Why Black Elders Experience More Pain and Less Pain Relief

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Why Black Elders Experience More Pain and Less
Pain Relief

• Carmen R. Green, M.D.
• Associate Professor of Anesthesiology
• National Press Foundation
• May 2005

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Life Expectancy at Birth in Yearsby Race and
Sex 2000
All Races
Black
White
Both Sexes Men Women
76.9 74.1 79.5
77.4 74.8 80.0
71.7 68.2 74.9
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Mortality Rates Significantly Higher for Some
Minorities, At All Ages
NOTE These data compare the mortality rate of
each ethnic group to that of Asian/Pacific
Islanders, the group with the lowest mortality
rates at each age. DATA National Center for
Health Statistics, National Vital Statistics
System. SOURCE National Vital Statistics Report,
Vol. 50, No. 15, September 16, 2002.
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Minorities are Much More Likely to Report Poor
Health
DATA National Center for Health Statistics,
National Health Interview Survey, 2000. SOURCE
Health, United States, 2003, Table 59.
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Adjusted Medicaid Managed Care Monthly Payment
Rates and Comparison to the National Median
Payment Rate, 2001
Adjusted MMC Rate
Above U.S. 50th Percentile
State
North Dakota . . . . U.S. 50th Percentile . . . .
. Texas Oklahoma Michigan
209.34 . . . . 150.60 . . . . . 127.63 118.32
105.35
39 . . . . - . . . . . -15 -21 -30
Source The Urban Institute, John Holahan and
Shinobu Suzuki, Medicaid Managed Care Payment
Methods and Capitation Rates in 2001, Results of
a New National Survey, March 31, 2003, at
http//www.urban.org/urlprint.cfm?ID-8357.
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Special Article

• The Effect of Race and Sex on Physicians
  Recommendations for Cardiac Catheterization
• New England Journal of Medicine 19973371209-14
• Kevin A. Schulman, M.D. et.al Jesse A. Berlin,
  Sc.D. William Harless, Ph.D. Jon Fl Kerner,
  Ph.D. Shyrl Sistrunk, M.D. Bernard J. Gersh,
  M.B., Ch.B., D. Phil. Ross Dube Christopher K.
  Taleghani, M.D. Jennifer E. Burke, M.A., M.S.
  Sankey Williams, M.D. John M. Eisenberg, M.D.
  and Jose J. Escarce, M.D., Ph.D.

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Institute of Medicine
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Institute of Medicine Report Findings

• Racial and ethnic disparities in healthcare occur
  in the context of broader historic and
  contemporary social and economic inequality.
• Racial and ethnic disparities in healthcare exist
  and, because they are associated with worse
  outcomes in many cases, are unacceptable.

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Bipartisan responses

• Racial and ethnic disparities in health care are
  unacceptable in a country that values equality
  and equal opportunity for all. And that is why
  we must act now with a comprehensive initiative
  that focuses on health care and prevention for
  racial and ethnic minorities.
• President Bill Clinton
• These gaps are simply unacceptable in America.
  Turning our back on these health disparity
  problems would be a national failure.
• Senate Majority Leader, Senator Bill Frist, MD

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Many Americans Suffer from Chronic Pain

• 86 million Americans suffer from chronic pain1
• 66 million are partially or totally disabled1
• Major reason for health care utilization
• 8 million are permanently disabled by back pain2
• There are 65,000 new cases of permanent
  disability diagnosed each year2
• Women, minorities, and elderly are at risk for
  under-treatment of pain

1 Medical Data International, Report 1620, Pain
Management Products. 2 Medical Data
International, op cit.
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Chronic Pain is Expensive

• Chronic pain disables more people than cancer or
  heart disease and costs the American people more
  than both combined.
• Pain problems cost 70 billion a year in medical
  costs, lost working days, and workers
  compensation.
• Major reason for health care utilization and
  disability
• Physician variability in pain management decision
  making

J. Bonica, International Association for the
Study of Pain (IASP)
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Pain Assessment Treatment

• Race and Ethnicity
• Ethnic minority patients have less access to pain
  management Cleeland 1998
• Ethnic minority patients are less likely to have
  pain recorded Bernabei 1998
• Ethnic minority patients receive less medication
  Edwards 1999
• Ethnic minority patients are at risk for
  under-treatment Anderson 2002, Cleeland 1997

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Pain Assessment Treatment

• Gender
• Gender differences exist in the prevalence of
  many chronic pain conditions, LeResche 1995
• Prevalence varies by stage in the life cycle,
  Riley 1998, Buckelew 1990, Lavolis 1984
• Women have an increased prevalence of chronic
  pain conditions, Rollman 2001, LeResche 1999
• Gender differences in pain symptoms, Jadelson
  1999
• Gender differences in response to analgesics,
  Kest 2000, Sarton 2000, Gear, Miaskowski 1996

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Pain Assessment Treatment

• Aging
• Prevalence of pain will increase with aging
• Accelerated aging is noted in racial and ethnic
  minorities
• Older patients are less likely to receive
  adequate analgesic treatment Cleeland 1996,
  Bernabei 1998
• High correlation between depression and pain Roy
  1987, von Korff 1996

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Are there racial, ethnic or gender differences in
the health of patients with chronic
pain? Supported by the Michigan Center for Urban
African American Aging Research
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Physical Health
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Pain Score at Present
Plt0.05


Ylt50 Ogt50
PAIN SCORE
0 NONE, 6 EXTREME
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Pain Severity via McGill Pain Questionnaire



Ylt50 Ogt50

Plt0.05
Pain Rating Index
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Comparing African Americans to Caucasian Americans
PDI Subscores
0 No, 10 Maximum
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Emotional and Social Health
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Depression and PTSD
plt0.05




Ylt50 Ogt50
BDI
PTSD
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Suffering Due to Painvia WHYMPI

Plt0.05

Ylt50 Ogt50
Suffering
0 None, 6 Extreme
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What about coping?
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Control Over Pain and Coping
plt0.05
Ylt50 Ogt50


Control
Coping
0 None, 6 Great deal
0 No success, 6 Extremely successful
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Answer African Americans with chronic pain
present with more impairment in their overall
health than Caucasian Americans with chronic pain
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What impact does pain have on QOL?
Supported by Michigan Center for Urban African
American Aging Research Hartford Foundation
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Mean Health Survey Short Form (SF-36) Subscores
by Race
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Question Are there differences in the attitudes
of African and Caucasian Americans regarding pain?
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Health Care Utilization Among African and
Caucasian Americans

• Survey study of 286 patients receiving treatment
  in a tertiary care pain center
• Caucasian Americans (n136)
• African Americans (n101)
• Caveats
• less income and education for African Americans

plt0.05


Green 2004 JNMA
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Pain Medications Cannot Really Control Pain by
Ethnicity and Gender
Female African Americans
Female Caucasian Americans
Male African Americans
Male Caucasian Americans
Frequency
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Good Patients Avoid Talking About Painby
Ethnicity and Gender
Female African Americans
Female Caucasian Americans
Male African Americans
Male Caucasian Americans
Frequency
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Health Care Access and Utilization
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Gender Affects Access to Pain Treatment
Frequency
Response
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Ethnicity/Culture Affects Access to Health Care
Frequency
Response
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Answer

• There are differences in attitudes and
  perceptions regarding health and pain based upon
  race and gender.

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Does physician pain management decision-making
vary based upon patient demographics?
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Goals for Pain Relief by Type of Pain
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Distribution of Physician Responses to Cancer
Vignettes
Worst Discharge him home on his previous home
regimen Poor Add oxycodone and acetaminophen to
his home regimen Fair Consider an IV home
PCA Optimal Consider a trial of intrathecal
opioids Alternate Refer to pain specialist
Percentage of Respondents
Answer Choices for Acute Pain Vignettes
Statistically significant (plt0.05) were observed
between the portions of optimal and referrals and
worst than poor in metastatic breast and prostate
cancer.
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Distribution of Physician Responses to Acute Pain
Vignettes
Poor Acetaminophen hydrocodone Optimal Start
IV PCA Worst - Ibuprofen Fair -
Epidural Alternate Refer to pain specialist
Statistically significant (plt0.05) were observed
between the proportions of best and worst
responses in myomectomy and prostatectomy
vignettes.
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Answer Physician variability in pain management
based upon type of pain, gender, and age.
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Pain medication availability in minority and
Caucasian neighborhoods in Michigan A
preliminary analysis

• Surveyed pharmacies (N190) in Caucasian and
  minority zip codes regarding their supply of
  opioid analgesics
• 80 response rate
• 52 Caucasian
• 57 chain pharmacies

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Results
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Conclusions

• Differences in the ability to access prescription
  opioid analgesics in Michigan
• Inability to assess prescription opioid
  analgesics may contribute to poor pain
  management.
• Racial and ethnic minorities have less access to
  pain medication throughout the state of Michigan.
• A race-income interaction exists

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• Of all the injustices, injustice in health is the
  most shocking and most inhumane.
• Martin Luther King, Jr