Racial and Ethnic Disparities in the Treatment of Chronic Pain

Differences in Acute Postoperative Opioid Use by English Proficiency, Race, and Ethnicity After Total Knee and Hip Arthroplasty

BACKGROUND

There is increasing interest in documenting disparities in pain management for racial and ethnic minorities and patients with language barriers. Previous studies have found differential prescription patterns of opioids for racial and ethnic minority group and patients having limited English proficiency (LEP) after arthroplasty. However, there is a knowledge gap regarding how the intersection of these sociodemographic factors is associated with immediate postoperative pain management. This study aimed to explore language and racial-ethnic disparities in short-term opioid utilization after total hip and knee arthroplasty.

METHODS

We conducted a retrospective cohort study of adult patients who underwent total hip and knee arthroplasty from 2015 to 2019 at an urban medical center. The primary predictor variables included LEP status and racial-ethnic category, and the primary outcome variables were oral morphine equivalents (OMEs) during 2 distinct postoperative periods: the first 12 hours after surgery and from the end of surgery to the end of postoperative day (POD) 1. Patient characteristics and perioperative metrics were described by language status, race, and ethnicity using nonparametric tests, as appropriate. We performed an adjusted generalized estimating equation to assess the total effect of the intersection of LEP and racial-ethnic categories on short-term postoperative opioid use in mean ratios (MRs).

RESULTS

This study included a total of 4090 observations, in which 7.9% (323) patients had LEP. Patients reported various racial-ethnic categories, with 72.7% (2975) non-Hispanic White, and minority groups including non-Hispanic Asian and Pacific Islander (AAPI), Hispanic/Latinx, non-Hispanic Black/African American, and Others. Patients self-identifying as non-Hispanic AAPI received fewer OME regardless of LEP status during the first 12 hours postoperatively (MR for English proficient [EP], 0.12 [95% confidence interval, CI, 0.08-0.18]; MR for LEP, 0.22 [95% CI, 0.13-0.37]) and from end of surgery to the end of POD 1 (MR for EP, 0.24 [95% CI, 0.16-0.37]; MR for LEP, 0.42, [95% CI, 0.24-0.73]) than EP non-Hispanic White. Hispanic/Latinx patients with LEP received lower amounts of OME during the first postoperative 12 hours (MR, 0.29; 95% CI, 0.17-0.53) and from end of surgery to the end of POD 1 (MR, 0.42; 95% CI 0.23-0.79) than EP non-Hispanic White. Furthermore, within the non-Hispanic White group, those with LEP received fewer OME within the first 12 hours (MR, 0.33; 95% CI, 0.13-0.83).

CONCLUSIONS

We identified an association between LEP, racial-ethnic identity, and short-term postoperative OME utilization after total knee and hip arthroplasty. The observed differences in opioid utilization imply there may be language and racial-ethnic disparities in acute pain management and perioperative care.

Access to Chronic Pain Services for Adults from Minority Ethnic Groups in the United Kingdom (UK): a Scoping Review

BACKGROUND

Chronic pain services in the UK are required to provide services which meet the diverse needs of patients, but little is known about the access and use of these services by minority ethnic groups.

OBJECTIVE

To assess the available evidence regarding the ethnic profile of adults who access secondary and tertiary chronic pain services in the UK.

METHODS

A scoping review was conducted (August 2021-October 2021), comprising comprehensive literature searches using Embase, Medline and CINAHL databases and the grey literature. Studies were included if they reported on (i) access to chronic pain services in secondary and/or tertiary care in the UK, (ii) adults and (iii) stated the ethnicity of the involved participants. Studies were included if published between 2004 and 2021, as demographic data during this period would be broadly representative of the UK population, as per the 2021 UK census. A descriptive synthesis of the extracted data was performed.

RESULTS

The search yielded 124 records after duplicates were removed. Following title and abstract screening, 44 full texts were screened, ten of which were included in the review.

CONCLUSIONS

This is the first review to explore access to chronic pain services for adults from minority ethnic groups in the UK. Given the limited number of studies that met the inclusion criteria, the review highlights the need for routine collection of ethnicity data using consistent ethnic categories within UK chronic pain services and increased involvement of minority ethnic groups within chronic pain research. Findings should inform future research that aims to improve access to UK chronic pain services for adults from minority ethnic groups.

Examination of Pain Comorbid Diagnoses in the Inpatient Rehabilitation Population Across All Impairment Groups

OBJECTIVE

Pain is common in inpatient rehabilitation patients; however, the prevalence of pain diagnoses in this population is not well-defined. This study examines comorbid pain diagnoses in inpatient rehabilitation patients across impairment groups.

DESIGN

Adult inpatient rehabilitation patients discharged from January 2016 through December 2019 were identified in the Uniform Data System for Medical Rehabilitation database using a literature-established framework containing International Classification of Diseases, Tenth Revision, Clinical (ICD-10-CM) pain diagnoses. Demographic data, clinical data, and pain diagnoses were compared across the 17 rehabilitation impairment groups.

RESULTS

Of 1,925,002 patients identified, 1,347,239 (70.0%) had at least one International Classification of Diseases, Tenth Revision (ICD-10) pain diagnosis. Over half of all patients in each impairment group had at least one pain diagnosis. The most common pain diagnoses were limb/extremity and joint pain, with variation between impairment groups. Female sex and being in the arthritis, major multiple trauma, and pain syndrome impairment groups were associated with a greater odds of a pain diagnosis.

CONCLUSIONS

Over half of all patients in each rehabilitation impairment group have a pain diagnosis, which varies between impairment groups. Because of the high prevalence of pain diagnoses, a new focus on pain management in inpatient rehabilitation patients is needed. Rehabilitation outcomes may also be affected by pain.

Discrimination and Dignity Experiences in Prior Oral Care Visits Predict Racialized Oral Health Inequities Among Nationally Representative US Adults

Racism, an oppressive and fallacious sociopolitical hierarchy, is a fundamental cause of oral health inequities worldwide. Everyday discrimination is associated with worse self-rated oral health, toothache and adult tooth loss, and lower oral care utilization. Few studies examine discrimination or microaggressions within oral care settings or their effects on oral health outcomes. We adapted the seven-item Everyday Discrimination Scale to the oral care setting (EDSOC); developed a four-item Dignity in Oral Care Scale (DOCS); fielded them to a probability-based nationally representative sample of US households as part of the 2022 State of Oral Health Equity in America survey (SOHEA, n = 5682); and examined associations between EDSOC and DOCS scores and three outcomes: self-rated oral health, duration since last oral care visit, and planning for future preventive/routine oral care. Nearly, all EDSCOC and DOCS measures were significantly associated with oral health outcomes. Discrimination experience in dental settings had an additive effect on reporting fair/poor oral health and a suppressive effect on planning a future dental visit. Indignity experience doubled-to-quadrupled the likelihood of reporting fair/poor oral health, not having visited a dentist in 2 years, and not planning a future oral care visit. Racio-ethnically minoritized patients may experience the unjust double bind of resolving urgent dental or completing preventive services needs amidst being treated in a discriminatory manner or without dignity. Oral health stakeholders should invest more effort to understand relationships between racism and oral health outcomes and introduce evidence-based interventions to ultimately abolish this societal harm.

Emergency department encounters and opioid prescribing following orthopaedic trauma among Black and White patients with substance use disorders

INTRODUCTION

Patients living with substance use disorder (SUD) have complex pain management needs, which may be mismanaged during hospital admission. Ineffectively managed pain following orthopaedic trauma, influenced by clinician biases related to race or SUD diagnosis, may subject patients to worse pain outcomes and subsequent emergency department (ED) encounters. This study examined ED encounters and opioid prescribing for pain-related complaints following orthopaedic trauma, among patients with SUD who identify as Black or African American relative to White patients.

METHODS

This retrospective analysis included 1089 patients with a SUD diagnosis discharged from a Level I trauma center, following hospitalization for orthopaedic injuries, between 2016 and 2021. Multivariable regressions assessed the associations among race, opioid prescribing, and ED encounters within 90 days for pain-related care.

RESULTS

Among the 1089 patients included in the sample, the proportion of individuals with an ED encounter within 90 days for pain-related care was 12.4 % and 4.5 % for Black and White patients, respectively (odds ratio [OR] = 3.0, p < .001). When adjusting for injury severity and demographics, the difference in ED encounters between Black and White patients remained significant (OR = 2.8, p = .002). Opioid prescription doses did not statistically differ by race.

CONCLUSIONS

The difference in ED encounters between Black and White patients with SUDs following orthopaedic trauma may indicate a need to optimize pain management prior to initial discharge and improve post-injury care.

Chronic pain and use of painkillers, healthcare services and long-term impairment among Syrian refugees: a cross-sectional study

BACKGROUND

The global increase in forcibly displaced populations highlights the importance of understanding their health needs. Chronic pain is prevalent among refugees, poses significant personal and public health challenges, and complicates their integration into new home countries. Understanding refugees' pain post-migration and how it is being managed is crucial for ensuring adequate and timely interventions and fostering health equity. This paper explores the associations between pain levels and the use of painkillers, healthcare services, and long-term impairment among Syrian refugees with chronic pain, one year after their resettlement in Norway.

METHODS

This cross-sectional study is based on survey data collected from 353 quota refugees in 2018-19, one year after resettlement in Norway. The primary outcomes were the use of painkillers, the use of healthcare services, and long-term impairment, according to reported chronic pain levels. Associations between these outcomes and chronic pain levels were studied using Poisson regression, adjusted by sociodemographic variables and trauma experience.

RESULTS

Of the 353 adults included, 52% were women, and the median age was 36 years. A total of 5% reported very mild/mild, 10% moderate, and 12% strong/very strong chronic pain over the last four weeks. Significant associations were found between all chronic pain levels and use of non-prescription painkillers (adjusted relative risks (aRR) (95% CI)); mild (3.1 (2.0-4.7)), moderate (1.8 (1.1-2.8)), strong (1.7 (1.1-2.6)), and prescription painkillers; mild (4.6 (2.2-9.5)), moderate (5.6 (3.2-10.0)), strong (6.7 (3.9-11.3)), compared to those without chronic pain. Use of emergency rooms, specialist care, and hospitalization were significantly associated with strong chronic pain, with aRR (95% CI) of 2.0 (1.2-3.5), 3.9 (2.1-7.0) and 2.4 (1.3-4.4), respectively. Long-term impairment was strongly associated with chronic pain across all pain levels; mild (8.6 (5.6-13.49)), moderate (6.7 (4.3-10.5)) and strong (6.6 (4.3-10.4)).

CONCLUSION

Despite their young age, more than a quarter of the Syrian refugees in our study reported chronic pain one year after resettlement in Norway. High levels of pain were related to the use of medication, healthcare services, and long-term impairment. Understanding the dynamics of pain among refugees is crucial to ensure adequate and timely management.

Examining Disparities in Regional Anesthesia Utilization, Opioid Prescriptions, and Pain Scores Among Patients Who Received Primary or Revision Total Knee Arthroplasty at a Veterans Affairs Medical Center: A Retrospective Cohort Study

INTRODUCTION

Total knee arthroplasty (TKA) is one of the most performed surgical operations in the United States. Managing postoperative pain after TKA is of vital importance, as it is positively associated with outcome measures related to recovery of function and quality of life. Two commonly used methods to control postoperative pain are regional anesthesia (RA), consisting of a single or a combination of peripheral nerve and epidural blocks, and pain medication, such as opioids. Our retrospective analysis sought to better understand whether revision versus primary TKA impacted previously discovered disparities in perioperative pain management and use of RA at the Atlanta Veterans Affairs Health Care System (AVAHCS). Before data collection, we hypothesized that revision TKA would have a higher proportion of Black and older patients and that revision TKA patients would have lower postoperative pain scores.

MATERIALS AND METHODS

This was a retrospective analysis of AVAHCS patients who underwent elective unilateral primary or revision TKA surgery between 2014 and 2020. After application of our exclusion criteria, data from 562 patients were analyzed. Data collected included demographics information, type of RA used, and pain scores. Statistical analyses included chi-square test, t-tests, multiple logistic regression, and multiple linear regression, as appropriate to the outcomes of interest.

RESULTS

Revision TKA patients were more likely to be Black (P = .018) and younger (P = .023 for <50 years of age group, P = .006 for 50 to 64 years of age compared to the >65 years group). Black patients, compared to White patients, had significantly higher pain scores at baseline (P = .0086) and at 24 hours postsurgery (P = .0037). Older patients (≥50 years old) had significantly higher baseline pain scores (P = .021 for the 50 to 64 years group, P < .01 for the >65 years group) and significantly lower first postanesthesia care unit pain scores (P < .05). Black race (P < .01) and age > 65 years (P < .01) were associated with a significant decrease in total oral morphine equivalents (OME) prescribed at discharge. None of the predictor variables-race, age, type of surgery (primary versus revision), baseline, and first postanesthesia care unit pain scores-were significantly associated with the use of RA in our cohort.

CONCLUSIONS

Sociodemographic disparities in pain management have been reported in all healthcare systems, including the VAHCS. This moderately sized retrospective study, conducted at a single veterans affairs site, yielded several noteworthy findings. One finding of particular interest was that, despite Black patients reporting higher baseline and 24-hour postoperative pain scores, they were prescribed fewer opioids at discharge. Our results highlight the presence of clinically significant disparities in perioperative TKA pain management, emphasizing the need for continuous investigation and focused mitigation efforts among Veterans.

Perceived discrimination and pain outcomes among black adults with chronic musculoskeletal pain: identifying modifiable psychosocial risk factors

Chronic musculoskeletal pain (CMP) is highly prevalent, frequently associated with negative health outcomes, and disproportionately impacts Black Americans. Perceived racial and ethnic discrimination has emerged as a factor that may influence the experience of chronic pain in this population. Identifying modifiable psychosocial factors that influence the link between perceived discrimination and pain and that can be directly targeted in treatment is vital to reducing the disproportionate burden of CMP among Black individuals. The present study examines the moderating role of five risk factors (i.e., pain avoidance, pain fusion, experiential avoidance, pain catastrophizing, and pain anxiety) on the relationship between perceived discrimination and pain outcomes (i.e., pain intensity and interference) in a sample of 401 Black adults with CMP. We recruited 401 Black individuals (Mage = 35.98, 51.9% female) with self-reported CMP and assessed their self-reported perceived discrimination, pain intensity, pain interference, and pain-related psychosocial risk factors. Results indicated that higher scores on each of the psychosocial risk factors (i.e., pain avoidance, pain fusion, experiential avoidance, pain catastrophizing, and pain anxiety) were significantly associated with greater pain intensity and pain interference (all ps < 0.01). Further, pain avoidance (B = 0.12, p = .006), pain fusion (B = 0.13, p = .002), and pain anxiety (B = 0.13, p = .002) each significantly moderated the relation between perceived discrimination and pain intensity. Greater perceived discrimination was associated with greater pain intensity at higher levels of avoidance and fusion, and was associated with less pain intensity at lower levels of avoidance and pain anxiety. In interaction models predicting pain interference, both pain fusion (B = 0.14, p = .001) and pain anxiety (B = 0.10, p = .01) significantly moderated the relation between perceived discrimination and pain interference. Perceived discrimination was associated with greater pain interference at higher levels of pain fusion and pain anxiety, and was not associated with pain interference at lower levels of pain fusion and pain anxiety. The present findings provide important insights into psychosocial risk factors that moderate the link between perceived discrimination and pain outcomes, providing important clinical implications for the treatment of Black adults with chronic musculoskeletal pain.

Pain Disparities Attributed to Linguistic Minoritization in Health Care Settings

There is a paucity of understanding about how language influences pain communication and outcomes for families who speak languages other than English in the United States. This is of great importance because 21.6% (68 million) of the population speak a language other than English, with 8% (25 million) of the population speaking English "less than very well." Thus, the aim of this paper is to present a narrative review that describes how spoken language influences pediatric pain assessment and outcomes for children who speak languages other than English and discuss hypothesized factors that contribute to pain disparities in hospital settings. Results from the narrative review reveal that children and families who speak languages other than English have disparate pain outcomes compared with children from English-speaking families. It is hypothesized that individual (eg, clinician bias), interpersonal (eg, miscommunication of pain concepts), cultural (eg, misunderstanding of cultural concepts of pain), and systemic (eg, lack of access to interpretation services) factors influence disparate pain outcomes for linguistically minoritized children. Empirical research, including randomized control trials, regarding hypothesized factors that contribute to pediatric pain disparities for language other than English-speaking children, is severely lacking. Thus, improved understanding of pain concepts and pain communication processes that center individual, interpersonal, cultural, and systemic factors will enable future research to design interventions that enhance culturally relevant pain assessment and management for families who speak languages other than English. PERSPECTIVE: This article summarizes factors that contribute to pain disparities for children who speak languages other than English. Hypothesized factors that contribute to pain disparities for language other than English-speaking children and families include clinician bias, misunderstanding of pain concepts, and lack of access to interpretation services.

Listening to Black Women's Perspectives of Birth Centers and Midwifery Care: Advocacy, Protection, and Empowerment

INTRODUCTION

Black women in Texas experience high rates of adverse maternal outcomes that have been linked to health inequities and structural racism in the maternal care system. Birth centers and midwifery care are highlighted in the literature as contributing to improved perinatal care experiences and decreased adverse outcomes for Black women. However, compared with White women, Black women underuse birth centers and midwifery care. Black women's perceptions in Texas of birth center and midwifery care are underrepresented in research. Thus, this study aimed to highlight the views of Black women residing in Texas on birth centers and midwifery care to identify their needs and explore ways to increasing access to perinatal care.

METHODS

Semistructured interviews were conducted with 10 pregnant and postpartum Black women residing in Texas. Questions focused on the women's access, knowledge, and use of birth centers and midwifery care in the context of their lived maternal care experiences. Interview transcripts were reviewed and analyzed using inductive, qualitative content analysis.

RESULTS

The Black women interviewed all shared experiences of discrimination and bias while receiving obstetric care that affected their interest in and overall perceptions of birth center and midwifery care. Participants also discussed financial and institutional barriers that impacted their ease of access to birth center and midwifery care services. Additionally, participants highlighted the need for culturally sensitive and respectful perinatal health care.

DISCUSSION

The Black women interviewed in this study emphasized the prevalence of racism and discrimination in perinatal health care encounters, a reflection consistent with current literature. Black women also expressed a desire to use birth centers and midwifery care but identified the barriers in Texas that impede access. Study findings highlight the need to address barriers to promote equitable perinatal health care access for Black women.

The Association Between Experienced Discrimination and Pain in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

BACKGROUND

The relationship between experienced discrimination and its effects on pain interference and management among racial disparities is not well explored. This research investigated these associations among Black and White U.S. adults.

METHODS

The analysis involved 9369 Black and White adults in the REasons for Geographic and Racial Differences in Stroke (REGARDS), assessing experiences of discrimination, pain interference (SF-12), and pain treatment, incorporating factors like demographics, comorbidities, and stress.

RESULTS

Black participants experiencing moderate discrimination were found to have a 41% increased likelihood of pain interference (aOR 1.41, 95% CI 1.02-1.95), similaritythose facing high levels of discrimination also showed a 41% increase (aOR 1.41, 95% CI 1.06-1.86) compared to those without such experiences. White individuals reporting moderate discrimination also faced a heightened risk, with a 21% greater chance of pain interference (aOR 1.21, 95% CI 1.01-1.45). Notably, the presence of moderate discrimination among Black participants correlated with a 12% reduced probability of receiving pain treatment (aOR 0.88, 95% CI 0.56-1.37). Furthermore, Black, and White individuals who reported discrimination when seeking employment had a 33% (aOR 0.67, 95% CI 0.45-0.98) and 32% (aOR 0.68, 95% CI 0.48-0.96) lower likelihood, respectively, of receiving treated pain.

CONCLUSION

The study elucidates how discrimination exacerbates pain interference and restricts access to treatment, affecting Black and White individuals differently. These findings underscore an urgent need for strategies to counteract discrimination's negative effects on healthcare outcomes. Addressing these disparities is crucial for advancing health equity and improving the overall quality of care.

Age, Race, Ethnicity, and Sex of Participants in Clinical Trials Focused on Chronic Pain

There is limited data on equitable inclusion in chronic pain trials. We aimed to 1) identify the frequency of reporting age, race, ethnicity, and sex in clinical trials targeting chronic pain, and 2) compare sociodemographic representation to the United States (US) population. We examined US-based intervention trials for chronic pain initiated between 2007 and 2021 and registered on ClinicalTrials.gov. We 1) assessed the frequency of reporting each demographic variable, 2) compared representation with US population estimates, and 3) explored change in reporting over time. Of 501 clinical trials, the frequency of reporting was as follows: 36.9% reported older adults, 54.3% reported race, 37.4% reported ethnicity, and 100% reported sex. Rates of race and ethnicity reporting increased, but older adult age reporting decreased over time (ps < .00001). Compared to 2020 US population estimates, there was an equitable representation of older adults, under-representation of individuals identifying as American Indian or Alaska Native (.8% vs .6%), Asian (5.6% vs 2.9%), Black or African American (12.6% vs 12.2%), with more than one race (2.9% vs 1.2%), and Hispanic/Latino (16.9% vs 14.1%). There was an over-representation of individuals identifying as Native Hawaiian or Pacific Islander (.2% vs .5%) or White (70.4% vs 72.9%), and of females (50.8% vs 68.4%). Some representation rates varied by chronic pain condition. Reporting of older adult age, race, and ethnicity was low in chronic pain trials in ClinicalTrials.gov, reinforcing the need for adhering to reporting guidelines. Representation varied across trials compared with US population data, particularly among those identifying as Hispanic/Latino and certain minority racial groups. PERSPECTIVE: Despite initiatives to increase the reporting of demographic information, doing so in clinical pain trials is far from ubiquitous. Moreover, efforts to improve diversity in these trials continue to be insufficient. Indeed, Black, Indigenous, and People of Color (BIPOC) remain under-represented in clinical pain trials.

Racial and Ethnic Patient Care Disparities in Anesthesiology: History, Current State, and a Way Forward

Disparities in patient care and outcomes are well-documented in medicine but have received comparatively less attention in anesthesiology. Those disparities linked to racial and ethnic identity are pervasive, with compelling evidence in operative anesthesiology, obstetric anesthesiology, pain medicine, and critical care. This narrative review presents an overview of disparities in perioperative patient care that is grounded in historical context followed by potential solutions for mitigating disparities and inequities.

Racial and Ethnic Disparities in the Prescribing of Pain Medication in US Primary Care Settings, 1999-2019: Where Are We Now?

BACKGROUND

Policy initiatives have attempted to reduce healthcare inequalities in the USA, but evidence on whether these initiatives have reduced racial and ethnic disparities in pain treatment in primary care is lacking.

OBJECTIVE

To determine whether racial and ethnic disparities in medication prescribed for pain in primary care settings have diminished over a 21-year period from 1999 to 2019.

DESIGN

An annual, representative cross-sectional probability sample of visits to US primary care physicians, taken from the National Ambulatory Medical Care Survey.

PATIENTS

Pain-related visits to primary care physicians.

MAIN MEASURES

Prescriptions for opioid and non-opioid analgesics.

KEY RESULTS

Of 599,293 (16%) sampled visits, 94,422 were pain-related, representing a population-weighted estimate of 143 million visits made annually to primary care physicians for pain. Relative risk analysis controlling for insurance, pain type, and other potential confounds showed no difference in pain medication prescribed between Black and White patients (p = .121). However, White patients were 1.61 (95% CI 1.32-1.97) and Black patients 1.57 (95% CI 1.26-1.95) times more likely to be prescribed opioids than a more underrepresented group consisting of Asian, Native-Hawaiian/Pacific-Islander, and American-Indian/Alaska-Natives (ps < .001). Non-Hispanic/Latino patients were 1.32 (95% CI 1.18-1.45) times more likely to receive opioids for pain than Hispanic/Latino patients (p < .001). Penalized cubic spline regression found no substantive narrowing of disparities over time.

CONCLUSIONS

These findings suggest that additional intervention strategies, or better implementation of existing strategies, are needed to eliminate ethnic and racial disparities in pain treatment towards the goal of equitable healthcare.

"My Goal is…to get Through the Day Without Pain": A Qualitative Study on Chronic Pain Experiences and Treatment Needs Among Child Caregiving Women

INTRODUCTION

We aimed to understand connections between pain, caregiving, physical and behavioral health treatment needs, and motivations for prescription opioid use among child caregiving women with chronic pain.

METHODS

We conducted in-depth, semi-structured interviews with 12 women (average age 48 years; 58% Black) in child caregiving roles, including women who were pregnant or trying to become pregnant and were caring for children or grandchildren < 18 years, and who received treatment at an outpatient pain management clinic. We used thematic text analysis to identify qualitative themes related to caregiving, pain, treatment, substance use, coping strategies, and sources of support.

RESULTS

A diverse sample of women reported high levels of stress and pain, substance use, interpersonal violence, depression, and financial strain. Most described difficulties at work, interacting with children or grandchildren, and engaging routine, daily activities due to their pain. Most indicated that they spent less time with family and friends due to their pain and had limited sources of support to help them navigate both caregiving and pain. Many described barriers to receiving appropriate healthcare, including prescription opioids, due to stigma or logistics, though most also reported positive healthcare experiences. Women also reported added daily-life, physical, mental health, and interpersonal stressors and difficulty navigating the healthcare system to receive needed care.

DISCUSSION

For women with chronic pain in child caregiver roles, results highlight the importance of care tailored to the physical needs of child caregiving and of trauma-informed approaches given the prevalence of comorbid conditions and trauma.

Treatment Goals and Preferences of Black Veterans with Chronic Musculoskeletal Pain

Understanding patient goals and preferences is critical in the context of complex conditions such as chronic pain. This need may be especially pronounced for Black patients, who experience significant health and healthcare disparities. The primary aim of this study was to describe the treatment goals and preferences of Black veterans with chronic musculoskeletal pain who were enrolled in the intervention arm of a randomized controlled trial testing a coaching intervention. In the coaching sessions, participants (n = 106) identified their most important pain-related treatment goals and preferences. Participants' top treatment goals were to improve physical functioning (61%), increase engagement in valued activities (45%), and reduce pain intensity (37%). Most participants (73%) preferred non-pharmacological treatments (eg, physical therapy, exercise, acupuncture, yoga). The 17% of participants who identified medications as a preferred treatment demonstrated higher levels of depression and anxiety compared to those who did not. Approximately 42% and 21% of participants stated a preference to avoid pharmacological and surgical pain treatments, respectively. Black patients with chronic pain prioritize improving physical functioning and pain intensity in service of increasing their engagement in exercise, work, relationships, and leisure activities. Also, in the current study, patients expressed a clear preference for non-pharmacological pain treatments. Future research should investigate ways to improve communication of goals and preferences with providers and facilitate access to non-pharmacological treatments for Black patients with chronic pain. PERSPECTIVE: This article describes the treatment goals and preferences of Black veterans with chronic pain. Most patients prioritized goals to improve physical functioning, pain severity, and participation in valued activities. Patients primarily preferred non-pharmacological treatments. This emphasizes the need for clear communication with Black patients regarding pain-related goals and non-pharmacological treatment options.

Prevalence of Chronic Pain by Immigration Status and Latino Ethnicity

OBJECTIVE

The goal of this study was to evaluate the Latino paradox and healthy migrant hypotheses by estimating the association between the prevalence of chronic pain, immigration status, and Latino ethnicity.

METHODS

This cross-sectional study analyzed pooled data from 85,395 adult participants of the 2019-2021 National Health Interview Survey. The dependent variables were any pain and chronic pain in the past 3 months. The independent variables were immigration status (US born, naturalized citizen, non-citizen) and Latino ethnicity.

RESULTS

Chronic pain was prevalent for nearly a quarter of US born non-Latino adults (24%) and non-citizen non-Latino adults had the lowest prevalence at 8%. In multivariable adjusted models, US born non-Latino immigration status and ethnicity was associated with a higher probability of reporting chronic pain in the last 3 months compared to US born Latino adults (-3.0%; 95% CI = -4.4%, -1.6%), naturalized citizen non-Latino adults (-4.7%; 95% CI = -5.9%, -3.4%), naturalized citizen Latino adults (-6.7%; 95% CI = -8.5%, -4.9%), non-citizen non-Latino adults (-3.1%; 95% CI = -4.7%, -1.5%), and non-citizen Latino adults (-8.9%; 95% CI = -10.8%, -7.0%).

CONCLUSION

US Born non-Latino adults reported the highest prevalence of chronic pain and non-citizen Latino adults reported the lowest prevalence of chronic pain providing support for the Latino paradox and healthy migrant effect hypotheses.

Improving pain communication between limited English-speaking Hmong patients, medical interpreters, and health care providers in primary care: A pilot study

This pilot study assessed the feasibility of implementing a pain assessment information visualization (InfoViz) tool to address cultural and language barriers among limited English proficiency (LEP) Hmong patients in primary care. We used a static group comparison design to collect data from 20 patient, interpreter, and provider triads under usual care (i.e., interpreter using verbal pain descriptions), followed by another 20 triads under the intervention (i.e., interpreter using verbal pain descriptions and the InfoViz tool). Feasibility outcomes included recruitment and retention rates, InfoViz tool completion, acceptability, and fidelity. We also assessed mutual understanding (MU) and pain electronic health record (EHR) documentation. Descriptive data were calculated and thematic analysis was conducted. Thirty-six LEP Hmong patients (n = 29 female, mean age = 59.03), 27 providers (n = 15 female), and four interpreters participated in this study. The patient recruitment rate was 18% while the retention rate was 81%. Interpreter recruitment rate was 80%, and 75% for retention rate. The intervention fidelity mean score was 83%. In the intervention condition, patient-provider MU of pain severity improved by 30%, coupled with a 28% increase in pain severity EHR documentation compared to usual care. While communication of pain quality did not improve, there was a higher mean number of pain descriptors (3.31 in the intervention vs. 1.79 in usual care) in EHR documentation. All participants had a positive experience with the tool, reporting it as valuable with 100% completeness of all tools. Findings revealed the tool was acceptable and feasible to use among LEP patients-interpreters-providers, providing support for an efficacy study.

Determinants of implementation for group medical visits for patients with chronic pain: a systematic review

BACKGROUND

Despite the critical need for comprehensive and effective chronic pain care, delivery of such care remains challenging. Group medical visits (GMVs) offer an innovative and efficient model for providing comprehensive care for patients with chronic pain. The purpose of this systematic review was to identify barriers and facilitators (determinants) to implementing GMVs for adult patients with chronic pain.

METHODS

The review included peer-reviewed studies reporting findings on implementation of GMVs for chronic pain, inclusive of all study designs. Pubmed, EMBASE, Web of Science, and Cochrane Library were searched. Studies of individual appointments or group therapy were excluded. The Mixed Methods Appraisal Tool was used to determine risk of bias. Data related to implementation determinants were extracted independently by two reviewers. Data synthesis was guided by the updated Consolidated Framework for Implementation Research.

RESULTS

Thirty-three articles reporting on 25 studies met criteria for inclusion and included qualitative observational (n = 8), randomized controlled trial (n = 6), quantitative non-randomized (n = 9), quantitative descriptive (n = 3), and mixed methods designs (n = 7). The studies included in this review included a total of 2364 participants. Quality ratings were mixed, with qualitative articles receiving the highest quality ratings. Common multi-level determinants included the relative advantage of GMVs for chronic pain over other available models, the capability and motivation of clinicians, the cost of GMVs to patients and the health system, the need and opportunity of patients, the availability of resources and relational connections supporting recruitment and referral to GMVs within the clinic setting, and financing and policies within the outer setting.

CONCLUSIONS

Multi-level factors determine the implementation of GMVs for chronic pain. Future research is needed to investigate these determinants more thoroughly and to develop and test implementation strategies addressing these determinants to promote the scale-up of GMVs for patients with chronic pain.

TRIAL REGISTRATION

This systematic review was registered with PROSPERO 2021 CRD42021231310 .

Short-acting opioid prescriptions and Workers' Compensation using the National Ambulatory Medical Care Survey

BACKGROUND

Short-acting opioids have been utilized for pain management with little known about their use in patients on Workers' Compensation (WC) insurance. Our goal was to investigate this association in the ambulatory care setting.

METHODS

Using the National Ambulatory Medical Care Survey, visits from patients aged 18-64 during the years 2010 until 2018 were evaluated (excluding 2017 due to data availability). Demographic and co-morbidity data from each visit was obtained along with the visit year. The first short-acting opioid medication prescribed in the database was considered. Survey-weighted frequencies were evaluated. Logistic regression estimated the crude and adjusted odds ratios (OR) with 95% confidence intervals for the use of short-acting opioid prescription.

RESULTS

There were 155,947 included visits with 62.5% for female patients. Most patients were White with 11.7% identifying as Black, and 6% identifying as another race. Over 13% of the sample was of Hispanic descent. WC was the identified insurance type in 1.6% of the sample population. Of these patients, 25.6% were prescribed a short-acting opioid, compared with 10.1% of those with another identified insurance. On multivariable regression, Black patients had increased odds of being prescribed a short-acting opioid compared to white patients (OR: 1.22, 95% CI: 1.11-1.34). Those on WC had 1.7-fold higher odds of being prescribed short-acting opioids (95% CI: 1.46-2.06).

CONCLUSION

Certain patient characteristics, including having WC insurance, increased the odds of a short-acting opioid prescription. Further work is needed to identify prescribing patterns in specific high-risk occupational groups, as well as to elicit potential associated health outcomes.

Sociodemographic disparities and potential biases in persistent pain estimates: Findings from 5 waves of the Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

Pain is a prevalent, debilitating condition among older adults. Much evidence on this topic comes from cohort studies, which may be affected by attrition and measurement bias. Little is known about the impact of these biases on pain estimates for European older adults. Additionally, there is a lack of longitudinal research on pain and sociodemographic disparities in Irish older adults.

METHODS

We analysed data from 8171 participants (aged ≥50 at baseline) across five waves of the Irish Longitudinal Study on Ageing. Longitudinal pain severity and sociodemographic disparities in pain were explored visually and using a latent growth curve model. Using multivariate logistic regression, we examined bias due to attrition at later waves associated with reported pain at Wave 1. Measurement biases due to reporting heterogeneity were assessed by investigating associations between sociodemographic factors and pain-related disability for given pain levels.

RESULTS

Wave 1 severe pain was associated with increased odds of attrition due to death by Wave 5 (AOR: 1.63, 95% CI: 1.20, 2.19). Not having private health insurance was associated with increased odds of pain-related disability at Wave 1, controlling for pain severity (AOR: 1.37, 95% CI: 1.15, 1.64). These results suggested mortality bias and reporting heterogeneity measurement bias, respectively. Sex, education level, and private health insurance status disparities in pain were observed longitudinally.

CONCLUSIONS

Mortality bias and reporting heterogeneity measurement bias must be accounted for to improve older adult pain estimates. There is a need for policymakers to address sociodemographic disparities in older adult pain levels.

SIGNIFICANCE

This study highlights a need to address bias in the estimation of pain in observational studies of older adults. Understanding the sources and extent of these biases is important so that health practices and policies to address pain disparities can be guided by accurate estimates. Women, those with lower educational attainment, and those without private health insurance were found to have the highest pain burden longitudinally, suggesting a need for targeted interventions for these groups in Ireland and internationally.

Retention, adherence, and acceptability testing of a digital health intervention in a 3-group randomized controlled trial for chronic musculoskeletal pain

OBJECTIVES

Evaluate a digital health intervention using Auricular Point Acupressure (APA) for chronic musculoskeletal pain in terms of participant retention, adherence, acceptability, and satisfaction. Chronic musculoskeletal pain is a global concern and there are persistent challenges in pain management. Despite the value of digital health interventions, these interventions need to be fully evaluated for feasibility.

METHODS

We conducted a 3-group, longitudinal, randomized controlled trial (RCT). After Institutional Review Board approval, we posted recruitment flyers in a university, healthcare clinics, and community settings. Participants were randomized into an in-person + app group (n = 8), virtual + app group (n = 7), and a wait-list, education-enhanced control group (n = 8), evaluating our outcomes using standard feasibility measures. The 4-week intervention consisted of virtual sessions, telecommunications, and our APA app, followed by a 3-month follow-up.

RESULTS

Data from 22 participants were subsequently analyzed (95.7%). All app participants adhered to the study protocol and used APA at the minimum recommended frequency and duration. The virtual + app group used APA more during the intervention and follow-up periods. All app participants found the intervention to be acceptable and at least 80% overall were satisfied with APA at the 3-month follow-up. There were no adverse events reported.

CONCLUSIONS

Our digital health intervention was found to be acceptable and sustainable; participants adhered to and were satisfied with the intervention providing support for a larger RCT.

CLINICAL TRIAL

#: NCT05020470.

Exploring downstream effects of gender roles in healthcare decision-making and relationships within systems: A cross-sectional analysis of openness to treatment in pediatric headache

OBJECTIVE

Socio-culturally defined identity factors present significant and often understudied influences on the experience, management, and treatment of chronic pain. For instance, there exist societal narratives about how males and females are expected to experience and express pain. Such gender roles may impact youth and caregiver openness to individual multidisciplinary treatments for pediatric headache.

METHODS

In this cross-sectional study, participants (N = 1087 youth/caregiver dyads, Mage = 14.5 years, 71% female, 97% cisgender, 77% White) completed a series of questionnaires, including Openness to Headache Treatment (OHT), upon presenting for initial multidisciplinary evaluation of chronic headache. Pearson correlations, independent samples t-tests and hierarchical regressions were used to analyze potential gender differences in youth and caregiver openness, as well as its relationships with pain-related and psychological factors.

RESULTS

Overall, female youth and their caregivers were more open to headache treatment, broadly and for individual interventions, when compared to male counterparts. Caregiver distress related to their child's headaches (i.e., fear and avoidance) was significantly correlated with openness in female youth and their caregivers, but not males.

CONCLUSION

Gendered patterns in healthcare decision-making in youth and caregivers provide insight on individual, societal, and systemic gender bias.

Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System

Prescription opioids still account for a large proportion of overdose deaths and contribute to opioid use dependence (OUD). Studies earlier in the epidemic suggest clinicians were less likely to prescribe opioids to racial/ethnic minorities. As OUD-related deaths have increased disproportionately amongst minority populations, it is essential to understand racial/ethnic differences in opioid prescribing patterns to inform culturally sensitive mitigation efforts. The purpose of this study is to estimate racial/ethnic differences in opioid medication use among patients prescribed opioids. Using electronic health records and a retrospective cohort study design, we estimated multivariable hazard models and generalized linear models, assessing racial/ethnic differences in OUD diagnosis, number of opioid prescriptions, receiving only one opioid prescription, and receiving ≥18 opioid prescriptions. Study population (N=22,201) consisted of adult patients (≥18years), with ≥3 primary care visits (ensuring healthcare system linkage), ≥1 opioid prescription, who did not have an OUD diagnoses prior to the first opioid prescription during the 32-month study period. Relative to racial/ethnic minority patients, White patients, in both unadjusted and adjusted analyses, had a greater number of opioid prescriptions filled, a higher proportion received ≥18 opioid prescriptions, and a greater hazard of having an OUD diagnosis subsequent to receiving an opioid prescription (all groups p<0.001). Although opioid prescribing rates have declined nationally, our findings suggest White patients still experience a high volume of opioid prescriptions and greater risk of OUD diagnosis. Racial/ethnic minorities are less likely to receive follow-up pain medications, which may signal low care quality. Identifying provider bias in pain management of racial/ethnic minorities could inform interventions seeking balance between adequate pain treatment and risk of opioid misuse/abuse.

Pain mechanisms for the practicing rheumatologist

Pain in rheumatic diseases transcends the traditional nociceptive paradigm, incorporating complex interactions between nociceptive, neuropathic, and nociplastic mechanisms, as well as significant psychosocial factors. Advances in understanding chronic pain highlight the role of peripheral and central sensitization, and the emergence of nociplastic pain-a result of altered central nervous system processing. This modern perspective acknowledges the influence of mood disorders, environmental stressors, and cognitive patterns like catastrophizing, revealing the intricate interplay between biological, psychological, and social determinants of pain. Research emphasizes the brain's pivotal role in pain perception, underscoring the importance of comprehensive approaches that integrate medical, psychological, and social interventions to address the multifaceted nature of chronic pain in rheumatic diseases effectively.

Racial Disparities in Opioid Use and Lumbar Spine Surgery for Chronic Pain and in Pain and Function Over 3 Years: A Retrospective Cohort Study

This study aims to compare treatments and outcomes among Black and White patients with chronic low back pain in the United States. A retrospective cohort study was conducted within a pain research registry, including 1,443 participants with up to 3 years of follow-up. Pain treatments were measured at quarterly research encounters using reported current opioid use and prior lumbar spine surgery. Pain intensity and functional disability were also measured quarterly with a numerical rating scale and the Roland-Morris Disability Questionnaire, respectively. Longitudinal data were analyzed with generalized estimating equations, including multivariable models to measure temporal trends and adjust for potential confounders. The mean baseline age of participants was 53.5 years (SD, 13.1 years); 1,074 (74.4%) were female, and 260 (18.0%) were Black. In longitudinal multivariable analyses, Black participants reported more frequent current opioid use (odds ratio, 1.40; 95% confidence interval [CI], 1.03-1.91; P = .03) and less frequent lumbar spine surgery (odds ratio, .45; 95% CI, .28-.72; P < .001). Black participants also reported greater pain intensity (mean, 6.6; 95% CI, 6.3-6.9 vs mean, 5.6; 95% CI, 5.4-5.8; P < .001) and functional disability (mean, 15.3; 95% CI, 14.6-16.0 vs mean, 13.8; 95% CI, 13.2-14.3; P = .002). Racial disparities were clinically important (risk ratio = 1.28 and risk ratio = .49, respectively, for opioid use and surgery; and d = .46 and d = .24, respectively, for pain and function). Racial disparities in pain and function also widened over time. Thus, barriers to guideline-adherent and specialized pain care among Black patients may affect pain and function outcomes. Greater efforts are needed to address the observed racial disparities. PERSPECTIVE: Widening racial disparities in pain and function over time indicate that new approaches to chronic pain management are needed in the United States. Considering race as a social framework represents an emerging strategy for planning and improving pain treatment services for Black patients.

Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): a Qualitative Analysis of a Tailored Coaching Program for Black Patients with Chronic Pain

BACKGROUND

Racial inequities in pain treatment are well-documented and persist despite national priorities focused on health equity. The COOPERATE (Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity) intervention was a patient-centered, tailored intervention aimed at improving health equity by targeting patient activation-the knowledge and confidence to manage one's health. COOPERATE led to significant and sustained increases in patient activation, significant short-term increases in communication self-efficacy (confidence to communicate with clinicians), and more intervention participants experienced clinically significant (≥ 30%) reductions in pain at 3 months than control group participants.

OBJECTIVE

To understand how participants experienced the intervention, including their perspectives on its effects on their health and healthcare experiences.

DESIGN

Semi-structured qualitative interviews.

PARTICIPANTS

Black veterans with chronic pain who participated in the COOPERATE intervention.

KEY RESULTS

Participants described acquiring new tools and cultivating skills to use in their clinic visits, including preparing for their visit (writing an agenda, listing questions); asking focused, effective questions; and expressing concerns and communicating goals, values, and preferences. Participants indicated that by putting these tools to use, they felt more confident and able to take ownership of their own pain care; for some, this led to better pain management and improved pain. Participants expressed mixed views of disparities in pain care, with some believing race and racism did not play a role in their care, while others valued being part of an intervention that helped equip them with tools to exercise autonomy over their healthcare.

CONCLUSIONS

Black patients with chronic pain described gaining greater confidence to self-manage and communicate with their clinicians after participating in the COOPERATE intervention. With its focus on empowering individuals, the COOPERATE intervention represents a promising approach to help advance equity in pain care.

Trends in Racial Inequalities in the Administration of Opioid and Non-opioid Pain Medication in US Emergency Departments Across 1999-2020

BACKGROUND

Despite initiatives to eradicate racial inequalities in pain treatment, there is no clear picture on whether this has translated to changes in clinical practice.

OBJECTIVE

To determine whether racial disparities in the receipt of pain medication in the emergency department have diminished over a 22-year period from 1999 to 2020.

DESIGN

We used data from the National Hospital Ambulatory Medical Care Survey, an annual, cross-sectional probability sample of visits to emergency departments of non-federal general and short-stay hospitals in the USA.

PATIENTS

Pain-related visits to the ED by Black or White patients.

MAIN MEASURES

Prescriptions for opioid and non-opioid analgesics.

KEY RESULTS

A total of 203,854 of all sampled 625,433 ED visits (35%) by Black or White patients were pain-related, translating to a population-weighted estimate of over 42 million actual visits to US emergency departments for pain annually across 1999-2020. Relative risk regression found visits by White patients were 1.26 (95% CI, 1.22-1.30; p<0.001) times more likely to result in an opioid prescription for pain compared to Black patients (40% vs. 32%). Visits by Black patients were also 1.25 (95% CI, 1.21-1.30; p<0.001) times more likely to result in non-opioid analgesics only being prescribed. Results were not substantively altered after adjusting for insurance status, type and severity of pain, geographical region, and other potential confounders. Spline regression found no evidence of meaningful change in the magnitude of racial disparities in prescribed pain medication over 22 years.

CONCLUSIONS

Initiatives to create equitable healthcare do not appear to have resulted in meaningful alleviation of racial disparities in pain treatment in the emergency department.

Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial

ABSTRACT

Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one's health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus +0.13 in control group, 95% CI: 0.48, 7.34; P = 0.03). These improvements in the intervention group were sustained, with +7 from baseline at 6 months and +5.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.

Pain Care Disparities and the Use of Virtual Care Among Racial-Ethnic Minority Groups During COVID-19

BACKGROUND AND OBJECTIVE

COVID-19 led to an unprecedented reliance on virtual modalities to maintain care continuity for patients living with chronic pain. We examined whether there were disparities in virtual specialty pain care for racial-ethnic minority groups during COVID-19.

DESIGN AND PARTICIPANTS

This was a retrospective national cohort study with two comparison groups: primary care patients with chronic pain seen immediately prior to COVID-19 (3/1/19-2/29/20) (N = 1,649,053) and a cohort of patients seen in the year prior (3/1/18-2/28-19; n = 1,536,954).

MAIN MEASURES

We assessed use of telehealth (telephone or video) specialty pain care, in-person care specialty pain care, and any specialty pain care for both groups at 6 months following cohort inclusion. We used quasi-Poisson regressions to test associations between patient race and ethnicity and receipt of care.

KEY RESULTS

Prior to COVID-19, there were Black-White (RR = 0.64, 95% CI [0.62, 0.67]) and Asian-White (RR = 0.63, 95% CI [0.54, 0.75]) disparities in telehealth use, and these lessened during COVID-19 (Black-White: RR = 0.75, 95% CI [0.73, 0.77], Asian-White: RR = 0.81, 95% CI [0.74, 0.89]) but did not disappear. Individuals identifying as American Indian/Alaska Native used telehealth less than White individuals during early COVID-19 (RR = 0.98, 95% CI [0.85, 1.13] to RR = 0.87, 95% CI [0.79, 0.96]). Hispanic/Latinx individuals were less likely than non-Hispanic/Latinx individuals to use telehealth prior to COVID-19 but more likely during early COVID-19 (RR = 0.70, 95% CI [0.66, 0.75] to RR = 1.06, 95% CI [1.02, 1.09]). Disparities in virtual pain care occurred over the backdrop of overall decreased specialty pain care during the early phase of the pandemic (raw decrease of n = 17,481 specialty care encounters overall from pre-COVID to COVID-era), including increased disparities in any VA specialty pain care for Black (RR = 0.81, 95% CI [0.80, 0.83] to RR = 0.79, 95% CI [0.77, 0.80]) and Asian (RR = 0.91, 95% CI [0.86, 0.97] to RR = 0.88, 95% CI [0.82, 0.94]) individuals.

CONCLUSIONS

Disparities in virtual specialty pain care were smaller during the early phases of the COVID-19 pandemic than prior to the pandemic but did not disappear entirely, despite the rapid growth in telehealth. Targeted efforts to increase access to specialty pain care need to be concentrated among racial-ethnic minority groups.

Pharmacological Prescribing and Satisfaction with Pain Treatment Among Non-Hispanic Black Men with Chronic Pain

Introduction

Pharmacological strategies are often central to chronic pain management; however, pain treatment among non-Hispanic Black men may differ because of their disease profiles and healthcare interactions. However, less is known about pain medication prescribing and patients' satisfaction with pain treatment and management among non-Hispanic Black men with self-reported chronic pain.

Purpose

This study assessed factors associated with non-Hispanic Black men being prescribed/recommended narcotics/opioids for chronic pain and their satisfaction with pain treatment/management.

Methods

Data were analyzed from 286 non-Hispanic Black men with chronic pain who completed an internet-delivered questionnaire. Participants were recruited nationwide using a Qualtrics web-based panel. Logistic regression was used to identify factors associated with being prescribed/recommended narcotics/opioids for pain management treatment. Then, ordinary least squares regression was used to identify factors associated with their satisfaction level with the pain treatment/management received.

Results

On average, participants were 56.2 years old and 48.3% were prescribed/recommended narcotics/opioids for chronic pain. Men with more chronic conditions (Odds Ratio [OR] = 0.57, P = 0.043) and depression/anxiety disorders (OR = 0.53, P = 0.029) were less likely to be prescribed/recommended narcotics/opioids. Men who were more educated (OR = 2.09, P = 0.044), reported more frequent chronic pain (OR = 1.28, P = 0.007), and were allowed to participate more in decisions about their pain treatment/management (OR = 1.11, P = 0.029) were more likely to be prescribed/recommended narcotics/opioids. On average, men with more frequent chronic pain (B = -0.25, P = 0.015) and pain problems (B = -0.16, P = 0.009) were less satisfied with their pain treatment/management. Men who were allowed to participate more in decisions about their pain treatment/management reported higher satisfaction with their pain treatment/management (B = 0.55, P < 0.001).

Conclusion

Playing an active role in pain management can improve non-Hispanic Black men's satisfaction with pain treatment/management. This study illustrates the importance of patient-centered approaches and inclusive patient-provider interactions to improve chronic pain management.

Race-Based Differences in the Response to a Mindfulness Based Integrative Medical Group Visit Intervention for Chronic Pain

Background

Chronic pain is one of the most common drivers of healthcare utilization and a marked domain for health disparities, as African American/Black populations experience high rates of chronic pain. Integrative Medical Group Visits (IMGV) combine mindfulness techniques, evidence-based integrative medicine, and medical group visits. In a parent randomized controlled trial, this approach was tested as an adjunct treatment in a diverse, medically underserved population with chronic pain and depression.

Objective

To determine race-based heterogeneity in the effects of a mindfulness based treatment for chronic pain.

Methods

This secondary analysis of the parent trial assessed heterogeneity of treatment effects along racialized identity in terms of primary patient-reported pain outcomes in a racially diverse sample suffering from chronic pain and depression. The analytic approach examined comorbidities and sociodemographics between racialized groups. RMANOVAs examined trajectories in pain outcomes (average pain, pain severity, and pain interference) over three timepoints (baseline, 9, and 21 weeks) between participants identifying as African American/Black (n = 90) vs White (n = 29) across both intervention and control conditions.

Results

At baseline, African American/Black participants had higher pain severity and had significantly different age, work status, and comorbidity profiles. RMANOVA models also identified significant race-based differences in the response to the parent IMGV intervention. There was reduced pain severity in African American/Black subjects in the IMGV condition from baseline to 9 weeks. This change was not observed in White participants over this time period. However, there was a reduction in pain severity in White participants over the subsequent interval from 9 to 21 week where IMGV had no significant effect in African American/Black subjects during this latter time period.

Conclusion

Interactions between pain and racialization require further investigation to understand how race-based heterogeneity in the response to integrative medicine treatments for chronic pain contribute to the broader landscape of health inequity.

'Engaging on a slightly more human level': A qualitative study exploring the care of individuals with back pain in a multidisciplinary pain clinic

Chronic low back pain is characterised by multiple and overlapping biological, psychological, social and broader dimensions, affecting individuals' lives. Multidisciplinary pain services have been considered optimal settings to account for the multidimensionality of chronic low back pain but have largely focused on cognitive and behavioural aspects of individuals' pain. Social dimensions are usually underexplored, considered outside or beyond healthcare professionals' scope of practice. Employing Actor Network Theorist Mol's concept multiplicity, our aim in this paper is to explore how a pain service's practices bring to the fore the social dimensions of individuals living with low back pain. Drawing on 32 ethnographic observations and four group exchanges with the service's clinicians, findings suggest that practices produced multiple enactments of an individual with low back pain. Although individuals' social context was present and manifested during consultations at the pain service (first enactment: 'the person'), it was often disconnected from care and overlooked in 'treatment/management' (second enactment: 'the patient'). In contrast, certain practices at the pain service not only provided acknowledgement of, but actions towards enhancing, individuals' social contexts by adapting rules and habits, providing assistance outside the service and shifting power relations during consultations (third enactment: 'the patient-person'). We therefore argue that different practices enact different versions of an individual with low back pain in pain services, and that engagement with individuals' social contexts can be part of a service's agenda.

Immigration bias among medical students: a randomized controlled trial

BACKGROUND AND IMPORTANCE

Racial bias is found in both physicians and medical students. Immigrants in many parts of the world face challenges similar to racial minorities. Identification of immigrants might however be more subtle than identification by race, and currently, no data are available on a possible bias against the large minority group of migrants in Europe.

DESIGN

Randomized control trial.

SETTINGS AND PARTICIPANTS

Second-year medical students were randomized into four groups to watch a video of either a male or female patient with pain, with or without immigrant status.

INTERVENTION

Students were asked whether they would administer pain medication (primary outcome).

OUTCOME MEASURES AND ANALYSIS

Immigrant status, patient's gender, student's gender, age, and language skills were covariates in a logistic regression model. Secondary outcomes included pain medication potency and the student's rating of the patient's pain intensity.

MAIN RESULTS

We recruited 607 students [337 females (56%), 387 (64%) between 18 and 22 years old]. Analgesia was administered in 95% (n = 576). Immigrant status was not associated with the probability of receiving pain medication [95 vs. 95%, odds ratio (OR) 0.81, 95% confidence interval (CI) 0.39-1.70, P  = 0.58]. Immigrants received high-potency analgesia less often (26 vs. 33%, OR 0.69, 95% CI 0.50-0.96, P  = 0.03). Female students administered pain medication more frequently (96 vs. 93%, OR 2.29, 95% CI 1.05-5.02, P  = 0.04), and rated the patients' pain higher (mean numeric rating scale 7.7, SD 0.9 vs. 7.4, SD 1.0, OR 1.36, 95% CI 1.16-1.60, P  < 0.001).

CONCLUSION

Medical students showed no immigration bias with regard to administering pain medication but were less likely to choose high-potency analgesia in immigrants. We also found a gender difference in pain management. These results demonstrate the importance of including knowledge about immigration bias in medical training.

Opioid and High-Risk Prescribing Among Racial and Ethnic Minority Veterans

INTRODUCTION

The purpose of this study is to compare opioid prescribing and high-risk prescribing by race and ethnicity in a national cohort of U.S. veterans.

METHODS

A cross-sectional analysis of veteran characteristics and healthcare use was performed on electronic health record data for 2018 Veterans Health Administration users and enrollees in 2022.

RESULTS

Overall, 14.8% received an opioid prescription. The adjusted odds of being prescribed an opioid were lower for all race/ethnicity groups than for non-Hispanic White veterans, except for non-Hispanic multiracial (AOR=1.03; 95% CI=0.999, 1.05) and non-Hispanic American Indian/Alaska Native (AOR=1.06; 95% CI=1.03, 1.09) veterans. The odds of any day of overlapping opioid prescriptions (i.e., opioid overlap) were lower for all race/ethnicity groups than for the non-Hispanic White group, except for the non-Hispanic American Indian/Alaska Native group (AOR=1.01; 95% CI=0.96, 1.07). Similarly, all race/ethnicity groups had lower odds of any day of daily dose >120 morphine milligram equivalents than the non-Hispanic White group, except for the non-Hispanic multiracial (AOR=0.96; 95% CI=0.87, 1.07) and non-Hispanic American Indian/Alaska Native (AOR=1.06; 95% CI=0.96, 1.17) groups. Non-Hispanic Asian veterans had the lowest odds for any day of opioid overlap (AOR=0.54; 95% CI=0.50, 0.57) and daily dose >120 morphine milligram equivalents (AOR=0.43; 95% CI=0.36, 0.52). For any day of opioid-benzodiazepine overlap, all races/ethnicities had lower odds than non-Hispanic White. Non-Hispanic Black/African American (AOR=0.71; 95% CI=0.70, 0.72) and non-Hispanic Asian (AOR=0.73; 95% CI=0.68, 0.77) veterans had the lowest odds of any day of opioid-benzodiazepine overlap.

CONCLUSIONS

Non-Hispanic White and non-Hispanic American Indian/Alaska Native veterans had the greatest likelihood to receive an opioid prescription. When an opioid was prescribed, high-risk prescribing was more common in White and American Indian/Alaska Native veterans than in all other racial/ethnic groups. As the nation's largest integrated healthcare system, the Veterans Health Administration can develop and test interventions to achieve health equity for patients experiencing pain.

Validation of the PEG Scale in Spanish (PEG-S) Among Adults Receiving Care for Pain in US Primary Care

This study sought to evaluate the psychometric properties of a Spanish version of the PEG scale (PEG-S, whose items assess Pain intensity and pain interference with Enjoyment of life and General activity) in a sample of Spanish-speaking adults receiving care for pain at primary care clinics in the Northwestern United States. We evaluated the PEG-S's 1) internal consistency, 2) convergent validity, and 3) discriminant validity. All participants (n = 200, mean age = 52 years [SD = 15], 76% women, mean PEG-S score = 5.7 [SD = 2.5]) identified as having Hispanic or Latino ethnicity, and detailed ethnic origin was predominantly Mexican or Chicano (70%). The PEG-S's internal consistency (Cronbach's alpha, .82) was good. Correlations between the PEG-S scale scores and established measures of pain intensity and interference ranged from .68 to .79, supporting the measure's convergent validity. The correlation between the PEG-S scale score and the Patient Health Questionnaire-9 (r = .53) was weaker than those between the PEG-S scale and measures of pain intensity and interference, supporting the measure's discriminant validity. The findings support reliability and validity of the PEG-S for assessing a composite score of pain intensity and interference among Spanish-speaking adults. PERSPECTIVE: We present evidence supporting the reliability and validity of the PEG scale in Spanish (PEG-S) in a sample of adults receiving pain care at primary care clinics in the Northwestern United States. This 3-item composite measure of pain intensity and interference can help clinicians and researchers assess pain among Spanish-speaking adults.

The Interconnection Between Social Support and Emotional Distress Among Individuals with Chronic Pain: A Narrative Review

Chronic pain is a public health concern affecting over 100 million U.S. adults. Because chronic pain is multifactorial, it requires a biopsychosocial approach to understand how biological, psychological, and social factors contribute to both the development and maintenance of pain. On average, individuals with chronic pain report higher levels of emotional distress compared to pain-free individuals. Research has demonstrated that social support is associated with better pain outcomes and less emotional distress. It has been proposed that social support may improve pain outcomes by reducing the influence of stressors. However, the majority of research exploring the relationships between social support and pain-related outcomes has focused on the direct relationship between these variables, largely overlooking the process by which social support has a positive influence on pain. This narrative review synthesizes research on how chronic pain, emotional distress, and social support are highly interconnected, yet research investigating chronic pain and emotional distress within a social context is limited. We then highlight disparities in chronic pain, such that the burden of chronic pain is unequal between demographic groups. Next, we discuss existing evidence for the use of group-based interventions to address pain-related outcomes. Lastly, we summarize limitations of prior research studies and highlight gaps in the current literature. Overall, longitudinal research comprehensively investigating the distinct nuances in the measurement of social support and how these nuances relate to emotional distress and pain outcomes is needed and may provide insight into the unique needs of individuals or subgroups. Further, demographically diverse randomized controlled trials are needed to identify the process by which group-based interventions improve pain outcomes and whether these interventions are more effective for particular groups in order to personalize treatment approaches and address inequities in pain care.

Health disparities in ethnic and racial minority populations with pain and opioid use disorder

Healthcare providers are not prepared to address health disparities among ethnic and racial minority populations with either persistent and chronic pain or substance use disorder (SUD). Recognizing biases from policies to provide pain management and treatment for SUD in our healthcare systems, from our individual state laws and federal guidelines, is necessary. Biases are embedded in the screening and treatment of patients with chronic pain through the use of screening tools, opioid treatment agreements, and prescription drug monitoring programs. Additionally, the punitive treatment of people of ethnic and racial minority populations who experience persistent and chronic pain, opioid use disorders, or other SUDs needs to be redirected to facilitate solutions rooted in equity.

Labeled as "drug-seeking": nurses use harm reduction philosophy to reflect on mending mutual distrust between healthcare workers and people who use drugs

Introduction

Over 50 years of approaching drug use from the "War on Drugs" has led to ignoring the systemic structural and social determinants of health, enforced drug use stigma, and damaging stereotypes of people who use drugs or are labeled as "drug-seeking," and sorely failed to support those needing assistance.

On philosophy of harm reduction and power

People who use drugs are often disenfranchised and pathologized by being labeled as "a drug addict," which then serves as a rationalization for mistreatment by healthcare providers. This is in opposition to a harm-reduction approach. Harm reduction philosophy is an epistemic valuation necessary for drug use stigma and our moral obligation to reduce harm from interlocking systems of power that perpetuate harm.

On drug-seeking mistrust and human rights

We have encountered many clients who use drugs that report harmful interactions with healthcare providers. Harm reduction is an issue of health equity, social justice, and fundamental human rights. This paper presents three vignettes, the author's experiences of being labeled as-and advocating for family members labeled as "drug-seeking."

Discussion

To better serve as healthcare providers, workers must be equipped to work with people who use drugs and reinforce the social justice commitment against medical stigma, neglect, racism, and inadequate pain coverage and withdrawal treatment. Nurses and our epistemic lens can meet the challenge of complex intersectional issues affecting our use of power to develop more just and equitable health systems and advance our rebuilding of a trusting relationship with the people we serve.

The impact of ethnic discrimination on chronic pain: the role of sex and depression

ABSTRACTPerceived ethnic discrimination (PED) is predictive of chronic pain-related outcomes. Less is known about pathways through which these constructs interact. The goal of this study was to test whether PED was predictive of chronic pain-related outcomes (pain interference, pain intensity, and symptoms related to central sensitization), whether depression mediated the relationship between PED and pain outcomes, and if these relationships were maintained across sex in a sample of racially and ethnically minoritized adults (n = 77). PED significantly predicted pain interference, pain intensity, and symptoms related to central sensitization. Sex accounted for a significant proportion of the variance in pain interference only. Depression explained the relationship between PED and pain interference and pain intensity. Sex moderated the indirect pathway, such that for men, the relationship between PED and pain interference and pain intensity was explained via depression. Depression partially explained the relationship between PED and symptoms related to central sensitization. Sex did not moderate this mediational effect. This study provided a unique contribution to the pain literature by providing a contextual analysis of PED and pain. Addressing and validating experiences of lifetime discrimination may be a clinically relevant tool in the management of chronic pain for of racially and ethnically minoritized adults.

Development of the Chronic Pain Cognition Scale: A Culture-Sensitive Pain Measurement in Chinese

Purpose

People with pain problems are highly vulnerable to cultural disparities, and it is imperative to reduce these inequalities. This cross-sectional study aimed to develop a culturally sensitive Chronic Pain Cognition Scale (CPCS) for Chinese-/Chinese dialect-speaking populations and investigate its psychometric properties.

Patients and Methods

Adult patients with chronic low back pain or chronic neck pain who visited pain clinics at a medical center in northern Taiwan were enrolled. Participants completed the demographic, intensity of pain, and two other related sensations, "Sng ()" and "Ma ()", often reported in Chinese-speaking populations, CPCS, Chronic Pain Acceptance Questionnaire-8, and Pain Self-Efficacy Questionnaire.

Results

200 patients were included. Patients' mean age was 64.84 ± 14.33, 126 (63.0%) were female, and 83 (41.5%) had 13+ years of education. The average duration of pain was 77.25 ± 97.46 months, the intensity of pain was 6.04 ± 2.50, Ma was 3.43 ± 3.24, and Sng was 4.54 ± 3.14. The CPCS comprised four factors: pain impact (how pain impact one's life), losing face (how one being disrespected due to pain), helplessness, and avoidance, with good structural validity and adequate reliability (Cronbach α, 0.60-0.81) and satisfactory criterion-related validity. Moreover, losing face, an essential concept in Chinese relationalism, was significantly related to pain, Sng, and Ma (r = 0.19, 0.15 and 0.16), but not to pain acceptance or self-efficacy, indicating a culturally specific element in pain measurement.

Conclusion

The CPCS has good psychometric properties and is suitable for evaluating chronic pain in the clinical setting, and might be generalizable to other Chinese-/Chinese dialect-speaking populations.

Race-based reporting and participation of Black individuals in registered pain clinical trials, United States, 2000 to 2019

ABSTRACT

There are numerous, well-established racial disparities in the management of pain. The degree to which these are evident at the stage of conducting clinical trials is unknown. To address this knowledge gap, we examined race-based reporting, participation of Black individuals, and the factors associated with reporting and participation in pain clinical trials in the United States. Data were extracted from Clinicaltrials.gov and published articles. One thousand two hundred trials met our inclusion criteria; 482 (40.2%) reported participant race. More recent, publicly funded, and larger trials were more likely to report race. Of 82,468 participants included in pain clinical trials that reported race, 15,101 were Black individuals (18.3%). Participation of Black individuals was significantly associated with pain type (ß = +27% in cardiovascular disease pain compared with acute pain, P < 0.05), study population (ß = +33% and +7% in pain in minoritized populations and women, respectively, compared with general population, P < 0.05), pain intervention (ß = +7.5% for trials of opioid interventions compared with nonopioid interventions, P < 0.05), and a diverse team of investigators (ß = +8.0% for studies incorporating a visible non-White investigator compared with those that did not, P < 0.05). Our results indicate that representation of Black participants in pain clinical trials generally aligns with national demographics in the United States. Increased representation corresponds with health conditions more prevalent among Black individuals (eg, cardiovascular disease) and with a diverse study team composition. Despite these encouraging results, less than half of pain trials reported race, which introduces potential publication bias and limits external validity.

Veterinary education and experience shape beliefs about dog breeds Part 1: Pain sensitivity

Over 95% of veterinarians report believing that dog breeds differ in pain sensitivity. Ratings made by veterinarians differ from those of the general public, suggesting these beliefs may be learned during veterinary training or clinical experiences. Therefore, the current study's primary objective was to evaluate dog breed pain sensitivity ratings during veterinary training and compare these ratings to those of the general public and undergraduates in animal-health related fields. Using an online survey, members of the general public, undergraduates, veterinary students across all four years, and veterinary faculty and staff rated pain sensitivity of 10 different dog breeds, identified only by their pictures. Compared to the general public and undergraduates, veterinary students rated pain sensitivity across breeds of dog more similarly to veterinary faculty and staff. Further, when undergraduates had clinical experience, they also rated certain dog breeds in a similar way to the veterinary students and professionals. Our findings suggest that veterinary education and clinical experiences influence pain sensitivity ratings across dog breeds. Future research should identify how these pain sensitivity beliefs are communicated and whether these beliefs affect recognition and treatment of pain by veterinarians.

Racial and Ethnic Disparities in Opioid Prescriptions for Patients with Abdominal Pain: Analysis of the National Ambulatory Medical Care Survey

BACKGROUND

Disparities in pain control have been extensively studied in the hospital setting, but less is known regarding the racial/ethnic disparities in opioid prescriptions for patients with abdominal pain in ambulatory clinics.

METHODS

We examined opioid prescriptions during visits by patients presenting with abdominal pain between the years of 2006 and 2015, respectively, in the National Ambulatory Medical Care Survey database. Data weights for national-level estimates were applied.

RESULTS

We identified 4006 outpatient visits, equivalent to 114 million weighted visits. Rates of opioid use was highest among non-Hispanic White patients (12%), and then non-Hispanic Black patients (11%), and was the lowest in Hispanic patients (6%). Hispanic patients had lower odds of receiving opioid prescriptions compared to non-Hispanic White patients (OR = 0.49; 95% CI, 0.31-0.77, p = 0.002) and all non-Hispanic patients (OR 0.48; 95% CI 0.30-0.75; p = 0.002). No significant differences were noted in non-opioid analgesia prescriptions (p = 0.507). A higher frequency of anti-depressants/anti-psychotic prescriptions and alcohol use was recorded amongst the non-Hispanic patients (p = 0.027 and p = 0.001, respectively).

CONCLUSIONS

Rates of opioid prescriptions for abdominal pain patients were substantially lower for the Hispanic patients compared with the non-Hispanic patients, despite having a decreased rate of high-risk features, such as alcohol use and depression. The root cause of this disparity needs further research to ensure equitable access to pain management.

Buprenorphine and opioid analgesics: Dispensation and discontinuity among accidental overdose fatalities in the Indianapolis metropolitan area, 2016-2021

BACKGROUND

This study describes overall trends and sociodemographic disparities in buprenorphine and opioid analgesic uptake and prescribing patterns prior to fatal overdose events.

METHODS

We examined toxicology data from all accidental overdose deaths from 2016 to 2021 (N = 2682) in a large metropolitan area. These data were linked at the individual-level with a prescription drug monitoring program (PDMP).

RESULTS

Fewer than half of all deaths had any kind of PDMP record (39.9 %, n = 1070). Among those with a buprenorphine prescription, 10.6 % (n = 35) of decedents had a buprenorphine dispensation within 7 days of their death, while the majority (64.7 %, n = 214) were dispensed buprenorphine more than 30 days prior to death. Evidence existed of racial disparities among those with any buprenorphine uptake, whereby Black individuals (7.3 %, n = 24) had significantly fewer any dispensations compared to White individuals (92.7 %, n = 307). Among those with an opioid analgesic prescription, about 12.2 % (n = 90) were dispensed within 7 days of death, with the majority (68.5 %, n = 506) occurring more than 30 days prior to death. Like buprenorphine dispensations, Black individuals were prescribed a significantly smaller proportion of opioid analgesics (21.9 %, n = 162) versus White individuals (77.7 %, n = 574). Buprenorphine was detected in 78.5 % of deaths where fentanyl was present in the toxicology record, significantly greater when compared to opioid analgesics (57.5 %).

CONCLUSION

Consistent with prior research, our findings suggest prescription opioid analgesics may protect against fatal overdoses. Access to buprenorphine treatment did not keep pace with the rising lethality of the overdose crisis, and in recent years, a smaller percentage of the people at risk of fatal overdose availed themselves of MOUD preceding their death.

Disparities in Pain Management

Health disparities in pain management remain a pervasive public health crisis. Racial and ethnic disparities have been identified in all aspects of pain management from acute, chronic, pediatric, obstetric, and advanced pain procedures. Disparities in pain management are not limited to race and ethnicity, and have been identified in multiple other vulnerable populations. This review targets health care disparities in the management of pain, focusing on steps health care providers and organizations can take to promote health care equity. A multifaceted plan of action with a focus on research, advocacy, policy changes, structural changes, and targeted interventions is recommended.

Considering pharmacoequity when deprescribing potentially inappropriate medications

This editorial comments on the article by Niznik et al. in this issue.

Racial and Ethnic Disparities in Opioid Access and Urine Drug Screening Among Older Patients With Poor-Prognosis Cancer Near the End of Life

PURPOSE

To characterize racial and ethnic disparities and trends in opioid access and urine drug screening (UDS) among patients dying of cancer, and to explore potential mechanisms.

METHODS

Among 318,549 non-Hispanic White (White), Black, and Hispanic Medicare decedents older than 65 years with poor-prognosis cancers, we examined 2007-2019 trends in opioid prescription fills and potency (morphine milligram equivalents [MMEs] per day [MMEDs]) near the end of life (EOL), defined as 30 days before death or hospice enrollment. We estimated the effects of race and ethnicity on opioid access, controlling for demographic and clinical factors. Models were further adjusted for socioeconomic factors including dual-eligibility status, community-level deprivation, and rurality. We similarly explored disparities in UDS.

RESULTS

Between 2007 and 2019, White, Black, and Hispanic decedents experienced steady declines in EOL opioid access and rapid expansion of UDS. Compared with White patients, Black and Hispanic patients were less likely to receive any opioid (Black, -4.3 percentage points, 95% CI, -4.8 to -3.6; Hispanic, -3.6 percentage points, 95% CI, -4.4 to -2.9) and long-acting opioids (Black, -3.1 percentage points, 95% CI, -3.6 to -2.8; Hispanic, -2.2 percentage points, 95% CI, -2.7 to -1.7). They also received lower daily doses (Black, -10.5 MMED, 95% CI, -12.8 to -8.2; Hispanic, -9.1 MMED, 95% CI, -12.1 to -6.1) and lower total doses (Black, -210 MMEs, 95% CI, -293 to -207; Hispanic, -179 MMEs, 95% CI, -217 to -142); Black patients were also more likely to undergo UDS (0.5 percentage points; 95% CI, 0.3 to 0.8). Disparities in EOL opioid access and UDS disproportionately affected Black men. Adjustment for socioeconomic factors did not attenuate the EOL opioid access disparities.

CONCLUSION

There are substantial and persistent racial and ethnic inequities in opioid access among older patients dying of cancer, which are not mediated by socioeconomic variables.