Disparities In Pain Management Research Articles

End-of-life care in nursing home settings: Do race or age matter?

One-quarter of all U.S. chronic-disease deaths occur in nursing homes, yet few studies examine palliative care quality in these settings. This study tests whether racial and/or age-based differences in end-of-life care exist in these institutional settings. We abstracted residents' charts (N = 1133) in 12 nursing homes. Researchers collected data on indicators of palliative care in two domains of care--advance care planning and pain management--and on residents' demographic and health status variables. Analyses tested for differences by race and age. White residents were more likely than minorities to have DNR orders (69.5% vs. 37.3%), living wills (39% vs. 5%), and health care proxies (36.2% vs. 11.8%; p < .001 for each). Advance directives were highly and positively correlated with age. In-depth advance care planning discussions between residents, families, and health care providers were rare for all residents, irrespective of demographic characteristics. Nursing staff considered older residents to have milder and less frequent pain than younger residents. We found no disparities in pain management based on race. To the extent that advance care planning improves care at the end of life, racial minorities in nursing homes are disadvantaged compared to their white fellow residents. Focusing on in-depth discussions of values and goals of care can improve palliative care for all residents and may help to ameliorate racial disparities in end-of-life care. Staff should consider residents of all ages as appropriate recipients of advance care planning efforts and should be cognizant of the fact that individuals of all ages can experience pain. Nursing homes may do a better job than other health care institutions in eliminating racial disparities in pain management.

Disparities in Pain Management Between Cognitively Intact and Cognitively Impaired Nursing Home Residents

This study tests the association between residents' cognitive impairment and nursing homes' pain management practices. We used chart abstraction to collect data on 551 adults in six North Carolina nursing homes. From the standard data collected in the Minimum Data Set, 24% of residents experienced pain in the preceding week. Reports of pain decreased as cognitive abilities declined: nurses completing the Minimum Data Set reported pain prevalence of 34%, 31%, 24%, and 10%, respectively, for residents with no, mild, moderate, and severe cognitive impairment ( P < 0.001), demonstrating a “dose-response”-type result. Eighty percent of cognitively intact residents received pain medications, compared to 56% of residents with severe impairment ( P < 0.001). Cognitively impaired residents had fewer orders for scheduled pain medications than did their less cognitively impaired peers. Yet the presence of diagnoses likely to cause pain did not vary based on residents' cognitive status. We conclude that pain is underrecognized in nursing home residents with cognitive impairment and that cognitively impaired residents often have orders for “as needed” analgesics when scheduled medications would be more appropriate.

Racial disparities in pain management in the USA

In the USA, patients with cancer from ethnic minorities face substantial disparities in the way their pain is treated, according to two studies published at the end of 2007. The first study showed that race is a risk factor for pain in women with metastatic breast cancer (Cancer 2008; 112: 162–70). “We found that non-Caucasian women had significantly higher hazards over a year for severe pain; the adequacy of their pain management should be investigated as a potential cause”, says lead author Liana Castel (University of North Carolina, Chapel Hill, NC, USA). Secondary analysis of data from several assessments of postoperative patients, done by Jeanette McNeill (University of Texas School of Nursing, Houston, TX, USA), showed disparity in postoperative pain management of non-white patients with acute pain, including cancer pain, which adversely affects treatment outcomes (Oncol Nurs Forum 2007; 34: 1121–28).

Racial and Ethnic Disparities in Pain Management in the United States

To critically examine research on racial and ethnic disparities in pain management with a focus on who has been studied, the magnitude of disparities, and potential explanations for those disparities. A systematic literature review. Articles included were reports of original research in which at least two racial or ethnic groups were compared on adequacy of pain management. Review of research articles published between 1990 and 2004 with the primary aim of identifying the influence of race or ethnicity on pain management in the US. Databases were CINAHL, Medline, and Pubmed. Relevant articles were categorized by pain type. Effect sizes were calculated where sufficient data were provided. Studies were focused on Blacks or African Americans, Whites or non-Hispanic Whites, Hispanics, and Asians. Terms for describing these groups were neither well defined nor consistently used within and across studies. Disparities in pain management were reported in relation to minority status, but the magnitudes of these disparities were mostly small. Greater clarity and consistency are needed in the use of the terms race, ethnicity, and minority. Groups were treated as if they were homogeneous, and details were lacking about whether subgroups of different races or ethnicities had been studied. Although reported disparities in pain management were small, they were consistent. Further research is needed to examine differences within groups and to explain possible reasons for disparities across groups.

Pain and Aging: A Call to Those with the Power of Inquiry, the Skills to Teach, and the Desire to Heal

Unlike other medical specialties, geriatric medicine arose not from a unique body of knowledge, but because of the need for one. This “development out of necessity” principle also applies to the field of pain and aging, which is still in its infancy. Geriatrics practitioners have long realized the challenges of treating pain in older adults imposed by their tremendous physical and cognitive heterogeneity. In response to this realization, some have established successful multidisciplinary pain management clinics for older patients [1,2]. Others have highlighted the age-related pain management disparities that exist in multiple settings of care (e.g., emergency rooms, hospitals, outpatient clinics, and long-term care facilities) across multiple disciplines (e.g., physicians and nurses), and for multiple pain disorders (e.g., acute and chronic pain, malignant and nonmalignant pain), so as to spur practitioners into action [3–11]. The American Geriatrics Society has published comprehensive pain management guidelines to help practitioners navigate the sometimes murky waters of pain management for older adults [12]. Practitioners have established the need to advance …

Psychological Approaches to Understanding and Treating Disease-Related Pain

Psychologists are increasingly involved in the assessment and treatment of disease-related pain such as pain secondary to arthritis or cancer. This review is divided into four sections. In the first section, we provide a conceptual background on this area that discusses the limitations of the biomedical model of disease-related pain and traces the evolution of psychosocial theories of pain. In the second section, we discuss special issues and challenges involved in working with persons having disease-related pain, including the reluctance of some persons to report pain and to become involved in psychological treatments for pain. Section three provides an overview of psychosocial research conducted on arthritis pain and cancer pain that addresses both psychosocial factors related to pain and psychosocial interventions for pain management. In the final section, we describe important future directions, including strategies for disseminating psychosocial treatments and disparities in pain management.

Leveling the Playing Field: Recognizing and Rectifying Disparities in Management of Pain

Fifty to seventy percent of primary care visits have a complaint of pain. Between 3.5 and 6 million patients with cancer experience pain. Over 23 million surgical patients will experience pain. And 53 million people in the United States will have pain due to injury. How pain is managed differs among segments of the population. People at particular risk of receiving inadequate management of pain include children, the elderly, people with a history of substance abuse, the mentally ill, women, minorities, and people of color. Pain has been undertreated, undermanaged, improperly assessed, and inadequately taught in our health professions schools. This issue of Pain Medicine is devoted to research on the issues of disparities in health status and delivery of health services for the poor, minority citizens, and segments of the population who are at risk for suboptimal access to healthcare and effective treatment. Our nation has achieved a remarkable improvement in life expectancy of its citizens during the 20th century. An infant born in 1900 had a life expectancy of 47 years. Among the major causes of death at that time were conditions such as pneumonia, diphtheria, tuberculosis, gastrointestinal infections, childhood communicable diseases, and vitamin deficiency disorders [1]. One hundred years later, the life expectancy of an infant born today in the United States is approximately 77 years, representing almost a doubling of life expectancy in our nation during the 20th century [2]. This is due to better nutrition, safer drinking water and improved sanitation, childhood immunizations, development of antibiotics, other antimicrobials, and other advances in health sciences. Advances in global longevity have occurred more in the past 40 years than in the previous 4000 years [3]. Improvements in public health and in medicine have greatly enhanced the lives of Americans during the …