The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment

Racial Disparities in Opioid Prescribing in the United States from 2011 to 2021: A Systematic Review and Meta-Analysis

Background

This meta-analysis is an update to a seminal meta-analysis on racial/ethnic disparities in pain treatment in the United States (US) published in 2012. Since then, literature has accumulated on the topic and important policy changes were made.

Objective

Examining racial/ethnic disparities in pain management and investigating key moderators of the association between race/ethnicity and pain outcomes in the US.

Methods

We performed a systematic search of publications (between January 2011 and February 2021) from the Scopus database. Search terms included: race, racial, racialized, ethnic, ethnicity, minority, minorities, minoritized, pain treatment, pain management, and analgesia. All studies were observational, examining differences in receipt of pain prescription medication in various settings, across racial or ethnic categories in US adult patient populations. Two binary analgesic outcomes were extracted: 1) prescription of "any" analgesia, and 2) prescription of "opioid" analgesia. We analyzed these outcomes in two populations: 1) Black patients, with White patients as a reference; and 2) Hispanic patients, with non-Hispanic White patients as a reference.

Results

The meta-analysis included twelve studies, and the systematic review included forty-three studies. Meta-analysis showed that, compared to White patients, Black patients were less likely to receive opioid analgesia (OR 0.83, 95% CI [0.73-0.94]). Compared to non-Hispanic White patients, Hispanic patients were less likely to receive opioid analgesia (OR 0.80, 95% CI [0.72-0.88]).

Conclusion

Despite a decade's gap, the findings indicate persistent disparities in prescription of, and access to opioid analgesics for pain among Black and Hispanic populations in the US.

Bystander Acknowledgment Mitigates the Psychological and Physiological Pain of Racial Discrimination for Black Young Adults: A Randomized Controlled Trial

Racism increases pain sensitization and contributes to racialized pain inequities; however, research has not tested interventions targeting racism to reduce pain. In this study, we examined whether White bystanders can act to mitigate racism's pain-sensitizing effects. To simulate racial exclusion in the laboratory, Black young adults (age 18-30; N = 92) were randomly assigned to be included or excluded by White players in a ball-tossing game (Cyberball). For half of the excluded participants, White bystanders acknowledged and apologized for the racial exclusion. Participants completed a cold pressor task to assess pain threshold, tolerance, and unpleasantness, and completed a survey assessing psychological needs (ie, belongingness, self-esteem, meaningful existence, and self-control). Participants who experienced racial exclusion reported significantly more threatened psychological needs and increased laboratory pain sensitization (ie, lower pain threshold and tolerance) than those who were included. However, when a White bystander acknowledged the racism, excluded participants reported higher levels of self-control, self-esteem, and decreased pain sensitization (pain threshold and tolerance) relative to excluded participants whose experience was not acknowledged. Our findings support that racism increased Black people's pain sensitivity and provide initial evidence for White bystander acknowledgment as a health intervention. PERSPECTIVE: Continual exposure to racism likely contributes to inequities in pain sensitization. We demonstrate that acute exposure to mild racism increases acute pain sensitization. Results suggest that a bystander acknowledging witnessed racism can buffer the acute sensitizing effects of racism on pain, pointing to the potential of interpersonal interventions targeting racism. TRIAL REGISTRATION: Clinicaltrials.gov NCT06113926.

A Narrative Review of the Current Research in Cancer-Related Pain Inequities: The Necessity of Applying Intersectionality to Advance Cancer Pain Research

Cancer-related pain has a significant impact on quality of life for patients with cancer. In populations without cancer, there are documented pain inequities associated with minoritized racial and/or ethnic groups, women, and low socioeconomic status. However, our understanding of pain inequities specifically among patients with cancer remains incomplete. We narratively synthesized published quantitative research on cancer-related pain inequities in the US in the past decade. A search identified 17 English-language articles examining pain for patients with various cancer types at different treatment stages. Our review revealed mixed findings comparing cancer-related pain by racial group (e.g., Black vs White) and sex (male vs female), but consistent findings indicating that people with lower (vs higher) socioeconomic status and younger (vs older) patients report more cancer-related pain. Research on cancer pain among sexual and gender minorities remains scant. Key research gaps include a need for more research that incorporates an intersectional perspective by exploring intersecting subgroups and measuring social and structural processes that drive pain inequities. These findings underscore an important need for researchers to use an intersectional approach to cancer pain to help elucidate key populations at-risk for exacerbated cancer-related pain and identify ways to mitigate social and structural processes that drive these inequities.

Examining the effects of physician burnout on pain management for patients with advanced lung cancer

PURPOSE

Physician burnout is generally associated with worse clinical outcomes. The purpose of this study is to examine the effects of physician burnout on the quality of physicians' pain assessment and opioid prescribing for patients with advanced lung cancer. Moreover, we test whether these relationships are moderated by patient-level factors, such as patient race and activation level, that have a demonstrated impact on clinical encounters.

METHODS

We conducted a secondary analysis of data from a multisite randomized field experiment. From 2012 to 2016, 96 primary care physicians and oncologists who treated solid tumors were recruited from hospitals and medical sites in three small metropolitan and rural areas in the USA. Physicians saw two unannounced standardized patients who presented with advanced lung cancer. Standardized patients varied across race (Black or White) and activation level (activated, typical). Visits were audio recorded and transcribed. Pain management was evaluated by the quality of pain assessment and opioid prescribing during these visits.

RESULTS

Mixed-effects linear regression and generalized mixed-effects modeling showed that higher levels of burnout were associated with a greater likelihood of prescribing an opioid and prescribing stronger opioid doses for patients. These effects were not moderated by patient race or activation level.

CONCLUSION

Findings from this work inform our understanding of physician-level factors that impact clinical decision-making in the context of cancer pain management. Specifically, this study identifies the role of physician burnout on the quality of prescribing for patients with advanced lung cancer.

Effect of EGFR-TKI targeted therapy in patients with advanced non-small cell lung cancer

OBJECTIVE

To investigate the effect of EGFR-TKI targeted therapy in patients with advanced non-small cell lung cancer (NSCLC).

METHODS

Eighty-four cases of NSCLC were retrospectively assigned into an observation group (OG, n=42) and a control group (CG, n=42) according to the treatment methods. The CG received conventional chemotherapy, and the OG received icotinib hydrochloride EGFR-TKI targeted therapy. The clinical efficacy, cellular immunity, humoral immunity, quality of life, adverse reactions and survival time were compared between the two groups. Cox regression analysis was used to analyze the factors influencing the prognosis of advanced NSCLC.

RESULTS

The total response rate was substantially higher, and the incidence of adverse reactions was considerably lower in the OG than those in the CG (all P<0.05). The post-treatment SF-36 score was increased in both groups with significantly higher score in the OG than the CG (all P<0.001). The post-treatment CD4⁺ counts in both groups were notably lower than those of pre-treatment, and the count was lower in the CG than that in the OG (all P<0.001). The post-treatment CD8⁺ counts in both groups were notably higher after treatment than those of pre-treatment and was higher in the CG than that in the OG (all P<0.001). The post-treatment levels of IgM and IgA in both groups were declined compared with those of pre-treatment (P<0.001) with significantly lower levels in the OG than the CG (P<0.01). The 18-month mortality of the OG was significantly lower than that of the CG (P<0.05). Cox regression analysis showed that lesion diameter and differentiation degree of tumor cells were independent factors influencing the prognosis (P<0.05).

CONCLUSION

EGFR-TKI targeted therapy can relieve clinical symptoms, and improve immune function and quality of life of patients with advanced NSCLC, which is worthy of clinical application.

Patient activation reduces effects of implicit bias on doctor-patient interactions

Disparities between Black and White Americans persist in medical treatment and health outcomes. One reason is that physicians sometimes hold implicit racial biases that favor White (over Black) patients. Thus, disrupting the effects of physicians' implicit bias is one route to promoting equitable health outcomes. In the present research, we tested a potential mechanism to short-circuit the effects of doctors' implicit bias: patient activation, i.e., having patients ask questions and advocate for themselves. Specifically, we trained Black and White standardized patients (SPs) to be "activated" or "typical" during appointments with unsuspecting oncologists and primary care physicians in which SPs claimed to have stage IV lung cancer. Supporting the idea that patient activation can promote equitable doctor-patient interactions, results showed that physicians' implicit racial bias (as measured by an implicit association test) predicted racially biased interpersonal treatment among typical SPs (but not among activated SPs) across SP ratings of interaction quality and ratings from independent coders who read the interaction transcripts. This research supports prior work showing that implicit attitudes can undermine interpersonal treatment in medical settings and provides a strategy for ensuring equitable doctor-patient interactions.

Is physician implicit bias associated with differences in care by patient race for metastatic cancer-related pain?

Rationale

Implicit racial bias affects many human interactions including patient-physician encounters. Its impact, however, varies between studies. We assessed the effects of physician implicit, racial bias on their management of cancer-related pain using a randomized field experiment.

Methods

We conducted an analysis of a randomized field experiment between 2012 and 2016 with 96 primary care physicians and oncologists using unannounced, Black and White standardized patients (SPs)who reported uncontrolled bone pain from metastatic lung cancer. We assessed implicit bias using a pain-adaptation of the race Implicit Association Test. We assessed clinical care by reviewing medical records and prescriptions, and we assessed communication from coded transcripts and covert audiotapes of the unannounced standardized patient office visits. We assessed effects of interactions of physicians’ implicit bias and SP race with clinical care and communication outcomes. We conducted a slopes analysis to examine the nature of significant interactions.

Results

As hypothesized, physicians with greater implicit bias provided lower quality care to Black SPs, including fewer renewals for an indicated opioid prescription and less patient-centered pain communication, but similar routine pain assessment. In contrast to our other hypotheses, physician implicit bias did not interact with SP race for prognostic communication or verbal dominance. Analysis of the slopes for the cross-over interactions showed that greater physician bias was manifested by more frequent opioid prescribing and greater discussion of pain for White SPs and slightly less frequent prescribing and pain talk for Black SPs with the opposite effect among physicians with lower implicit bias. Findings are limited by use of an unvalidated, pain-adapted IAT.

Conclusion

Using SP methodology, physicians’ implicit bias was associated with clinically meaningful, racial differences in management of uncontrolled pain related to metastatic lung cancer. There is favorable treatment of White or Black SPs, depending on the level of implicit bias.

Demographic and clinical factors associated with variations in opioid administration using conscious sedation during HDR brachytherapy for cervical cancer

PURPOSE/OBJECTIVES To examine patient characteristics that predispose to higher opioid administration during tandem and ovoid (T&O) high-dose rate (HDR) brachytherapy. METHODS A single-institution retrospective review was performed on patients who underwent brachytherapy for cervical cancer. Patients were included if they received at least one fraction of HDR T&O brachytherapy with analgesia administration recorded in the Medication Administration Record. Fentanyl dose was dichotomized as "low" (mean <125 μg per fraction), or "high" (mean ≥ 125 μg per fraction). Descriptive statistics and multiple logistic regression analysis were performed comparing mean opioid dose per fraction with demographic and clinical information. RESULTS From July 2014 through May 2020, 113 patients underwent 531 T&O HDR brachytherapy fractions with oral benzodiazepine and intravenous opioid fentanyl for conscious sedation. The median opioid dose per fraction was 100 μg fentanyl (range 0-250 μg). Using multiple logistic regression analysis, younger age (OR 1.071, p = 0.002) and higher BMI (OR 1.091, p = 0.019) were associated with increased opioid administration during brachytherapy. Black women received less opioid during brachytherapy when compared to White women (OR 0.296, p = 0.047). FIGO stage, ECOG score, smoking status, prior narcotic use, prior illicit drug use, parity, prior cervical procedure, Smit sleeve placement, and distance to treatment center were not associated with high opioid dose. CONCLUSION Cervical cancer patients who are younger or have higher BMI receive more narcotic analgesia during HDR brachytherapy whereas Black women received less narcotic analgesia, irrespective of age and BMI. This underscores the immediate need to address how pain is assessed and managed during brachytherapy.

Designing Actionable Solutions and Curriculum for Pain Disparities Education

The Liaison Committee on Medical Education (LCME) require medical schools to teach their students how to recognize and work towards eliminating health disparities. However, time constraints and a dearth of guidance for educators in teaching pain disparities curricula, pose significant challenges. Herein, we describe successes and lessons learned after designing, implementing, and evaluating an innovative pain disparities curriculum that was embedded in a longitudinal health equity curriculum for third year medical school students at an academic institution. Although the curriculum was developed for medical school students, the concepts may be broadly applicable to other training settings such as residency and fellowship programs.

Health Disparities: Impact of Health Disparities and Treatment Decision-Making Biases on Cancer Adverse Effects Among Black Cancer Survivors

BACKGROUND

Health disparities affect cancer incidence, treatment decisions, and adverse effects. Oncology providers may hold biases in the decision-making process, which can perpetuate health disparities.

OBJECTIVES

The purpose of this article is to describe health disparities across treatment decisions and adverse effects, describe decision-making biases, and provide suggestions for nurses to mitigate adverse outcomes.

METHODS

A scoping review of the literature was conducted.

FINDINGS

Factors affecting health disparities stem, in part, from structural racism and decision-making biases, such as implicit bias, which occurs when individuals have unconscious negative thoughts or feelings toward a particular group. Other decision-making biases, seemingly unrelated to race, include default bias, delay discounting bias, and availability bias. Nurses and nurse navigators can mitigate health disparities by providing culturally appropriate care, assessing health literacy, providing education regarding adverse effects, serving as patient advocates, empowering patients, evaluating personal level of disease knowledge, and monitoring and managing cancer treatment adverse effects.

Racial/Ethnic Differences in Staff-Assessed Pain Behaviors Among Newly Admitted Nursing Home Residents

CONTEXT

Nonverbal pain behaviors are effective indicators of pain among persons who have difficulty communicating. In nursing homes, racial/ethnic differences in self-reported pain and pain management have been documented.

OBJECTIVES

We sought to examine racial/ethnic differences in nonverbal pain behaviors and pain management among residents with staff-assessed pain.

METHODS

We used the U.S. national Minimum Data Set 3.0 and identified 994,510 newly admitted nursing home residents for whom staff evaluated pain behaviors and pain treatments between 2010 and 2016. Adjusted prevalence ratios (aPRs) and 95% CIs estimated using robust Poisson models compared pain behaviors and treatments across racial/ethnic groups.

RESULTS

Vocal complaints were most commonly recorded (18.3% non-Hispanic black residents, 19.3% of Hispanic residents, and 30.3% of non-Hispanic white residents). Documentation of pain behaviors was less frequent among non-Hispanic black and Hispanic residents than non-Hispanic white residents (e.g., vocal complaints: aPR_Black: 0.76; 95% CI: 0.73-0.78; with similar estimates for other pain behaviors). Non-Hispanic blacks (47.3%) and Hispanics (48.6%) were less likely to receive any type of pharmacologic pain intervention compared with non-Hispanic white residents (59.3%) (aPR_Black: 0.87; 95% CI: 0.86-0.88; aPR_Hispanics: 0.87; 95% CI: 0.84-0.89).

CONCLUSION

Among residents requiring staff assessment of pain because they are unable to self-report, nursing home staff documented pain and its treatment less often in Non-Hispanic blacks and Hispanics than in non-Hispanic white residents. Studies to understand the role of differences in expression of pain, explicit bias, and implicit bias are needed to inform interventions to reduce disparities in pain documentation and treatment.

"I did not know it was a medical condition": Predictors, severity and help seeking behaviors of women with female sexual dysfunction in the Volta region of Ghana

Objectives

The study’s main objective was to describe the prevalence and severity of female sexual dysfunction (FSD) amongst a group of Ghanaian women in the outpatient setting of the predominantly rural Volta region of Ghana. Additionally we determine the predictors of FSD severity and care seeking behaviors of women with the condition.

Study design and setting

This was a cross sectional study conducted in the outpatient setting of the Ho Teaching Hospital in the rural-savannah, agro-ecological zone of Volta Region, Ghana.

Methods and procedures

FSD was assessed using the Female Sexual Function Index (FSFI) questionnaire. FSD was defined with a cutoff of ≤23 so as not to under-estimate the prevalence in this conservative setting. FSFI score >23 was designated “no FSD”. We further categorized women with FSD as having mild (FSFI Total score 18–23), moderate (FSFI Total score <18 to >10) or severe (FSFI Total score ≤10) FSD. Due to sample size restrictions, we combined the moderate and severe FSD groups in our analyses and defined “moderate/severe FSD” as an FSFI Total score < 18. Participants with FSD were further asked to indicate whether or not they sought help for their conditions, the reasons they sought help, and the types of help they sought. We used p<0.05 to determine statistical significance for all analyses and logistic regression models were used to determine crude and age-adjusted effect estimates.

Results

FSD Prevalence: Out of 407 women approached, 300 (83.8%) agreed and consented to participate in the study. The prevalence of FSD was 48.3% (n = 145). Compared to those without FSD, over a third of the FSD women resided in rural settings (37.90% vs 20.60%; p = 0.001) and tended to be multiparous, with a significantly greater proportion having at least three children (31.70% vs 18.10%; p = 0.033).

FSD Severity: Over a quarter of the sample (27.6%, n = 40) met the cut-off for moderate to severe FSD. In age-adjusted models, lubrication disorder was associated with 45 times the odds of moderate/severe FSD (age-adj. OR: 45.38, 95% CI: 8.37, 246.00; p<0.001), pain with 17times the odds (age-adj. OR: 17.18, 95% CI: 4.50, 65.50; p<0.001) and satisfaction almost 5times the odds (age-adj. OR: 4.69, 95% CI: 1.09, 20.2; p = 0.04). Compared to those with 1–3 children, nulliparous women had 3.5 times higher odds of moderate/severe sexual dysfunction as well (age-adj. OR:3.51, 95% CI:1.37,8.98; p = 0.009).

FSD-related Health Seeking Behaviors: Statistically significant predictors of FSD-related care seeking included having FSD of pain disorder (age-adj. OR: 5.91, 95% CI:1.29, 27.15; p = 0.02), having ≥4 children (age-adj. OR: 6.29, 95%CI: 1.53, 25.76; p = 0.01). Of those who sought help, seven in 10 sought formal help from a healthcare provider, with General Practitioners preferred over Gynecologist. About one in 3 (31.3%) who did not seek help indicated that they did not know their sexual dysfunction was a medical condition, over a quarter (28.9%) “thought it was normal” to have FSD, and interestingly, 14.1% did not think a medical provider would be able to provide them with assistance.

Conclusions

Sexual dysfunctions are prevalent yet taboo subjects in many countries, including Ghana. Awareness raising and efforts to feminize the physician workforce are necessary to meet the healthcare needs of vulnerable members of Ghanaian society.