COVER STORY

An Enduring DiscrePAINcy: Pain and the African American Patient

The effects of pain are all around us: it accounts for more than one fourth of all sick days taken by full-time workers. The Pain Relief Advocacy and Information Network asserts that pain, in general, accounts for $100 billion of annual medical costs in this country. According to a MarketResearch.com report published by Marketdata Enterprises, Inc, last November, pain management therapies alone command a market of more than $7 billion dollars (www.marketresearch.com/map/prod/937557.html). We have medications that are supposed to improve our patients, and grant them a quality of life that couldn’t have even been imagined just five years ago. It seems hard to believe that pain, with all of the means we have available to manage it, would be such a significant dilemma in healthcare, but it is. In fact, many experts estimate that pain is the third largest health problem in the world, with significant global impact on health and wellness. With pain comes a whole host of additional problems of equal significance and scope. Chronic pain remains a major reason for physician consultation and disability. Beyond its obvious physical manifestations, such as sleep perturbations, depression, and disability, pain causes significant suffering and psychological symptoms including depression, post-traumatic stress disorder, and anxiety, impairing overall health. We have no doubt improved our patients’ chances for survival by leaps and bounds over the past few decades; but despite all of our progress in medical research, we may as well be running in place as far as our efforts to improve quality of life are concerned. As long as our patients are still in pain, it’s as though our job as doctors is left unfinished. We all realize that adequate chronic pain management is critically important to decrease further suffering and deliver the quality of life that our breakthrough treatments make possible. But quality chronic pain care hinges on ensuring adequate pain assessment and optimizing pain treatment, two research areas that have been all but neglected in medical school, residency training, and continuing medical education programs. Despite knowledge that adequate pain management improves quality of life and health, it remains an unexplored frontier in current research, and is largely absent from both medical education and public health curricula. Furthermore, little is known about how race and ethnicity influence the pain care experience. Here, we’ll discuss why the burden of pain endures today and how that burden manifests itself specifically in healthcare for African American patients. By pinpointing a few of the major areas that must be explored further for us to make progress in the area of pain management, it is our hope that through their continued work and much needed research, our readers can ease the burden of pain.

How Pain Discriminates
The medical advances and interventions that have allowed non-Hispanic whites increased longevity and enhanced quality of life have not been uniformly translated into improvements in health or quality of life for African Americans. Overall, stark differences exist in health status and the healthcare experience based upon race and ethnicity. Within Healthy People 2000, and subsequently Healthy People 2010, is an overarching agenda to improve health-related quality of life and to eliminate racial and ethnic disparities in health and healthcare. The agenda’s website (www.healthypeople.gov) outlines several health objectives intended to help us identify and reduce preventable health threats; however, little attention is directed at differences in pain or potential racial and ethnic disparities in pain care. The Institute of Medicine’s report, entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,” and accessible online at www.nap.edu/books/030908265X/html, briefly addresses racial and ethnic disparities in analgesic treatment, but focuses only on cancer and emergency room care. In general, the impact of chronic pain upon African Americans has been and continues to be largely overlooked. However, there is an emerging literature that demonstrates that a health status and healthcare gap also exists for chronic pain among African Americans. More specifically, there is clear evidence suggesting that African Americans across the age continuum suffer more impairment in their overall health due to chronic pain than non-Hispanic whites.

Structural Barriers to Care
According to a report from the Henry J. Kaiser Foundation, "minorities are much more likely to be uninsured than white Americans," with 22% of African Americans and one third of the Hispanic population lacking any type of health insurance coverage. Only 12% of white Americans are uninsured. These statistics and many more are posted on the Kaiser Foundation website at www.kff.org. African Americans without health insurance coverage often forego preventive care measures, such as prostate exams and mammograms, which insured patients consider routine. While receiving lesser quality medical care once diagnosed with a disease, uninsured African Americans also have poorer health status with accompanying higher morbidity and mortality. Inconsistencies in health and healthcare persist despite similar health insurance coverage and social stratification. For example, much of the current literature finds that older African Americans are more likely to rate their health as fair or poor when compared to non-Hispanic whites despite similar socioeconomic status and insurance (www.cmwf.org/programs/minority/ collins_minority_chartbook_321.pdf). In addition, African Americans (across the age continuum) with chronic pain receiving treatment at tertiary care pain centers reported poorer overall health than non-Hispanic whites in several studies, one of which can be found at http://www2.us.elsevierhealth.com/scripts/om.dll/serve?retrieve=/pii/S1526590002650084&. The research shows that, despite receiving care and having access to chronic pain treatment, African Americans more frequently reported that chronic pain was a major financial burden (www.nmanet.org/OC1jnma0104.pdf).

Sources of Care
Lacking a usual source of care or a primary care physician also contributes to disparities. Overall, African Americans without health insurance coverage are more likely to use the emergency room or outpatient clinics for care and are less likely to have a regular primary care physician. This is particularly important, since there is also an increased disease burden for many conditions associated with pain (eg, diabetes and arthritis). In addition, a physician’s ability to refer a patient may also be limited by the patient’s health insurance company. Thus, racial and ethnic differences in the healthcare experience provide evidence that race and ethnicity are important contributors to health and well-being and may lead to suboptimal pain treatment and access to pain care. In a recent study, African American patients with chronic pain believed more frequently than non-Hispanic whites that they should have been referred to a pain center sooner (www.nmanet.org/OC1jnma0104.pdf). African Americans with chronic pain also reported decreased access to healthcare and increased difficulty paying for pain care, and believed that ethnicity influenced pain care more so than Caucasian Americans.