New study reveals racial disparities in chronic pain management

Opioids are frequently prescribed for pain management in noncancer patients, but recommended clinical guidelines for monitoring effectiveness and signs of drug abuse are often not implemented. Alongside well-documented racial disparities in prescribing opioid medications for pain, researchers report racial differences in the use of recommended opioid monitoring and follow-up treatment practices. The study is published in the current issue of PAIN®.

"In our study, we examined whether racial disparities exist in a more comprehensive set of opioid monitoring and treatment practices, including the use of an opioid agreement, the assessment of pain during follow-up visits, the use of urine drug screenings, and referrals to pain and substance abuse specialty clinics," says lead investigator Leslie R.M. Hausmann, PhD, Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and Assistant Professor of Medicine, University of Pittsburgh.

A retrospective cohort study examined racial differences in the documentation of pain and the involvement of specialists in the care of patients who are prescribed opioids for chronic noncancer pain. Investigators pulled data from electronic health records for 1646 white and 253 black patients who filled opioid prescriptions for noncancer pain for more than 90 days at the Veterans Affairs Pittsburgh Healthcare System pharmacy from October 2007 to September 2009. Additional data about opioid monitoring and follow-up treatment practices were pulled for a 12-month follow-up period, to complete a comprehensive profile.

Of these patients, nearly 94% were male, 22% were aged 65 or older, and 45% were married or lived with a partner. Patients were most often being treated for back pain or joint pain. About half of the study sample had at least one comorbid physical or mental health diagnosis, and one-third had a history of substance abuse.

Compared with white patients, black patients were significantly younger, less likely to be married, and less likely to have back pain. They had more physical comorbid conditions, more primary care appointments, and higher maximum pain scores. They were less likely to have a mental health diagnosis. Both study groups were equally likely to have a history of substance abuse. However, statistical analysis revealed significant racial differences in recommended opioid monitoring and follow-up treatment practices. Specifically, pain levels were less frequently documented for black patients than for white patients during medical visits. Among patients who had at least one urine drug test, black patients were also subjected to more tests, especially if they were on higher doses of opioids. Finally, black patients were less likely than white patients to be referred to a pain specialist and more likely to be referred for substance abuse assessment after being prescribed opioids.

"The emerging picture is that black patients who are able to overcome the barriers to securing a prescription for opioid medications may still be subjected to differential monitoring and follow-up treatment practices that could impact the effectiveness of their pain management," concludes Dr. Hausmann. "Addressing disparities in opioid monitoring practices may be a previously neglected route to reducing racial disparities in pain management."

Dr. Hausmann and colleagues suggest that "providing pain management support to primary care providers in the form of training on recommended guidelines and assistance with managing patients on long-term opioid regimens could improve overall adherence to recommended guidelines."

In an accompanying commentary, Megan Crowley-Matoka, PhD, of the Medical Humanities and Bioethics Program, Feinberg School of Medicine, Northwestern University, Chicago, says, "Pain management remains a persistent and pervasive problem across the practice of medicine. Despite strong consensus about the clinical, ethical, and economic importance of better managing pain, serious problems with both quality and equity continue to be routinely reported. The findings of Hausmann et al. suggest that, even for patients who overcome the barriers to receiving opioids, implementation of guideline recommendations is highly uneven and often racially disparate. Yet it is difficult to fully interpret what these data really tell us about the quality or equity of pain care, because we still know far too little regarding the efficacy of many of these practices, as well as what their appropriate level of use should be for most patients - much less how their differential use may affect black and white patients. Further complicating matters is the fact that so many of these practices associated with good pain care also run serious risk of being used by clinicians - and experienced by patients - in ways that are both punitive and prejudicial. These findings push us to move beyond this important first step of asking whether these practices are used, to examine more thoroughly and rigorously why and how they are used, and what outcomes are thus achieved."