Disparities In Pain Management Research Articles

Examining Disparities in Regional Anesthesia Utilization, Opioid Prescriptions, and Pain Scores Among Patients Who Received Primary or Revision Total Knee Arthroplasty at a Veterans Affairs Medical Center: A Retrospective Cohort Study.

Total knee arthroplasty (TKA) is one of the most performed surgical operations in the United States. Managing postoperative pain after TKA is of vital importance, as it is positively associated with outcome measures related to recovery of function and quality of life. Two commonly used methods to control postoperative pain are regional anesthesia (RA), consisting of a single or a combination of peripheral nerve and epidural blocks, and pain medication, such as opioids. Our retrospective analysis sought to better understand whether revision versus primary TKA impacted previously discovered disparities in perioperative pain management and use of RA at the Atlanta Veterans Affairs Health Care System (AVAHCS). Before data collection, we hypothesized that revision TKA would have a higher proportion of Black and older patients and that revision TKA patients would have lower postoperative pain scores. This was a retrospective analysis of AVAHCS patients who underwent elective unilateral primary or revision TKA surgery between 2014 and 2020. After application of our exclusion criteria, data from 562 patients were analyzed. Data collected included demographics information, type of RA used, and pain scores. Statistical analyses included chi-square test, t-tests, multiple logistic regression, and multiple linear regression, as appropriate to the outcomes of interest. Revision TKA patients were more likely to be Black (P = .018) and younger (P = .023 for <50 years of age group, P = .006 for 50 to 64 years of age compared to the >65 years group). Black patients, compared to White patients, had significantly higher pain scores at baseline (P = .0086) and at 24 hours postsurgery (P = .0037). Older patients (≥50 years old) had significantly higher baseline pain scores (P = .021 for the 50 to 64 years group, P < .01 for the >65 years group) and significantly lower first postanesthesia care unit pain scores (P < .05). Black race (P < .01) and age > 65 years (P < .01) were associated with a significant decrease in total oral morphine equivalents (OME) prescribed at discharge. None of the predictor variables-race, age, type of surgery (primary versus revision), baseline, and first postanesthesia care unit pain scores-were significantly associated with the use of RA in our cohort. Sociodemographic disparities in pain management have been reported in all healthcare systems, including the VAHCS. This moderately sized retrospective study, conducted at a single veterans affairs site, yielded several noteworthy findings. One finding of particular interest was that, despite Black patients reporting higher baseline and 24-hour postoperative pain scores, they were prescribed fewer opioids at discharge. Our results highlight the presence of clinically significant disparities in perioperative TKA pain management, emphasizing the need for continuous investigation and focused mitigation efforts among Veterans.

Disparities in pain management among transgender patients presenting to the emergency department for abdominal pain.

Transgender and gender-diverse (TGD) individuals have a gender identity or expression that differs from the sex assigned to them at birth. They are an underserved population who experience health care inequities. Our primary objective was to identify if there are treatment differences between TGD and cisgender lesbian/gay/bisexual/queer (LGBQ) or heterosexual individuals presenting with abdominal pain to the emergency department (ED). Retrospective observational cohort study of patients ≥12 years of age presenting to 21 EDs within a health care system with a chief complaint of abdominal pain between 2018 and 2022. TGD patients were matched 1:1:1:1 to cisgender LGBQ women and men and cisgender heterosexual women and men, respectively. Propensity score matching covariates included age, ED site, mental health history, and gastrointestinal history. The primary outcome was pain assessment within 60 min of arrival. The secondary outcome was analgesics administered in the ED. We identified 300 TGD patients, of whom 300 TGD patients were successfully matched for a total cohort of 1300 patients. The median (IQR) age was 25 (20-32) years and most patients were treated in a community ED (58.2%). There was no difference between groups in pain assessment within 60 min of arrival (59.0% TGD vs. 63.2% non TGD, p = 0.19). There were no differences in the number of times pain was assessed (median [IQR] 2 [1-3] vs. 2 [1-4], p = 0.31) or the severity of pain between groups (5.5 [4-7] vs. 6 [4-7], p = 0.11). TGD patients were more likely to receive nonsteroidal anti-inflammatory drugs (32.0% vs. 24.9%, p = 0.015) and less likely to receive opioids than non-TGD patients (24.7% vs. 36.9%, p = <0.001). TGD and nonbinary patients, along with LGBQ cisgender women (24.7%) and heterosexual cisgender women (34%), were less likely to receive opioids than LGBQ cisgender men (54%) and heterosexual cisgender men (42.3%, p < 0.01). There was no difference in frequency of pain assessment, regardless of gender identity or sexual orientation. More cisgender men, compared to TGD and cisgender women, received opioids for their pain.

Comparison of symptom clusters between Black and White patients with cancer within an electronic patient-reported outcome remote symptom monitoring program.

328 Background: Disparities in pain management for Black patients with cancer are well-documented, but less is known about other symptom clusters like gastrointestinal (GI), respiratory, and urinary symptoms. This study assessed racial disparities in electronically reported symptom clusters among Black and White patients with cancer enrolled in a Remote Symptom Monitoring (RSM) program. Methods: Patients with cancer at the University of Alabama at Birmingham (UAB) and the Mitchell Cancer Institute (MCI) reported symptoms weekly using the Patient Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAEs). The GI symptom cluster included decreased appetite, nausea, vomiting, constipation, and diarrhea; the respiratory cluster included cough and shortness of breath; the urinary cluster included frequent urinary problems. We assessed the presence of any moderate/severe symptoms or any severe symptoms (triggering a nurse alert) in the clusters. The study evaluated surveys submitted within the first six months after RSM enrollment. Generalized linear mixed effects modeling with random effects adjusting for cancer type, sex, and age were used to calculate the odds of reporting any moderate/severe pain between Black and White patients. Results: Among 1454 patients (31% Black, 69% White), 17,937 surveys were analyzed. The median age for Black patients was 59 (IQR 47-66) and 63 (IQR 54-71) for White patients. Breast cancer was most common in both groups (36% Black, 23% White), followed by gynecological (20% Black, 17% White) and gastrointestinal cancers (19% Black, 18% White). At baseline, both races reported similar proportions of moderate/severe or severe symptom for all clusters (Table). During the first six months in the RSM program, symptom proportions remained similar (Table). These findings were consistent in adjusted analysis for the GI (OR 0.85; 95% CI 0.68-1.07), respiratory (OR 1.18; 95% CI 0.87-1.61), and urinary clusters (OR 0.92; 95% CI 0.61-1.39). Conclusions: Our findings suggest no significant racial disparities in reporting moderate/severe or severe symptoms among Black and White patients with cancer at baseline or within their initial six months in the RSM program across GI, respiratory, and urinary symptom clusters. Survey characteristics. Total Surveys(N=17,937) Baseline Surveys 6 Months Surveys White (n=999) Black(n=455) White(n=11,344) Black(n=5139) Gastrointestinal Symptoms, No. (%) Severe 1376 (8) 121 (12) 59 (13) 783 (7) 413 (8) Moderate/Severe 4701 (26) 300 (30) 130 (29) 2971 (26) 1300 (25) Respiratory Symptoms, No. (%) Severe 438 (2) 28 (3) 29 (6) 241 (2) 140 (3) Moderate/Severe 1612 (9) 90 (9) 62 (14) 996 (8) 464 (9) Urinary Symptoms, No. (%) Severe 333 (2) 31 (3) 13 (3) 184 (2) 105 (2) Moderate/Severe 620 (3) 44 (4) 21 (5) 372 (3) 183 (4)

Financial needs and opioid use among head and neck cancer (HNC) survivors: Baseline findings from the HN-STAR trial (WF-1805CD).

365 Background: HNC survivors often experience post-treatment pain. Given known disparities in pain management and opioid use in the non-cancer population, we explored sociodemographic predictors of opioid use in HNC survivors enrolled in the HN-STAR trial (NCT04208490, funding: American Cancer Society and UG1CA189824). Methods: Survivors of HNC (stages I-III) who completed therapy 6-24 months prior and had no evidence of disease were enrolled throughout the NCI Community Oncology Research Program (NCORP). Survivors were randomized to a clinical informatics intervention or usual care. Baseline surveys elicited recent prescription opioid use in the prior week (yes/no). Blinded to arm assignment, we conducted bivariate analyses of recent opioid use and the following sociodemographic predictors: age, gender, marital status, race and ethnicity (non-white/Latinx vs all others), highest level of education, and being able to meet daily financial needs in the prior 4 weeks. We conducted stepwise multivariable logistic regression to evaluate the association of these factors on opioid use. Results: Among 254 survivors (mean age 63, 74% male, 25% non-white/non-Latinx, 13% reporting financial need) at 25 oncology practices, 14% (n=35) reported recent opioid use. In bivariate analyses, survivors who reported financial needs were more likely to have used opioids (odds ratio [OR] 4.35, 95% confidence interval [CI] 1.85-10.20, p&lt;.001). In stepwise multivariable analyses, only having financial needs remained in the final model (Table). Conclusions: In a national sample of post-treatment HNC survivors during a subacute survivorship period (6-24 months after treatment completion), 1 in 7 survivors reported using opioids in the past week – more than twice the annual rate of opioid receipt in the general adult population. Several demographic factors related to opioid use were examined and not associated with recent opioid use among HNC survivors. Findings suggest that financial concerns may be a barrier to non-narcotic pain management (e.g., cognitive behavioral approaches, physical therapy) – or simply that unmet financial needs are associated with lower quality of pain management. Attention should focus on equitable pain management in this population. Clinical trial information: NCT04208490 . Predictors of opioid use in past week. Bivariate Models Estimate (standard error) p-value Age (years) -.01 (.02) .52 OR (95% CI) p-value Female .98 (.41, 2.16) .97 Latinx/non-white .71 (.27, 1.63) .45 Married .56 (.27, 1.18) .13 Some college or more .62 (.30, 1.30) .20 Had financial needs 4.35 (1.85,10.20) &lt;.001 Final model OR (95% CI) p-value Had financial needs 4.35 (1.85,10.20) &lt;.001

Differences in Acute Postoperative Opioid Use by English Proficiency, Race, and Ethnicity After Total Knee and Hip Arthroplasty.

There is increasing interest in documenting disparities in pain management for racial and ethnic minorities and patients with language barriers. Previous studies have found differential prescription patterns of opioids for racial and ethnic minority group and patients having limited English proficiency (LEP) after arthroplasty. However, there is a knowledge gap regarding how the intersection of these sociodemographic factors is associated with immediate postoperative pain management. This study aimed to explore language and racial-ethnic disparities in short-term opioid utilization after total hip and knee arthroplasty. We conducted a retrospective cohort study of adult patients who underwent total hip and knee arthroplasty from 2015 to 2019 at an urban medical center. The primary predictor variables included LEP status and racial-ethnic category, and the primary outcome variables were oral morphine equivalents (OMEs) during 2 distinct postoperative periods: the first 12 hours after surgery and from the end of surgery to the end of postoperative day (POD) 1. Patient characteristics and perioperative metrics were described by language status, race, and ethnicity using nonparametric tests, as appropriate. We performed an adjusted generalized estimating equation to assess the total effect of the intersection of LEP and racial-ethnic categories on short-term postoperative opioid use in mean ratios (MRs). This study included a total of 4090 observations, in which 7.9% (323) patients had LEP. Patients reported various racial-ethnic categories, with 72.7% (2975) non-Hispanic White, and minority groups including non-Hispanic Asian and Pacific Islander (AAPI), Hispanic/Latinx, non-Hispanic Black/African American, and Others. Patients self-identifying as non-Hispanic AAPI received fewer OME regardless of LEP status during the first 12 hours postoperatively (MR for English proficient [EP], 0.12 [95% confidence interval, CI, 0.08-0.18]; MR for LEP, 0.22 [95% CI, 0.13-0.37]) and from end of surgery to the end of POD 1 (MR for EP, 0.24 [95% CI, 0.16-0.37]; MR for LEP, 0.42, [95% CI, 0.24-0.73]) than EP non-Hispanic White. Hispanic/Latinx patients with LEP received lower amounts of OME during the first postoperative 12 hours (MR, 0.29; 95% CI, 0.17-0.53) and from end of surgery to the end of POD 1 (MR, 0.42; 95% CI 0.23-0.79) than EP non-Hispanic White. Furthermore, within the non-Hispanic White group, those with LEP received fewer OME within the first 12 hours (MR, 0.33; 95% CI, 0.13-0.83). We identified an association between LEP, racial-ethnic identity, and short-term postoperative OME utilization after total knee and hip arthroplasty. The observed differences in opioid utilization imply there may be language and racial-ethnic disparities in acute pain management and perioperative care.

Health inequities, bias, and artificial intelligence

Musculoskeletal (MSK) pain leads to significant healthcare utilization, decreased productivity, and disability globally. Due to its complex etiology, MSK pain is often chronic and challenging to manage effectively. Disparities in pain management - influenced by provider implicit biases and patient race, gender, age, and socioeconomic status - contribute to inconsistent outcomes. Interventional radiology (IR) provides innovative solutions for MSK pain through minimally invasive procedures, which can alleviate symptoms and reduce reliance on opioids. However, IR services may be underutilized, especially due to current treatment paradigms, referral patterns, and in areas with limited access to care. Artificial intelligence (AI) presents a promising avenue to address these inequities by analyzing large datasets to identify disparities in pain management, recognizing implicit biases, improving cultural competence, and enhancing pain assessment through multimodal data analysis. Additionally, patients who may benefit from an IR pain procedure for their MSK pain may then receive more information through their providers after being identified as a candidate by AI sifting through the electronic medical record. By leveraging AI, healthcare providers can potentially mitigate their biases while ensuring more equitable pain management and better overall outcomes for patients.

Unraveling the Tapestry of Pain: A Comprehensive Review of Ethnic Variations, Cultural Influences, and Physiological Mechanisms in Pain Management and Perception.

The medical management of pain is a nuanced challenge influenced by sociocultural, demographic, and ethical factors. This review explores the intricate interplay of these dimensions in shaping pain perception and treatment outcomes. Sociocultural elements, encompassing cultural beliefs, language, societal norms, and healing practices, significantly impact individuals' pain experiences across societies. Gender expectations further shape these experiences, influencing reporting and responses. Patient implications highlight age-related and socioeconomic disparities in pain experiences, particularly among the elderly, with challenges in managing chronic pain and socioeconomic factors affecting access to care. Healthcare provider attitudes and biases contribute to disparities in pain management across racial and ethnic groups. Ethical considerations, especially in opioid use, raise concerns about subjective judgments and potential misuse. The evolving landscape of placebo trials adds complexity, emphasizing the importance of understanding psychological and cultural factors. In conclusion, evidence-based guidelines, multidisciplinary approaches, and tailored interventions are crucial for effective pain management. By acknowledging diverse influences on pain experiences, clinicians can provide personalized care, dismantle systemic barriers, and contribute to closing knowledge gaps, impacting individual and public health, well-being, and overall quality of life.

Reducing Disparities in Pain Management in Primary Care

Pain is a healthcare challenge impacting millions of people in the US. On average, 50 million people live with chronic pain in the US. Reducing disparities in pain management is important. Pain has a devastating impact on patients, affecting physical and mental functioning. It also affects patients’ quality of life. Patients who experience pain report limitations in doing activities, restriction on mobility, lost work productivity, higher anxiety levels, depression, increased suicidal risk, and more likelihood of abusing and misusing substances. Racial and gender disparities have been reported in managing pain in primary care. African Americans, Hispanics, and other racial minorities report poor management of pain than whites. Socioeconomic factors also contribute to pain disparities. Being less educated, having lower income levels, lower levels of education, and lacking medical insurance have been associated with poor management of pain. Addressing these disparities can improve pain outcomes. Improving patient-provider communication, making systematic and structural changes, shared-decision making, using a multi-disciplinary approach, and tailoring pain management approaches to specific patient needs are some of the measures that can reduce disparities in managing pain.

Unintended Consequences of Opioid Policy on Disparities in Pain Management for Older Adults with Serious Illness

Unintended Consequences of Opioid Policy on Disparities in Pain Management for Older Adults with Serious Illness

Exploring the relationship between language, postoperative pain, and opioid use

Racial and ethnic disparities in pain management are well documented. Differences in pain assessment and management by language have not been studied in the postoperative setting in gynecologic surgery. This study aimed to investigate the association between language and immediate postoperative pain management by comparing pain assessments and perioperative opioid use in non-English speakers and English speakers. This was a retrospective cohort study comparing perioperative outcomes between non-English-speaking patients and English-speaking patients who had undergone a gynecologic oncology open surgery between July 2012 and December 2020. The primary language was extracted from the electronic medical record. Opioid use is expressed in oral morphine equivalents. Proportions are compared using chi-square tests, and mean values are compared using 2-sample t tests. Although interpreter services are widely available in our institution, the use of interpreters for any given inpatient-provider interaction is not documented. Between 2012 and 2020, 1203 gynecologic oncology patients underwent open surgery, of whom 181 (15.1%) were non-English speakers and 1018 (84.9%) were English speakers. There was no difference between the 2 cohorts concerning body mass index, surgical risk score, or preoperative opioid use. Compared with the English-speaking group, the non-English-speaking group was younger (57 vs 54 years old, respectively; P<.01) and had lower rates of depression (26% vs 14%, respectively; P<.01) and chronic pain (13% vs 6%, respectively; P<.01). Although non-English-speaking patients had higher rates of hysterectomy than English-speaking patients (80% vs 72%, respectively; P=.03), there was no difference in the rates of bowel resections, adnexal surgeries, lengths of surgery, intraoperative oral morphine equivalents administered, blood loss, use of opioid-sparing modalities, lengths of hospital stay, or intensive care unit admissions. In the postoperative period, compared with English-speaking patients, non-English-speaking patients received fewer oral morphine equivalents per day (31.7 vs 43.9 oral morphine equivalents, respectively; P<.01) and had their pain assessed less frequently (7.7 vs 8.8 checks per day, respectively; P<.01) postoperatively. English-speaking patients received a median of 19.5 more units of oral morphine equivalents daily in the hospital and 205.1 more units of oral morphine equivalents at the time of discharge (P=.02 and P=.04, respectively) than non-English-speaking patients. When controlling for differences between groups and several factors that may influence oral morphine equivalent use, English-speaking patients received a median of 15.9 more units of oral morphine equivalents daily in the hospital cohort and similar oral morphine equivalents at the time of discharge compared with non-English-speaking patients. Patients who do not speak English may be at risk of undertreated pain in the immediate postoperative setting. Language barrier, frequency of pain assessments, and provider bias may perpetuate disparity in pain management. Based on this study's findings, we advocate for the use of regular verbal pain assessments with language-concordant staff or medical interpreters for all postoperative patients.

Racial Bias in Pain Measurement Frequency in ICU and its Impact on Early Readmission

A significant portion of hospitalizations result in readmissions, many of which are preventable. Additionally, over a quarter of admissions necessitate intensive care unit (ICU) stays. These trends impose significant strain on healthcare systems, leading to penalties and reduced reimbursements for healthcare facilities. Consequently, reducing readmissions stands as a critical priority for healthcare institutions, with a specific focus on ICU processes and procedures. While some healthcare processes, such as vital sign monitoring, are consistent across patient cohorts, disparities in pain management have been well-documented. Existing research predominantly explores biases in outpatient settings, particularly in the underestimation and undertreatment of pain for Black patients. However, these biases can extend to the frequency of pain measurements in ICUs, where continuous monitoring plays a pivotal role in patient care. This study investigates disparities in pain measurement frequencies in ICUs for patients of different races and their impact on early readmission rates. Utilizing a dataset of ICU stays from a major U.S. healthcare institution, we employ mediation analysis with instrumental variables by performing a two-step mediation analysis using an IV-Probit estimator to answer these research questions. Our findings reveal that the frequency of pain measurements in the ICU stays partially mediates the relationship between a patient's race and the probability of early readmission. Specifically, Black patients receive fewer pain measurements during their ICU stays compared to White patients, increasing their likelihood of 30-day readmission. This study represents the first to demonstrate that bias in pain management extends to the frequency of pain measurements in intensive care settings, shedding light on a critical aspect of healthcare disparities and their impact on readmission rates. The implications of our findings span healthcare practice, operations, and the growing body of literature on healthcare equity, offering valuable insights into addressing these disparities.

Cultural variability in pain perception: A review of cross-cultural studies

Pain perception is a complex phenomenon influenced by biological, psychological, and socio-cultural factors. This review presents a review of cross-cultural studies investigating the cultural variability in pain perception. Understanding how different cultures experience and express pain is crucial for providing effective healthcare interventions and improving patient outcomes. Cross-cultural research reveals significant variations in pain perception across different cultural groups. Cultural beliefs, values, and practices shape individuals' interpretation and expression of pain. Studies have shown that cultural norms dictate whether individuals express pain openly or suppress it, impacting their willingness to seek medical help and their response to pain management strategies. Furthermore, cultural differences in pain expression extend to non-verbal cues and pain-related behaviors. For instance, some cultures may perceive stoicism as a virtue, leading individuals to underreport their pain levels, while others may encourage vocal expressions of pain. These cultural nuances influence healthcare professionals' interpretation of patients' pain experiences and may lead to disparities in pain assessment and treatment. Moreover, cultural factors interact with biological mechanisms to modulate pain perception. Genetic predispositions and physiological differences contribute to variations in pain sensitivity among different ethnic groups. However, cultural factors such as coping mechanisms, social support networks, and cultural rituals also play a significant role in shaping individuals' pain experiences. The impact of culture on pain perception extends beyond individual differences to influence healthcare systems and policies. Cultural competency training for healthcare providers is essential to address disparities in pain management and ensure culturally sensitive care. Additionally, integrating cultural factors into pain assessment tools and treatment protocols can improve the accuracy of pain assessment and enhance patient care outcomes. Cultural variability significantly influences pain perception, expression, and management. Cross-cultural studies provide valuable insights into the complex interplay between culture, biology, and socio-cultural factors in shaping individuals' experiences of pain. Recognizing and addressing cultural differences in pain perception is essential for delivering equitable and effective healthcare services worldwide.

Differences in Pain Experience Among Different Racial and Ethnic Groups.

The objective of this study was to examine the role of pain catastrophizing and pain self-efficacy as possible mediators of race-based differences in pain intensity, and to evaluate the possible moderating role of race on the relationship between pain catastrophizing and pain self-efficacy with pain outcomes among persons with chronic spinal pain receiving physical therapy. This study was a secondary analysis of a cluster-randomized trial. Participants were persons with chronic spinal pain in outpatient physical therapy clinics who consented to complete assessments at baseline and after 2weeks and 12weeks. Assessments included pain intensity, physical function, pain catastrophizing, and self-efficacy. Baseline comparisons between Black and non-Hispanic White participants were made. Mediation analyses used a regression-based framework to examine whether baseline pain catastrophizing and self-efficacy mediated the association between race and pain intensity. Moderation analyses used multiple linear regression to evaluate the role of race in the relationship of baseline pain catastrophizing and self-efficacy with 12-week pain intensity outcomes. A total of 274 participants were included (51 [18.6%] Black and 223 [81.4%] non-Hispanic White; mean age = 51.6years [SD = 14.9]; 180 [65.7%] female). At baseline, Black participants had higher pain intensity scores (mean difference = 0.80; 95% CI = 1.5 to 0.12). Both pain catastrophizing and self-efficacy mediated the relationship between race and baseline pain intensity. Race moderated the relationships between baseline pain catastrophizing and self-efficacy and 12-week pain intensity scores. Pain catastrophizing and self-efficacy had differential impacts on pain intensity based on race for both cross-sectional and longitudinal analyses among persons receiving physical therapy for chronic spinal pain. Improved understanding of the differences in pain experience based on factors such as race, ethnicity, cultural background, and experience with the health care system may help reduce disparities in pain management.

Telehealth delivery of physical therapist-led interventions for persons with chronic low back pain in underserved communities: lessons from pragmatic clinical trials.

In this perspective, we present our experience developing and conducting two pragmatic clinical trials investigating physical therapist-led telehealth strategies for persons with chronic low back pain. Both trials, the BeatPain Utah and AIM-Back trials, are part of pragmatic clinical trial collaboratories and are being conducted with persons from communities that experience pain management disparities. Practice guidelines recommend nonpharmacologic care, and advise against opioid therapy, for the primary care management of persons with chronic low back pain. Gaps between these recommendations and actual practice patterns are pervasive, particularly for persons from racial or ethnic minoritized communities, those with fewer economic resources, and those living in rural areas including Veterans. Access barriers to evidence-based nonpharmacologic care, which is often provided by physical therapists, have contributed to these evidence-practice gaps. Telehealth delivery has created new opportunities to overcome access barriers for nonpharmacologic pain care. As a relatively new delivery mode however, telehealth delivery of physical therapy comes with additional challenges related to technology, intervention adaptations and cultural competence. The purpose of this article is to describe the challenges encountered when implementing telehealth physical therapy programs for persons with chronic low back pain in historically underserved communities. We also discuss strategies developed to overcome barriers in an effort to improve access to telehealth physical therapy and reduce pain management disparities. Inclusion of diverse and under-represented communities in pragmatic clinical trials is a critical consideration for improving disparities, but the unique circumstances present in these communities must be considered when developing implementation strategies.

DISPARITIES AND TRENDS IN COMPREHENSIVE PAIN MANAGEMENT AMONG THE ADULT POPULATION IN THE POST-OPIOID EPIDEMIC

Abstract Introduction Chronic pain is an epidemic, but there are various therapies that are effective at treating it. Disparities in access to chronic back pain management are well documented. However, studies have largely focused on the gap in utilization between Black and White patients, and on the use opioid therapies. The extent of disparities in utilization for other groups and how disparities by demographics interact with socioeconomic characteristics, are unclear. Methods Using insurance claims from Optum Data, we identified patients who had chronic low back pain between 2010- 2020. We measured trends in pharmacological and nonpharmacological therapies, disaggregating measures by sex, age, race/ethnicity, educational attainment, income, and parenthood. We estimated linear probability models to understand which demographic and socioeconomic characteristics were most predictive of utilization. Results There were large differences in the utilization of pharmacological and nonpharmacological pain care, with surprising findings. First, we found that Black patients were the most likely to be prescribed opioids, as well gabapentin, muscle relaxers, and NSAIDs, followed by White patients, Hispanics; Asians were the least likely to engage in pharmacological therapy. Linear probability models indicated that the largest predictor of pharmacological and nonpharmacological pain management was education and income. Discussion We document disparities in pain management, which point to important policy implications. Preferences of pain management warrant further attention, as our findings suggest that income and education are the largest driver. It could be that the time and out-of-pocket costs associated with nonpharmacological pain management reduce the likelihood that patients opt for these therapies.

Racial disparities in pain management: Historical maleficence and solutions for equity.

Medical journals from the 1800s described differences in disease susceptibility, skin thickness, and pain tolerance among races. These misconceptions about biologic differences, the historical exploitation of minorities in research, and implicit biases among healthcare workers have all affected patient care. Discrepancies still exist in pain assessment and management for minority patients compared with their White counterparts and lead to poor health outcomes. By implementing specific changes in policy and practice, including standardization, implicit bias training, and building a diverse workforce, clinicians can begin to provide care that more equitably manages pain for all patients, regardless of race.

Race and Ethnicity and Prehospital Use of Opioid or Ketamine Analgesia in Acute Traumatic Injury

Racial and ethnic disparities in pain management have been characterized in many hospital-based settings. Painful traumatic injuries are a common reason for 911 activations of the EMS (emergency medical services) system. To evaluate whether, among patients treated by EMS with traumatic injuries, race and ethnicity are associated with either disparate recording of pain scores or disparate administration of analgesia when a high pain score is recorded. This cohort study included interactions from 2019 to 2021 for US patients ages 14 to 99 years who had experienced painful acute traumatic injuries and were treated and transported by an advanced life support unit following the activation of the 911 EMS system. The data were analyzed in January 2023. Acute painful traumatic injuries including burns. Outcomes were the recording of a pain score and the administration of a nonoral opioid or ketamine. The study cohort included 4 781 396 EMS activations for acute traumatic injury, with a median (IQR) patient age of 59 (35-78) years (2 497 053 female [52.2%]; 31 266 American Indian or Alaskan Native [0.7%]; 59 713 Asian [1.2%]; 742 931 Black [15.5%], 411 934 Hispanic or Latino [8.6%], 10 747 Native Hawaiian or other Pacific Islander [0.2%]; 2 764 499 White [57.8%]; 16 161 multiple races [0.3%]). The analysis showed that race and ethnicity was associated with the likelihood of having a pain score recorded. Compared with White patients, American Indian and Alaskan Native patients had the lowest adjusted odds ratio (AOR) of having a pain score recorded (AOR, 0.74; 95% CI, 0.71-0.76). Among patients for whom a high pain score was recorded (between 7 and 10 out of 10), Black patients were about half as likely to receive opioid or ketamine analgesia as White patients (AOR, 0.53; 95% CI, 0.52-0.54) despite having a pain score recorded almost as frequently as White patients. In this nationwide study of patients treated by EMS for acute traumatic injuries, patients from racial or ethnic minority groups were less likely to have a pain score recorded, with Native American and Alaskan Natives the least likely to have a pain score recorded. Among patients with a high pain score, patients from racial and ethnic minority groups were also significantly less likely to receive opioid or ketamine analgesia treatment, with Black patients having the lowest adjusted odds of receiving these treatments.

Racial and Ethnic Disparities in Inpatient Interventional Pain Management for Lumbar Radiculopathy

BACKGROUND: Chronic pain is a common reason adults seek care; patients often feel that their pain is inadequately managed. Spine-related pain is the most common chronic pain concern, and lumbar radiculopathy is often the cause. Racial and ethnic disparities in the pharmacologic management of pain are well described, but less is known about these disparities regarding interventional procedures. OBJECTIVE: To study the utilization rates of physical therapy, epidural steroid injection, surgery, and spinal cord stimulation in hospitalized patients with lumbar radiculopathy across different races, ethnicities, and genders. STUDY DESIGN: A retrospective cross-sectional study design. METHODS: The National Inpatient Sample was used to identify 252,790 patients with lumbar radiculopathy, after sample weighting, from 2016-2019. Independent variables were race, ethnicity, age, gender, insurance, geography, year, and severity. Dependent variables were physical therapy, epidural steroid injection, spinal cord stimulator, or surgery (reference group). Conservative management was defined as nonoperative treatment ranging from physical therapy to epidural steroid injection. Data were analyzed with a logistic regression for complex surveys. Regressions were adjusted for age, insurance, geography, and other socioeconomic factors. RESULTS: Most patients were white (78.3%) and received surgery (95.0%). Severe disease was most common among African Americans (9.3%), but was similar across other races, ethnicities, and genders. Medicaid was more common among African Americans and Hispanics. An adjusted analysis showed that African Americans and Hispanics received more epidural steroid injections (odds ratio [OR] = 1.52; 95%CI, 1.3 – 1.8) and (OR = 1.43; 95%CI, 1.1 – 1.8) respectively; and physical therapy (OR = 1.65; 95%CI, 1.1 – 2.5) and (OR = 1.83; 95%CI, 1.2 – 2.8) respectively, than whites compared to surgery. African Americans received a spinal cord stimulator less often than whites compared to surgery (OR = 0.63; 95%CI. 0.4 – 0.9). Women received an epidural steroid injection more frequently than men compared to surgery (OR = 1.29; 95%CI, 1.2 – 1.4). LIMITATIONS: Generalizability is limited because conservative therapies are often outpatient treatments. CONCLUSION: Disparities were observed in lumbar radiculopathy treatment after independent variable adjustment. African Americans received conservative therapy more often than whites despite increased disease severity. Hispanics and women had similar disease severity compared to whites and men, respectively, but received more conservative therapies. Further investigation in outpatient settings is needed to definitively describe these disparities. KEY WORDS: Chronic pain, pain management, back pain, lumbar radiculopathy, epidural steroid injection, spinal cord stimulation, low back surgery, physical therapy, racial disparities, gender disparities

From Awareness to Action: Pathways to Equity in Pain Management.

This commentary calls for a shift in the identification, analysis, and treatment of disparities in pain management. We provide context and research that summarize social and structural determinants that contribute to disparities across multiple levels of the pain management continuum. Informed by the evidence, we provide guideposts for mitigating disparities in the assessment, diagnosis, and care provided to those experiencing pain, with a focus on highlighting the specific needs of marginalized communities and the importance of culturally appropriate and context-specific approaches to pain management. This commentary informs efforts to promote equity by identifying areas of concern, guiding interventions, and advocating for policies that aim to eliminate disparities in pain treatment. Researchers, health care providers, and organizations can collectively work to provide equitable culturally sensitive pain management and improve overall patient outcomes.

SIO-ASCO guideline on integrative medicine for cancer pain management: implications for racial and ethnic pain disparities.

Racial and ethnic disparities in pain management pose major challenges to equitable cancer care delivery. These disparities are driven by complex interactions between patient-, provider-, and system-related factors that resist reductionistic solutions and require innovative, holistic approaches. On September 19, 2022, the Society for Integrative Oncology and the American Society of Clinical Oncology published a joint guideline to provide evidence-based recommendations on integrative medicine for cancer pain management. Integrative medicine, which combines conventional treatments with complementary modalities from cultures and traditions around the world, are uniquely equipped to resonate with diverse cancer populations and fill existing gaps in pain management. Although some complementary modalities, such as music therapy and yoga, lack sufficient evidence to make a specific recommendation, other modalities, such as acupuncture, massage, and hypnosis, demonstrated an intermediate level of evidence, resulting in moderate strength recommendations for their use in cancer pain management. However, several factors may hinder real-world implementation of the Society for Integrative Oncology and the American Society of Clinical Oncology guideline and must be addressed to ensure equitable pain management for all communities. These barriers include, but are not limited to, the lack of insurance coverage for many complementary therapies, the limited diversity and availability of complementary therapy providers, the negative social norms surrounding complementary therapies, the underrepresentation of racial and ethnic subgroups in the clinical research of complementary therapies, and the paucity of culturally attuned interventions tailored to diverse individuals. This commentary examines both the challenges and the opportunities for addressing racial and ethnic disparities in cancer pain management through integrative medicine.