatment and intermediate-term outcomes • Race/ethnicity appears to account for greater effect during active clinical management • Race/ethnicity and SES are associated with differences in long-term outcomes • SES accounts for greater long-term effects • What accounts for disparate clinical management?

  22. Judging Pain in Others: A Social Interaction

  23. Judging Pain in Others: A Projective Test? One Patient Two Providers Opinion #1 Opinion #2

  24. Internist Judgments of Chronic Low Back Pain(Chibnall, Dabney & Tait, Pain Medicine, 2000) • 48 internists from an academic school of medicine • 2 x 4 mixed between and within-subjects design • Vignettes describing hypothetical low back pain patients varied by pain severity (low vs. high) • Internists provided 4 waves of clinical information (history  physical exam findings  functional disability  diagnostic test results) • Measures = MD judgments regarding patient medical/psychological/disability status, treatment, diagnostic testing, and referral options

  25. MD Judgments: Reliability Across 4 Waves of Information

  26. Patient Characteristics (“The Target”)

  27. Pain Presentation Factors that Influence Judgments • Chronicity • Klein et al., 1982; Teske et al., 1983; Taylor et al., 1984; Leclere et al., 1990; Eccleston et al., 1997; Hahn, 2001 • Distribution • Ransford et al., 1976; Von Baeyer et al., 1983; Margolis et al., 1986; Tait et al., 1990 • Behavior • Prkachin et al., 1994; Krause et al., 1994;Solomon et al., 1997; Prkachin et al., 2001 • Severity • Grossman et al., 1991; Zalon, 1993; Chibnall and Tait, 1995; Lieberman et al., 1996; Solomon et al., 1997; Tait and Chibnall, 1997; Marquie et al., 2003

  28. Subject vs “Patient” Pain RatingsChibnall, Tait & Ross, J Behav Med, 1997

  29. RATES OF AGREEMENT IN PATIENT & CAREGIVER PAIN RATINGS(from Grossman et al., Correlation of patient and caregiver ratings of cancer pain, J. Pain Symp Manag, 1991; 6:53-57)

  30. Observer Perceptions of Low Back Pain: Effects of Pain Report and Other Contextual Factors(Chibnall & Tait, 1995) • 2 [hi/lo pain] x (2 [+ medical evidence] x 2 [+ relationship valence] x 2 [+ victim status]) • Dependent Variables • estimated pain, disability, emotional distress • + personality characteristics • 80 undergraduates • Context influences evident in main effects, 2-way, 3-way, and 4-way interactions

  31. Study Design: 2 x (2 x 2 x 2) Mixed Between and Within(Chibnall & Tait, 1995) Note: 8 vignettes; counterbalanced for order and sequence Pain: High (7/10) vs. Low (3/10) Medical Evidence: Present vs Absent Control: Present vs Absent Relationship: Positive vs Negative

  32. Example Vignettes and Levels of Independent Variables

  33. Reported Pain Severity & Medical Evidence: Effects on Pain Estimates(Chibnall & Tait, 1995) * P < 0.05; ** P < 0.001

  34. High Pain Severity: Implications for Clinical Judgment Pain Report Low (1-3) Moderate (4-6) High (7-10) Little likelihood of context effects Some likelihood of context effects without objective evidence High likelihood of context effects with/without objective evidence

  35. Sociodemographic Factors that Influence Judgments • Gender • Martin & Lemos, 2002; Taylor et al., 2005 • Age • Old (Hadjistravropoulos et al., 2007; Weiner et al, 2002) • Young (Howard, 2003; Anthony & Schanberg, 2005) • Socioeconomic status • Morrison et al., 2000; Mayberry et al., 2000 • Race/ethnicity • Todd et al., 1993; Green et al., 2003; IOM, 2003; Chibnall et al., 2005; Anderson et al., 2009; IOM, 2011; Meghani et al., 2012

  36. Claimants with HNP: Predictors of Surgery* • *No surgery vs surgery: 2(8) = 59.6, P < .001; R2 = 0.13 (N =640)

  37. Contextual Characteristics(“The Situation”)

  38. Factors that Influence Judgments: Situational Features • Compensation status • Hadler, 1994; Kennedy, 1997; Chibnall and Tait, 1999; Merskey and Teasell, 2000; Kappesser et al., 2006 • Medical evidence • Carey et al., 1988; Birdwell et al., 1993; Tait and Chibnall, 1994; Chibnall and Tait, 1995; Chibnall et al., 1997; Tait et al., 2006

  39. Study Design: 2 x 2 x 2 Within-Subjects(Tait & Chibnall, 1994) Note: 8 vignettes; counterbalanced for order and sequence Medical Evidence: Present vs Absent Control: Present vs Absent Relationship: Positive vs Negative

  40. Main Effects: Medical Evidence * P < 0.05; *** P < 0.001

  41. Incremental Certainty of Disability: Low Back Pain(Carey et al., J ClinEpidemiol 1988;41:691-697)

  42. Provider Characteristics (“The Judge”)

  43. Factors that Influence Judgments:Observer Features • Affect • Tait & Chibnall, 1994; Sharpe et al., 1994; Chibnall & Tait, 1995 • Empathy • Goubert et al., 2005; Tait et al., 2005; Tait, 2008 • Experience/Specialty • Lenburg et al., 1970; Choiniere et al., 1990; Chibnall & Tait, 2000; Prkachin et al., 2001; Marquie et al., 2003; Tait et al., 2010

  44. Judging Pain: Physician Specialty(Tait et al., 2010) * P < 0.05; ** P < 0.001

  45. Pain Management: A Social Transaction • Pain management is an interactive phenomenon • Social transaction (Craig et al., 2010) • Participative decision-making (Frantsve & Kerns, 2006) • Social contract (Kappesser et al., 2008) • Contract influenced by assumed relational roles (patient and provider) • Implied contractual demands of patients with severe, chronic pain • Fix me • At least help me—analgesic medications (opioids?) • Handle any regulatory implications • Assume long-term management (not cure) • Embrace high (ongoing?) time demands • Recognize the likelihood of associated psychological distress • Tackle disability-related sequelae • Manage sick role, litigation and other system issues • Treat likely co-morbidities • Prepare for high costs of care

  46. Imputed Response Cost: A Common Pathway? • Definition: Response cost or negative punishment is [a] way to make behavior less frequent • Increasing the cost of a response decreases the likelihood that it will occur • Imputed response cost: The expectation that a given action will result in costly and/or burdensome consequences • Treating patients with chronic pain occasions high imputed costs secondary to social contract responsibilities • Especially with high pain severity • How to reduce response cost • Decline (or share) treatment responsibility • Discount severity (reduce responsibility)

  47. Imputed Response Cost: Effects on Pain Judgment • Severe chronic pain presentation • 43 yo WM w/ severe pain x 12 mos (prior L4-5 discectomy) • Grade III spondylolisthesis at L5-S1, DJD at L4-5, +SLR on left, equivocal EMG—not deemed a surgery candidate • Comorbidities: HTN, ↑ Psych distress, frequent work absences • Oxycodone 30mg bid, ibuprofen 800mg tid, vicodinprn • Personal cost (hi/lo) • Ongoing treatment responsibility vs evaluation only • Societal cost (hi/lo) • Evaluation for disability determination vs FYI only • Dependent variables • Psychological attribution, pain-related dysfunction

  48. Pain & Dysfunction: Expected Effects of Imputed Personal/Societal Costs Mean T Score—Pain & Dysfunction Personal Cost

  49. Pain & Dysfunction: Actual Effects of Imputed Personal/Societal Costs Mean T Score—Pain & Dysfunction Personal Cost

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