Disparities in Pain Management: An Expert Interview With Carmen R. Green, MD

[Guest guest]

http://www.medscape.com/viewarticle/581003?src=mp & spon=26 & uac=124296HG

Disparities in Pain Management: An Expert Interview With Carmen R. Green, MD

Posted 09/29/2008

Darlene Field, PhD

Editor's Note:

Darlene Field, PhD, Medscape Neurology & Neurosurgery Scientific Director,

discussed the relationship between race, socioeconomic status, and chronic pain

with Dr. Carmen Green, Associate Professor of Anesthesiology at the University

of Michigan Medical School at Ann Arbor and Attending Physician at the

University

of Michigan Back & Pain Center.

Medscape: Can you explain for me the relationship between socioeconomic

disadvantage and risk for developing chronic pain?

Dr. Green: Socioeconomic status is a measure of an individual or family’s

relative economic and social ranking. It can be a function of income and

education.

The socioeconomic disadvantage commonly seen in chronic pain patients is

poverty. There's nothing like pain to put people into poverty. People who

develop

pain problems don't usually end up being rich people. People with manual or

labor-intensive jobs are at increased risk for potentially developing chronic

pain problems. That increased risk presents a challenge for people, and some

research is being done to explore the role of poverty on pain. It appears

that access to care and variability in how physicians or other healthcare

professionals might treat a patient are factors that need to be looked at more

closely. It makes sense that if you have a socioeconomically disadvantaged

individual, you may have decreased access and potentially decreased quality

of care. Although socioeconomic disadvantage may be a risk factor for developing

chronic pain, we've shown that race and ethnicity may actually trump that.

Medscape: Is there any evidence to suggest that positive pain relief and active

pain coping strategies are effective in managing chronic pain?

Dr. Green: Yes, there is plenty of data to suggest that getting patients back to

their best health and well-being using multidisciplinary techniques or

interdisciplinary techniques will help them manage their pain. Physicians,

clinicians, nurses, psychologists, social workers, and most importantly the

patient all play a key role in maintaining a patient's well-being and

controlling their pain. Patients who tend to get better sooner and maintain gain

are people who are willing to address the psychological impact that pain has on

their life. It is well established that active coping strategies as opposed

to passive coping strategies are associated with better patient outcomes.

Medscape: Do race and ethnicity play a role in the pain experience?

Dr. Green: We know there's variability in how race, ethnicity, gender, and age

influence pain perception using experimental models. However, how this

translates

to clinical pain experience is still unclear. What we do know is that the pain

complaints of minorities and the pain complaints of women receive less

attention.

However, this does not mean that Caucasian males always get the best treatment,

it just means in comparison. The prevalence of pain and its undertreatment

is rampant. Overall, we have a fair amount of work to do in order to improve the

quality of pain care, particularly for people who are more vulnerable

to the impact of pain and its negative sequelae, such as racial ethnic

minorities or women or the elderly or the socioeconomically disadvantaged.

Medscape: Have we yet to develop a standardized method to measure socioeconomic

disadvantage and its impact on chronic pain?

Dr. Green: No, there's a great deal of debate in the literature as to how do we

do this. Do we look at neighborhood socioeconomic status, do we look at

education or income? There needs to be more work on this area in the pain field.

So given that, I believe clinicians must start thinking and asking the

patient about the resources available to a patient in the community. We must

consider how does being impoverished or having less resources impact this

patient. For instance, do they have resources to pay their copay? This may

impact your management plan. The first step is you start off by obtaining the

socioeconomic data and use the data as another part of the health history that

you would take. Just like when we obtain the family or social history.

Medscape: Is it true that some of the pharmacies in more crime-ridden

communities may not be willing to stock pain medications because of problems

with

diversion?

Dr. Green: There are certain communities, both urban and rural, where you have

difficulty finding some pain medications. Overall, minorities may have decreased

access to pain medications even when they're at higher income status. This

dilutes some of the crime talk. People may have poor access to pain medications

for a variety of reasons. We were not able to examine crime rates in our study.

However, we need to further explore how to properly assess and treat patients

as well as how to get patients the medications they need while looking at other

types of barriers such as paperwork.

Medscape: Do you feel that most clinicians have a clear awareness of their

patients' life situation and can recognize that socioeconomic disadvantage can

contribute negatively to the pain experience.

Dr. Green: I don't think that we are typically collecting the data or asking the

questions " can you get this medication filled in your local pharmacy? "

or " do you have insurance? Do you have a copay? " Nor do we provide the

information " here’s the pharmacy that will most likely have this medication in

stock. "

So I think that again, we've focused somewhat on race and ethnicity, but we

haven't done some of the work that needs to be done regarding socioeconomic

disadvantage and how it impacts our patients.

Medscape: To sum up our conversation today, can you give me some key points that

you've learned from your own research on race and socioeconomic status

and pain?

Dr. Green: Yes, we have learned that pain complaints of racial ethnic minorities

and women and also the elderly receive less attention than others. If you

include socioeconomic status within that, or socioeconomically disadvantaged

people, it makes sense that their pain complaints may receive less attention.

Overall socioeconomically disadvantaged people may be at risk for their pain to

not be assessed as well. Pain assessment is the cornerstone for quality

pain care. Failure to assess pain well will make treatment much more

problematic. There's also variability in how clinicians, physicians, and nurses

treat

patients of racial and ethnic minority backgrounds as it relates to pain and

with women and minorities being at risk for lesser quality care. Even if they

or the socioeconomically disadvantaged patient get their pain assessed and

treated, they may be faced with additional structural barriers where they cannot

get their pain medication prescription filled at their local pharmacy. So all

those things put together make some patients more vulnerable to the pain

experience than others. Overall, we know that socioeconomically disadvantaged

people who are also minorities may have increased disabilities, decreased

quality of life, and decreased health and well-being in the context of pain. So

again we need to think about how do we improve the quality of pain care

for all. I believe that by actually improving the pain care for our most

vulnerable populations, we can develop mechanisms that improve pain care for all

and decrease the burden of pain.

This activity is supported by an educational grant from PriCara, Division of

Ortho-McNeil-Janssen Pharmaceuticals Inc., administered by Ortho-McNeil Janssen

Scientific Affairs, LLC.

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