COVER STORY

An Enduring DiscrePAINcy: Pain and the African American Patient

Physician-Patient Communication
Nowhere is effective communication more important than in the physician-patient interaction. An inherent requirement for effective communication is trust and mutual respect. Unfortunately, physician-patient communication can be complicated by misunderstandings and misinterpretations affecting the physician-patient relationship, patient behavior, and outcomes. A lack of trust in the healthcare system in general may contribute to poor communication. The Tuskegee syphilis experiments and other negative experiences with the healthcare system have colored African Americans’ perception of the healthcare system, as well as of their healthcare providers. In addition, several issues, some patient-driven and some physician-related, can affect communication between physicians and African American patients. Patient-related issues include socioeconomic factors, lower literacy levels and lower health literacy (the ability to obtain and understand basic health information to make appropriate health decisions) in particular, and a willingness (or lack thereof) to discuss sensitive issues. Also, differences in the way African Americans communicate their pain concerns may increase the likelihood of their complaints being discounted or attributed to a mental health disorder. Physician-related issues that can affect communication include poor cultural competency (the awareness of health beliefs and behaviors of different populations), language differences, and a healthcare provider’s level of willingness to hear the patient’s story.

Patient Attitudes and Preferences
Differences in coping styles and attitudes may influence an individual’s pain experience while contributing to diminished health and health related quality of life. Recent data suggests that an increase of depressive and PTSD symptoms among African Americans with pain complaints, when compared to non-Hispanic whites with pain complaints, may decrease their ability to cope with pain. The reluctance of African Americans to seek treatment for mental health disorders decreases their overall health. Another potential coping related factor is John Henryism—a pattern of actively coping with stressors by working harder against potentially insurmountable obstacles—which has been demonstrated in African Americans and is associated with hypertension and bodily pain. Availability of, quality of, and satisfaction with social support are important factors to consider in determining a patient’s adaptability to a chronic pain problem. Social support and health relationships for many chronic conditions (eg, diabetes) may also play an important role in pain management and accessing pain care for African Americans.

Patients’ attitudes often direct their preferences, information seeking, decision-making, and healthcare. In general, attitudes often direct perceptions and are valid until proven otherwise. African Americans with chronic pain tend to believe more than non-Hispanic whites that race, ethnicity, culture, and gender influence access to health and pain care. Overall, there is limited information available from African Americans regard-ing their attitudes about how chronic pain affects their life or their perceptions regarding their chronic pain management. To date, few studies have specifically addressed the African American perspective regarding chronic pain management. In addition, assessing African Americans’ perceptions of care is critically important to understanding quality of chronic pain care and assessing pain care outcomes.

Physician Variability
Many different modalities are available to treat pain complaints; however, pain remains relatively undertreated for all patients and among African Americans in particular. Although pain complaints are a major reason for patients to consult their physician, doctors may be ill-equipped to treat chronic pain due to limited knowledge and education. A number of studies have shown limitations in the physician’s knowledge of, attitudes toward, and treatments for pain. An enduring misconception among doctors today is the belief that prescribing strong opioid analgesics for pain management will attract a medical review of their prescribing habits. In fear of appearing as though they overprescribe pain medications, doctors often undertreat pain. An article published by the National Institutes of Health (www.nih.gov/news/NIH-Record/05_27_2003/story01.htm) points out that "undertreatment is generally a far greater problem than overtreatment" in pain management; furthermore, Washington University’s website outlining its palliative care training curriculum (http://depts.washington.edu/pallcare/training/curriculum_pdfs/PainModule.pdf) for pain management highlights the fact that undertreatment of pain often leads to future substance abuse by patients who self-medicate to find relief. By undertreating pain for fear of promulgating addiction, doctors may unwittingly be contributing to the very problem they are trying to prevent. Misperceptions like this may be particularly problematic in physicians treating racial and ethnic minorities and those practicing in African American neighborhoods. These beliefs suggest that regulatory monitoring contributes to physician variability and suboptimal pain management; a study emphasizing the importance of physician variability in chronic pain management may be found at www.aslme.org/pub_jlme/29.1_pdf/bonham.pdf. Another factor—physician goals for pain relief and how these goals are shaped by personal experience—also influences pain management. More specifically, research has indicated that physicians’ pain relief goals for their patients are significantly better when they have personal experience with pain or a relative who has. Thus, physician perceptions and goals may lead to variability and the unintentional undertreatment of pain.

Despite the fact that chronic pain profoundly affects morbidity and mortality, quality of life, and healthcare expenditures and may disproportionately impact African Americans, national goals as well as research on pain management outcomes are lacking to help guide physician practice. Guidelines developed to direct chronic pain care have not been universally adhered to, resulting in the relative undertreatment of chronic pain. The lack of racial and ethnic identifiers may complicate the ability to monitor disparities in pain care and to track outcomes in African Americans. A recent selective literature review revealed structural barriers to accessing pain treatment, difficulties with physician-patient communication, and unequal pain treatment across all types of pain (eg, acute, chronic, cancer-related) and treatment settings (eg, emergency room, outpatient clinics, hospitals) for African Americans.

Pain Assessment
How race and ethnicity influence chronic pain management and treatment seeking behavior is unclear. What is known is that the pain complaints of African Americans are handled less aggressively than those of non-Hispanic whites by physicians. Disturbing disparities in pain management have been identified for African Americans in all settings and for all types of pain. A 1993 study published in JAMA (http://jama.ama-assn.org/cgi/content/abstract/269/12/1537) showed that minority patients were more likely to receive no analgesics than non-Hispanic whites when receiving treatment in the emergency room for isolated long bone fractures. A survey of 13,625 elderly nursing home residents with cancer pain published in JAMA (http://jama.ama-assn.org/cgi/content/abstract/279/23/1877) revealed that African Americans were 63% more likely than non-Hispanic whites to receive no pain medications; 4% of African Americans reported daily pain, while 25% received no analgesics whatsoever. Another study, published in the New England Journal of Medicine (http://content.nejm.org/cgi/content/short/342/14/1023), showed that New York City pharmacies located in minority neighborhoods were less likely to carry opioid analgesics than those in other neighborhoods. Thus, poor pain assessment and insufficient patient access to pain medications that treat chronic pain limits our ability to provide optimal chronic pain management for African Americans.

Physician Treatment
Variability in chronic pain treatment based upon patient sociodemographic variables can lead to poorer outcomes for African Americans. An article entitled "The Effect of Race and Sex on Physicians’ Recommendations for Car-diac Catheterization" (http://content.nejm.org/cgi/content/abstract/340/8/618) identified differences in the treatment of chest pain based upon the patient’s race, with African Americans receiving lesser quality care. In addition, physicians have less ambitious goals for chronic pain relief, less satisfaction with their chronic pain management, and provided lesser quality chronic pain care than what was provided for acute and cancer pain. Physician variability and suboptimal treatment strategies for chronic pain may lead to increased suffering and adversely affect overall health among African Americans living with chronic pain.

Conclusions
Adequate chronic pain management is critically important. While unprecedented scientific advances have led to the ability to alleviate suffering associated with chronic pain, they have not been universally implemented. Furthermore, there is evidence that chronic pain may have unique health implications for African Americans, which are often unrecognized or overlooked. As yet, there is little information available about pain care perceptions, social roles, health service costs, or outcomes in the African American population; in order to optimize chronic pain management for African Americans, more studies are necessary to guide potential interventions designed to improve pain care. In addition, gender, age, and socioeconomic factors that may make certain African Americans more vulnerable to inadequate chronic pain treatment must be clarified. Adding to the problem is the lack of literature available to guide us regarding the presenting pain symptoms, pain duration, and disability due to chronic pain, or whether the health problems commonly seen in chronic pain patients (eg, depression and PTSD) are more problematic in African Americans. If so, African Americans who are women, impoverished, and/or elderly may be at additional risk and may experience more difficulty gaining access to appropriate pain management. Thus, it is imperative that more research is directed at understanding the chronic pain and the pain care experience among African Americans if we are to ensure appropriate interventions, improve the quality of pain care, and provide safe and efficacious therapy for this potentially vulnerable population. Only then will we begin to eliminate disparities in pain care.

Carmen R. Green, MD, is a tenured member of the faculty of the University of Michigan Medical School, where she is Associate Professor of Anesthesiology, Medical Director of the Acute Pain Service, Attending Physician in the Multidisciplinary Pain Center, Associate Director of Medical Student Anesthesiology Education for Special Projects, and Chair of the Pain Management Steering Committee. Dr. Green has also served on the American Society of Anesthesiologists (ASA) Committee on Pain Medicine, the ASA Task Force on Practice Parameters for Practice Guidelines for Acute Pain Management in the Perioperative Setting, and the American Pain Society’s (APS) Annual Meeting Committee; she currently chairs the APS Special Interest Group on Pain and Disparities.