Disparities in Pain Management for African Americans

1. Disparities in Pain Management for African Americans Megan Conner, CRNA, MSN

2. Background Problem Information • African Americans – 14% of population • Pain management is burden on health care system • Racial and ethnical differences in care

3. Contributing Factors • Biological • Possible difference in endogenous pain inhibition • Lower pain tolerance • Lower cortisol concentrations, blunted plasma norepinephrine and SBP

4. Contributing Factors • Socio-cultural • Impact decision to seek care • Health insurance status & type of policy • Income • Stretch time between prescription refills • Narcotics limits on refills • Fear of substance abuse or secondary gain by providers • Fear of addiction by African Americans

5. Contributing Factors • Stigma related to certain diseases • Stoicism • Family oriented, putting self last • Spirituality • Communicating pain related to gender and race • Nutritional deficiencies

6. Contributing Factors • Health Behaviors • Total pain sites, level of interferences, and feeling frustrated most predictive for number of pain reducing behaviors • African Americans employ a wide variety pain reducing strategies • Greater psychological burden due to chronic pain (PTSD, depression, disability, irritability) • Fear of discrimination by providers

7. Contributing Factors • Health Literacy • 44% of African Americans have low health literacy • 41% of English speaking patients are unable to understand direction for taking medicine on an empty stomach • Leads to higher rates of hospitalization, and difficulty communicating with provider • Physicians over estimated literacy 25% of the time (mean practice years 15.2)

8. Issues and Trends Related to AccessUse, Costs, and Quality of Health Care • Health insurance most significant factor influencing access to care • Not referred to pain specialist (95% of all patients) • Difficulty finding provider • Seek treatment in Emergency Room • African Americans more likely to extend time between onset and pursuit of treatment

9. Issues and Trends Related to Access Use, Costs, and Quality of Health Care • No difference nor significance in pharmacy geographical distribution • Those in white zip codes more likely to have sufficient stock of opioids • New drugs are targeted a physicians with more affluent educated white demographic patient population

10. Issues and Trends Related to Access Use, Costs, and Quality of Health Care • 25% never filled prescription • 42% filled prescription, but never took it • Patient preferences effected by individual meaning of pain, side effects, fears related to analgesic use, and cultural preferences • One study found: 11% against using analgesics; 20% believed in taking pain medications

11. Issues and Trends Related to Access Use, Costs, and Quality of Health Care • Health insurance & policy type • Out-of-pocket expenses • Large number of pain relievers sold • 1.2 million emergency room visits associated with pharmaceutical abuse or misuses • Procedures for pain reduction

12. Issues and Trends Related to Access Use, Costs, and Quality of Health Care • Male physicians prescribed twice the amount of pain medications for whites compared to African Americans. The opposite is true for females physicians. • “less intelligent, less educated, more likely to abuse drugs and alcohol, and more likely to fail to comply with medical advice, and more likely to lack social support” • Inadequate assessment of pain • Affected by health literacy and patient-provider communication

13. Issues Related to Outcome Measurement and Data Collection • Cultural distrust • Lack of understanding of research process • Inadequate recruitment efforts by researchers • Economic considerations • Research associated with social stigma (mental health)

14. Strategies for Culturally Sensitive Services • Cultural Encounter • Be aware of own cultural bias • Prefer formal title, and use of their surname • Depend more on non-verbal communication • Comfortable with closer personal space compare to other cultures • Address health literacy • Cultural Skill

15. Intervention • Focused on education with pretest/post-test design • Topics • Cultural Skill/Competency • Fact or Fiction • Medication Information • For: Patients and Health Care providers • Outcome Variables • Post-test scores • Change in pain scores

16. References • Agliata, A. K. & Renk, K. (2009). College students’ affective distress: The role of expectation discrepancies and communication. Journal of Child and Family Studies, 18(4), 396-411. • Bell, R. F., Borzan, J., Kalso, E., & Simonnet, G. (2012). Food, pain, and drugs: Does it matter what pain patients eat? Pain, 153, 1993-1996. • Campbell, C. M., France, C. R., Robinson, M. E., Logan, H. L., Geffken, G. R., & Fillingim, R. B. (2008). Ethnic differences in diffuse noxious inhibitory controls. The Journal of Pain, 9(8), 759-766. • Campinha-Bacote, J. (2009). A culturally competent model of care for African Americans. Urologic Nursing, 29(1), 49-54. • Centers for Disease Control and Prevention (CDC). (2006, November 15). New report finds pain affects millions of Americans. Retrieved fromwww.cdc.gov/nchs/pressroom/06facts /hus06.htm • Cintron, A. & Morrison, R. S. (2006). Pain and ethnicity in the United States: A systematic review. Journal of Palliative Medicine, 9(6), 1454-1473. • Coker, A. D., Huang, H., Kashubeck-West, S. (2009). Research with African Americans: Lessons learned about recruiting African American women. Journal of Multicultural Counseling and Development, 37, 153-165.

17. References • Ezenwa M. O., Ameringer, S., Ward, S. E., & Serlin, R. C. (2006). Racial and ethnic disparities in pain management in the United States. Journal of Nursing Scholarship, 38(3), 225-233. • Graves, J. L. (2011). Evolutionary versus racial medicine: Why it matters. In S. Krimsky & K. Sloan (Eds.), Race and the genetic revolution: Science, myth, and culture (pp. 142-170). New York: Columbia University Press. • Green, C. R., Anderson, K. O., Baker, T. A., Campbell, L. C., Decker, S., Fillingim, R. B., Kaloukalani, D. A., Lasch, K. E., Myers, C., Tait, R. C., Todd, K. H., & Vallerand, A. H. (2003). The unequal burden of pain: Confronting racial and ethnic disparities in pain. Pain Medicine, 4(3), 277-294. • Green, C. R., Ndao-Brumblay, S. K., West, B., & Washington, T. (2005). Differences in prescription opioid analgesic availability: Comparing minority and white pharmacies across Michigan. The Journal of Pain, 6(10), 689-699. • Grewen, K. M., Light, K. C., Mechlin, B., & Girdler, S. S. (2008). Ethnicity is associated with alterations in oxytocin relationship to pain sensitivity in women. Ethnicity & Health, 13(3), 219-241. • Hastie, B. A., Riley, J. L, & Fillingim, R. B. (2005). Ethnic difference and responses to pain in healthy young adults. Pain Medicine, 6(1), 61-71.

18. References • Im, E. (2008). African-American cancer patients’ pain experience. Cancer Nursing, 31(1), 38-48. • Joranson, D. E. (1994). Are health-care reimbursement policies a barrier to acute and cancer pain management. Journal of Pain and Symptom Management, 9(4), 244-253. • Kelly, P. A. & Haidet, P. (2007). Physician overestimation of patient literacy: A potential source of health care disparities. Patient Education and Counseling, 66, 119-133. • Mahmoudi, E. & Jensen, G. A. (2012). Diverging racial and ethnic disparities in access to physician care. Medical Care, 50(4), 327-334. • Meghani, S. H. & Keane, A. (2007). Preference for analgesic treatment for cancer pain among African Americans. Journal of Pain and Symptom Management, 34(2), 136-147. • Mechlin, M. B., Maixner, W., Light, K. C., Fisher, J. M., & Girdler, S. S. (2005). African Americans show alteration in endogenous pain regulatory mechanisms and reduced pain tolerance to experimental pain procedures. Psychosomatic Medicine, 67, 948-956. • Nguyen, M., Ugarte, C., Fuller, I., Haas, G., & Portenoy, R. K. (2005). Access to care for chronic pain: Racial and ethnic differences. The Journal of Pain, 6(5), 301-314.

19. References • Parmelee, P. A., Harralson, T. L., McPherron, J. A., DeCoster, J., & Schumacher, H. R. (2012). Pain, disability, and depression in osteoarthritis: Effects of race and sex. Journal of Aging and Health, 24(1), 168-187. • Paulozzi, L. J., Jones, C. M., Mack, K. A., & Rudd, R. A. (2011, November 4). Vital signs: Overdoses of prescription opioid pain relievers --- United States, 1999-2008. Morbidity and Mortality Weekly Report. Retrieved from http://www.cdc.gov/mmwr • Rahim-Williams, F. B., Riley, J. L., Herrera, D., Campbell, C., Hastie, B. A., & Fillingim, R. B. (2007). Ethnic identity predicts experimental pain sensitivity in African Americans and Hispanics. Pain, 129(1-2), 177-184. • Scudder, L. (2006). Words and well-being: How literacy affects patient health. Journal for Nurse Practitioners, 2(1), 28-35. • Shaya, F. T. & Blume, S. (2005). Prescriptions for Cyclooxygenase-2 inhibitors and other nonsteroidal anti-inflammatory agents in Medicaid managed care population: African Americans versus Caucasians. Pain Medicine, 6(1), 11-17. • Smedley, B. D., Stith, A. J., & Nelson, A. R. (Eds.). (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academic Press.

20. References • The Office of Minority Health (OMH). (2012). African American Profile. Retrieved from http://mintorityhealth.hhs.gov/templates/browse.aspx?lvl=3lvlid=23 • Weisse, C. S., Foster, K. K., & Fisher, E. A. (2005). The influence of experimenter gender and race on pain reporting: Does racial or gender concordance matter? Pain Medicine, 6(1), 80-87.