Racial and ethnic disparities in pain management in the United States

Photos Sculpt the Stories of Youth: Using Photovoice to Holistically Capture the Lived Experiences and Pain of Youth Who Underwent Spinal Fusion Surgery

Spinal fusion surgery is one of the most common major surgical procedures in youth. Adolescent idiopathic scoliosis (AIS) is the most frequent reason for corrective spinal fusion. AIS (∼25%-47% of cases) and spinal fusion surgeries are associated with pain, including the development of new onset chronic pain for up to 15% of youth. This research used photovoice approaches to explore the journeys of youth from before, during, and after spinal fusion surgery, to demonstrate their experiences both of and beyond pain. Twenty participants were recruited from a previous study conducted by the senior author's lab. Participants captured photos/videos in their daily life (Phase 1); collected previously taken photos/videos from before/during/after their surgery (Phase 2); and participated in individual interviews to reflexively discuss the meaning behind photos/videos (Phase 3). Before interviews, a questionnaire was administered to assess pain characteristics. Nineteen girls/women with scoliosis and one boy/man with kyphosis (12-19 years old, Mage = 16 years) participated; they identified as white (80%), other (15%), and Southeast Asian (5%). The researchers used a reflexive thematic analysis approach, which generated five themes: (1) body aesthetic versus machine; (2) expectations and anticipation of surgery/outcomes; (3) desire of normalcy and freedom; (4) navigating a hoped-for positive surgery experience; and (5) the journey sculpts identity formation and sense of self. Findings support youth advocacy, underscoring the need to validate youth concerns and inform healthcare professionals of the importance of individualized care. Youth perspectives highlighted opportunities for optimizing surgery/healthcare experiences and the psychosocial impacts of scoliosis on body image and appearance.

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.

The relationship between emotion regulation and pain catastrophizing in patients with chronic pain

OBJECTIVES

Pain catastrophizing (PC) is a cognitive/emotional response to and in anticipation of pain that can be maladaptive, further exacerbating pain and difficulty in emotion regulation (ER). There is a lack of research on the interplay between PC and ER and its impact on pain. Our aim was to investigate whether ER exacerbated the pain experience through PC.

METHODS

Adults with chronic non-cancer pain of >3 months' duration (n = 150) who were taking opioid medication were recruited from a large medical center in Pennsylvania. A battery of questionnaires was conducted to gather data on demographics, substance use, mental health histories, and health and pain outcomes. Measures used included the 18-Item Difficulties in Emotion Regulation Scale, the Pain Catastrophizing Scale, the Brief Pain Inventory-Short Form, and the Hospital Anxiety and Depression Scale. A structural equation model with latent variables was conducted to examine our aim.

RESULTS

Both pain interference and severity were significantly positively associated with several psychosocial variables, such as anxiety, depression, ER constructs, PC, and distress intolerance. The associations between subscales and pain interference were larger than the associations between subscales and pain severity. PC fully mediated the paths from ER to pain experiences.

DISCUSSION

Our results highlight the importance of several cognitive and emotional constructs: nonacceptance of negative emotions, lack of emotional awareness, magnification of the pain experience, and a sense of helplessness. Furthermore, by showing the indirect effects of PC in affecting ER and pain, we posit that ER, mediated by PC, might serve a critical role in influencing the pain experience in patients with chronic pain.

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.

Addressing the disparities: the approach to the African American patient with multiple myeloma

There are significant disparities with regards to incidence, timely diagnosis, access to treatment, clinical trial participation and health care utilization that negatively impact outcomes for African American patients with multiple myeloma. Health care providers have a role in ameliorating these disparities with thoughtful consideration of historical, sociocultural, individual and disease characteristics that influence the care provided to African American patient population. This review by a group of experts committed to health disparity in multiple myeloma provides a snapshot of disparities at both biologic and non-biologic levels, barriers to clinical care, and best practices to ensure that African American patients receive the best care available.

A historical review of pain disparities research: Advancing toward health equity and empowerment

BACKGROUND AND PURPOSE

This theory-guided review draws on 30 years of published data to examine and interrogate the current and future state of pain disparities research.

METHODS

Using the Hierarchy of Health Disparity Research framework, we synthesize and present an overview of "three generations" of pain disparities scholarship, while proposing directions for adopting a "fourth generation" that redefines, explains, and theorizes future pain disparities research in a diverse society.

DISCUSSION

Prior research has focused on describing the scope of disparities, and throughout the historical context of human existence, racialized groups have been subjected to inadequate pain care. It is imperative that research not only illuminates existing problems but also provides solutions that can be implemented and sustained across varying social milieus.

CONCLUSION

We must invest in new theoretical models that expand on current perspectives and ideals that position all individuals at the forefront of justice and equity in their health.

Racial and ethnic differences in the use of lumbar imaging, opioid analgesics and spinal surgery for low back pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

There is a substantial gap between evidence and clinical care for low back pain (LBP) worldwide despite recommendations of best practice specified in clinical practice guidelines. The aim of this systematic review was to identify disparities associated with race or ethnicity in the use of lumbar imaging, opioid analgesics, and spinal surgery in people with LBP.

DATABASES AND DATA TREATMENT

We included observational studies which compared the use of lumbar imaging, opioid analgesics, and spinal surgery for the management of non-serious LBP between people from different racial/ethnic populations. We searched in MEDLINE, EMBASE and CINAHL from January 2000 to June 2021. Risk of bias of included studies was appraised in six domains. For each type of care, we pooled data stratified by race and ethnicity using random effects models.

RESULTS

We identified 13 eligible studies; all conducted in the United States. Hispanic/Latino (OR 0.69, 95%CI 0.49-0.96) and Black/African American (OR 0.59, 95%CI 0.46-0.75) people with LBP were less likely to be prescribed opioid analgesics than White people. Black/African Americans were less likely to undergo or be recommended spinal surgery for LBP (OR 0.47, 95%CI 0.33-0.67) than White people. There was a lack of high certainty evidence on racial/ethnic disparities in the use of lumbar imaging.

CONCLUSION

This review reveals lower rate of the use of guideline-discordant care, especially opioid prescription and spinal surgery, in racial/ethnic minority populations with LBP in the United States. Future studies in other countries evaluating care equity for LBP are warranted. PROSPERO Registration ID: CRD42021260668.

SIGNIFICANCE

This systematic review and meta-analysis revealed that people with low back pain from the minority racial/ethnic backgrounds were less likely to be prescribed opioid analgesics and undergo spinal surgery than the majority counterparts. Strategic interventions to improve the access to, and the value of, clinical care for minority populations with low back pain are warranted.

Recruitment and retention for chronic pain clinical trials: a narrative review

Opioid misuse is at a crisis level. In response to this epidemic, the National Institutes of Health has funded $945 million in research through the Helping to End Addiction Long-term (HEAL) Pain Management Initiative, including funding to the Vanderbilt Recruitment Innovation Center (RIC) to strategize methods to catalyze participant recruitment. The RIC, recognizing the challenges presented to clinical researchers in recruiting individuals experiencing pain, conducted a review of evidence in the literature on successful participant recruitment methods for chronic pain trials, in preparation for supporting the HEAL Pain trials. Study design as it affects recruitment was reviewed, with issues such as sufficient sample size, impact of placebo, pain symptom instability, and cohort characterization being identified as problems. Potential solutions found in the literature include targeted electronic health record phenotyping, use of alternative study designs, and greater clinician education and involvement. For retention, the literature reports successful strategies that include maintaining a supportive staff, allowing virtual study visits, and providing treatment flexibility within the trial. Community input on study design to identify potential obstacles to recruitment and retention was found to help investigators avoid pitfalls and enhance trust, especially when recruiting underrepresented minority populations. Our report concludes with a description of generalizable resources the RIC has developed or adapted to enhance recruitment and retention in the HEAL Pain studies. These resources include, among others, a Recruitment and Retention Plan Template, a Competing Trials Tool, and MyCap, a mobile research application that interfaces with Research Electronic Data Capture (REDCap).

Patient Race, Ethnicity, Language, and Pain Severity in Primary Care: A Retrospective Electronic Health Record Study

BACKGROUND

Patient race, ethnicity, and culture including language are intertwined and may influence patient reporting of pain severity.

PURPOSE

To describe documentation of patient's self-reported pain presence and severity by race, ethnicity, and language, specifically, Spanish, Hmong, Lao, or Khmer requiring an interpreter or English.

DESIGN AND SAMPLE

Retrospective, electronic health record clinical data mining study of 79,195 patient visits with documented pain scores from one primary care clinic.

METHODS

Hurdle regression was used to explore the effect of race, ethnicity, and language on the chances of having any pain (vs. no pain) and pain severity for visits with pain scores ≥1, controlling for age, sex, and documentation of a pain diagnosis. Mann-Whitney tests were used to explore the influence of English vs. non-English language on pain severity within a race or ethnicity category.

RESULTS

Pain scores were higher for limited English proficiency, compared with English-speaking, patients within the Asian race or Hispanic/Latino ethnicity category. Older age, female sex, pain diagnosis, Black or African American race, and Spanish or Lao language increased the chance of having any pain. These same factors, plus American Indian or Alaska Native race, contributed to higher pain severity. Asian race, in contrast, decreased the chance of reporting any pain and contributed to lesser pain severity.

CONCLUSIONS

Race, in addition to a new area of focus, language, impacted both the chances of reporting any pain and pain severity. Additional research is needed on the impact of language barriers on pain severity reporting, documentation, and differences in pain outcomes and disparities.

Racial Differences in Treatments and Toxicity in Patients With Non-Small-Cell Lung Cancer Treated With Thoracic Radiation Therapy

PURPOSE

Historical racial disparities in lung cancer surgery rates resulted in lower survival in Black patients. Our objective was to examine racial differences in thoracic radiation treatments and toxicities in patients with non-small-cell lung cancer.

METHODS AND MATERIALS

A large institutional review board-approved statewide patient-level database of patients with stage II-III non-small-cell lung cancer who received definitive thoracic radiation from March 2012 to November 2019 was analyzed to assess associations between race and other variables. Race (White or Black) was defined by patient self-report. Provider-reported toxicity was defined by Common Terminology Criteria for Adverse Events version 4.0. Patient-reported toxicity was determined by the Functional Assessment of Cancer Therapy-Lung quality-of-life instrument. Univariable and multivariable regression models were fitted to assess relationships between race and variables of interest. Spearman rank-correlation coefficients were calculated between provider-reported toxicity and similar patient-reported outcomes.

RESULTS

One thousand four hundred forty-one patients from 24 institutions with mean age 68 years (range, 38-94 years) were evaluated. Race was not significantly associated with radiation or chemotherapy approach. There was significantly increased patient-reported general pain in Black patients at the preradiation and end-of-radiation time points. Black patients were significantly less likely to have provider-reported grade 2+ pneumonitis (odds ratio 0.36, P = .03), even after controlling for known patient and treatment factors. Correlation coefficients between provider- and patient-reported toxicities were generally similar across race groups except for a stronger correlation between patient- and provider-reported esophagitis in White patients.

CONCLUSION

In this large multi-institutional study, we found no evidence of racial differences in radiation treatment or chemotherapy approaches. We did, however, unexpectedly find that Black race was associated with lower odds of provider-reported grade 2+ radiation pneumonitis. The stronger correlation between patient- and provider-reported esophagitis and swallowing symptoms for White patients also suggests possible under-recognition of symptoms in Black patients. Further research is needed to study the implications for Black patients.

Addressing Challenges in Recruiting Diverse Populations for Research: Practical Experience From a P20 Center

BACKGROUND

Improving the recruitment and retention of underrepresented groups in all research areas is essential for health equity. However, achieving and retaining diverse samples is challenging. Barriers to recruitment and retention of diverse participants include socioeconomic and cultural factors and practical challenges (e.g., time and travel commitments).

OBJECTIVES

The purpose of this article is to describe the successful recruitment and retention strategies used by two related studies within a P20 center funded by the National Institute of Nursing Research focused on precision health research in diverse populations with multiple chronic conditions, including metabolic syndrome.

METHODS

To address the complexity, biodiversity, and effect of metabolic syndrome and multiple chronic conditions, we developed culturally appropriate, multipronged recruitment and retention strategies for a pilot intervention study and a longitudinal observational pilot study within our P20 center. The following are the underlying principles that guided the recruitment and retention strategies: (a) flexibility, (b) active listening and bidirectional conversations, and (c) innovative problem solving.

RESULTS

The intervention study (Pilot 1) enrolled 49 participants. The longitudinal observational study (Pilot 2) enrolled 45 participants. Women and racial/ethnic minorities were significantly represented in both. In Pilot 1, most of the participants completed the intervention and all phases of data collection. In Pilot 2, most participants completed all phases of data collection and chose to provide biorepository specimens.

DISCUSSION

We developed a recruitment and retention plan building on standard strategies for a general medical population. Our real-world experiences informed the adaption of these strategies to facilitate the participation of individuals who often do not participate in research-specifically, women and racial/ethnic populations. Our experience across two pilot studies suggests that recruiting diverse populations should build flexibility in the research plan at the outset.

Reflections of Healthcare Experiences of African Americans With Sickle Cell Disease or Cancer: A Qualitative Study

BACKGROUND

The experiences of African American adult patients before, during, and after acute care utilization are not well characterized for individuals with sickle cell disease (SCD) or cancer.

OBJECTIVE

To describe the experiences of African Americans with SCD or cancer before, during, and after hospitalization for pain control.

METHODS

We conducted a qualitative study among African American participants with SCD (n = 15; 11 male; mean age, 32.7 ± 10.9 years; mean pain intensity, 7.8 ± 2.6) or cancer (n = 15; 7 male; mean age, 53.7 ± 15.2 years; mean pain intensity, 4.9 ± 3.7). Participants completed demographic questions and pain intensity using PAINReportIt and responded to a 7-item open-ended interview, which was recorded and transcribed verbatim. We used content analysis to identify themes in the participants' responses.

RESULTS

Themes identified included reason for admission, hospital experiences, and discharge expectations. Pain was the primary reason for admission for participants with SCD (n = 15) and for most participants with cancer (n = 10). Participants of both groups indicated that they experienced delayed treatment and a lack of communication. Participants with SCD also reported accusations of drug-seeking behavior, perceived mistreatment, and feeling of not being heard or believed. Participants from both groups verbalized concerns about well-being after discharge and hopeful expectations.

CONCLUSIONS

Race-concordant participants with SCD but not with cancer communicated perceived bias from healthcare providers.

IMPLICATIONS FOR PRACTICE

Practice change interventions are needed to improve patient-provider interactions, reduce implicit bias, and increase mutual trust, as well as facilitate more effective pain control, especially for those who with SCD.

Pain Prevalence, Chronicity and Impact Within Subpopulations Based on Both Hispanic Ancestry and Race: United States, 2010-2017

We provide national surveillance estimates of pain chronicity, severity and impact in adult subpopulations defined by both Hispanic Ancestry and Race. Data are from 144,434 adults who completed validated questionnaires in the 2010-2017 National Health Interview Survey asking about pain status within the last 3 (N = 84,664) or 6 months (N = 59,770). Multivariable logistic regression was used to assess the relationship between pain and ethnicity/race. Compared to White Puerto Rican participants, White participants with Central/South American and Mexican ancestry had reduced odds of reporting Category 3-4 pain and High-Impact Chronic Pain (HICP), while those of Cuban ancestry had reduced odds of only HICP - eg, White participants with Mexican ancestry had 32% lower odds of having Category 3-4 pain and 50% lower odds of having HICP. While no differences were seen between White Puerto Rican and White Non-Hispanic participants for Category 3-4 pain, White Non-Hispanics had 40% lower odds of reporting HICP. Asian Non-Hispanic and Black Non-Hispanic participants had significantly lower odds of reporting Category 3-4 pain and HICP compared to White Puerto Rican participants, eg, Black Non-Hispanic participants had 26% lower odds off having Category 3-4 pain and 42% lower odds of having HICP. Perspective: By examining pain status in discrete demographic groups based on Hispanic Ancestry and Race, this report further documents substantial difference in health status among underserved populations and provides a baseline for continuing surveillance research on pain, with the eventual goal of eliminating disparities in pain assessment and treatment.

Comparison of Four Pain Scales Among Hmong Patients with Limited English Proficiency

BACKGROUND

Little is known about the relevance of existing pain scales for patients with limited English proficiency (LEP).

AIMS

To determine the ranking and perceptions of four pain intensity scales in LEP Hmong.

DESIGN

A sequential mixed-method study.

SETTINGS

A Midwestern city, USA.

PARTICIPANTS/SUBJECTS

Eight-four Hmong aged 19 to 80 years old.

METHODS

Participants ranked four pain intensity scales-the Red Gradation Scale, the Black Gradation Scale, the Wong-Baker Faces Pain Rating Scale, and the Faces Pain Scale - Revised- using Likert responses of 1 (most) to 4 (least) on the following factors: the extent to which they liked the scale, perceived it to be accurate, and preferred to use it in clinical settings. A follow-up interview asked participants' scale selection decisions. Spearman correlations and ordered logistic regression assessed the scale rankings. Thematic analysis was used to analyze the qualitative data.

RESULTS

Participants ranked the Wong-Baker Faces Pain Rating Scale as the most liked (3.22 ± 0.95, 50.6%), the most accurate (3.13 ± 0.93, 44.6%), and the most preferred (3.14 ± 1.03, 49.4%). Older Age predicted the selection of this scale. Six themes influenced participants' ranking decisions: the visual clarity of the scale, their experience or familiarity with the scale, the cultural connotations of pain, the type of emotions provoked by scale, the alignment of pain expression reflected in the scale, and the literacy concerns that the scale addressed.

CONCLUSIONS

The Wong-Baker Faces could be appropriate for older Hmong. Further validity and reliability studies are needed for the Wong-Baker Faces.

The influence of undertreated chronic pain in a national survey: Prescription medication misuse among American indians, Asian Pacific Islanders, Blacks, Hispanics and whites

Objective

Disparities in the assessment and treatment of chronic pain among racial/ethnic may lead to self-treatment for undertreated pain. This study examines whether pain intensity among US racial/ethnic groups’ influences rates of psychotherapeutic prescription drug misuse.

Methods

Data included civilian, non-institutionalized adults (age 18–99 years) residing in the United States (n = 34,653) from Waves 1 and 2 of the National Epidemiological Survey on Alcoholism and Related Conditions (NESARC; 2004–2005). The primary outcome variable was prescription drug misuse/PDM (i.e., use without a prescription or other than as prescribed) including tranquilizers, sedatives, stimulants, or opioids. Predictor variables included self-reported race/ethnicity (American Indian, Black, Hispanic, or White) and pain intensity. Data were analyzed in 2019.

Results

Overall, White and Hispanic participants’ pain intensity had a significantly curvilinear relationship with frequency of prescription medication (p < 0.01). PDM rose with pain intensity until pain levels reached “severe,” then PDM rates fell, not significantly differing from the “no pain” levels (χ²(1) = 0.65, p = 0.42). PDM rates for Black participants remained lowest of all other racial/ethnic groups and plateaued with increasing pain intensity.

Conclusions

Our results indicate that undertreated chronic pain may drive rates of PDM among varying racial/ethnic groups. Providing equitable assessment and treatment of pain intensity remains critical. Additional research is needed to examine provider decision-making and unconscious bias, as well as patient health beliefs surrounding perceived need for prescription pain medications.

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Prescription drug misuse (PDM) rates vary by racial/ethnic groups.

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Pain intensity appears to affect PDM.

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PDM is not more likely in Black patients than Whites.

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PDM reduction in racial/ethnic populations must address provider implicit bias.

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Provider education needs include differences in cultural pain expression.

“It Hurts as If…”: Pain-Associated Language, Visual Characterization, and Storytelling in Hmong Adults

Objective

Pain is challenging to diagnose and manage in primary care, especially when patients have limited English proficiency (LEP). Little is known about whether LEP patients can provide pain information that is consistent with the process and the content that providers expect in a clinical interaction. We explore how LEP Hmong patients communicate their pain to providers in primary care settings.

Methods

A qualitative study with 67 Hmong participants (63% female and x̄ age = 53.7 years) were recruited from a Midwestern state. Semistructured interviews on pain communication were conducted, audio-recorded, transcribed, and analyzed using directed content analysis.

Results

The Hmong participants described pain using stories that generally had the same dimensions of information that providers require for pain assessment. These included references to time, causality, associated symptoms or related experiences, intensity, and consequences of pain. However, the participants expressed some pain dimensions in language that was not shared by providers: visual metaphors that were generally in reference to pain quality and fewer words for pain location, intensity, and some qualities. Participants used two strategies to decide whether they should tell their pain story: assessing the provider and determining whether their story was appreciated. The perception that providers underappreciated their stories resulted in dissatisfaction and undertreatment of pain. Ultimately, this resulted in having less frequent contact with providers or changing providers.

Conclusions

Findings demonstrate a discordance in the expected process and content of the clinical interaction between LEP Hmong patients and providers, suggesting the need for culturally appropriate pain assessments in this population.

Thermal and mechanical quantitative sensory testing values among healthy African American adults

PURPOSE

Only a few studies have reported quantitative sensory testing (QST) reference values for healthy African Americans, and those studies are limited in sample size and age of participants. The study purpose was to characterize QST values in healthy, pain-free African American adults and older adults whose prior pain experiences and psychological status were also measured. We examined the QST values for differences by sex, age, and body test site.

PATIENTS AND METHODS

A cross-sectional sample of 124 pain-free African American adults (age 18-69 years, 49% female) completed demographic and self-reported pain, fatigue and psychosocial measures. QST was performed to obtain thermal and mechanical responses and associated pain intensity levels.

RESULTS

We found thermal detection values at the anterior forearm were (29.2 °C±1.6) for cool detection (CD) and (34.5 °C±1.2) for warm detection (WD). At that site the sample had cold pain threshold (CPTh) (26.3 °C±5.0), heat pain threshold (HPTh) (37.8 °C±3.6), and mechanical pain thresholds (MPTH) (16.7±22.2 grams of force, gF). There was a significant between sex difference for WD, with women being more sensitive (q=0.027). Lower body sites were less sensitive than upper body sites across all thermal modalities (q<0.003), but not for the mechanical modality.

CONCLUSION

The QST values from this protocol at the anterior forearm indicate that the healthy African American adults had average thermal pain thresholds close to the temperature of adaptation and average MPTh under 20 gF. Differences in responses to thermal and mechanical stimuli for upper verses lower body were consistent with prior research.

Improving Functional Status in African Americans With Cancer Pain: A Randomized Clinical Trial

OBJECTIVES

To determine the efficacy of the Power Over Pain-Coaching (POP-C) intervention to improve functional status among African American outpatients with cancer pain.
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SAMPLE & SETTING

310 African American patients were recruited from an urban comprehensive cancer center. The study took place in the patients' homes.
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METHODS & VARIABLES

A two-group randomized design with repeated measures was used. Data were analyzed with linear mixed effects regression analysis and structural equation change score models. Variables were pain, pain-related distress, functional status, perceived control over pain, and the following antecedents to control.

RESULTS

Functional status was improved in POP-C participants relative to control group participants (p < 0.05). Distress also was differentially decreased (p < 0.05). Pain intensity ratings decreased significantly in all patients (p < 0.05). The largest intervention effects were observed in the living with pain component. 
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IMPLICATIONS FOR NURSING

Perceived control over pain was strongly related to functional status and is amenable to interventions using the POP-C intervention components described in this article.

Neighborhood, Socioeconomic, and Racial Influence on Chronic Pain

The purpose of this review is to highlight the neighborhood, socioeconomic, and racial influences on chronic pain. Negative influences on the experience of chronic pain are explored and defined as any adverse stressor common in low socioeconomic, urban neighborhoods that potentially contributes to health disparity in African Americans experiencing chronic pain. The multifactorial influences on chronic pain disparity in African Americans are explored and expounded upon in this review of existing evidence. Databases used for the search included CINAHL, PubMed, and PsycArticles. The experience of chronic pain is multifaceted, existing with multiple comorbidities and lasting consequences. To improve the burden of chronic pain requires a multifactorial assessment that considers neighborhood risk factors, emphasis on environmental stressors, limitations to support networks, barriers to physical activity, and access to primary care providers with whom communication is open and without bias. A comprehensive assessment of barriers will aid in the development of interventions that reach beyond the physical factors of chronic pain, also considering the psychosocial barriers to improving the burden of chronic pain in African Americans living in impoverished urban neighborhoods.

The frequency of nonaccidental trauma in children under the age of 3 years with femur fractures: is there a better cutoff point for universal workups?

The purpose of this study was to evaluate narrower age groups in children aged 0-4 years to determine whether guidelines should be refined when investigating femur fractures for nonaccidental trauma (NAT). This was a retrospective review of the pediatric trauma database at our level 1 pediatric trauma center. The database was examined from 2009 to present. We examined rates of NAT in the less than or equal to 12-month, 13-24-month, 25-36-month, and 37-48-month age groups. χ was used to compare rates of NAT between these groups, and P less than 0.05 was considered to be significant. Over the indicated time period, there were 138 femur fractures in children aged 0-4 years, of which 30 were determined to be NAT. The rate of NAT in the less than or equal to 12-month age group was 74.1%, accounting for 20 of the 30 NAT femur fractures. A significant difference in rates of NAT was found between the less than or equal to 12-month age group and all other age groups (P<0.00001). No significant difference in rates of NAT was found between the 13-24-month, 25-36-month, and 37-48-month age groups. Although our institution has generally felt that NAT should be universally evaluated in patients below 36 months of age with femur fractures, our data suggest that there is little justification for universally evaluating 13-36-month-old patients with femur fractures for NAT when the rates do not differ for 37-48-month-old patients. NAT does exist in femur fractures in children above 12 months of age, but it is most worrisomely high in patients of less than or equal to 12 months of age.

Differences in Sensory Pain, Expectation, and Satisfaction Reported by Outpatients with Cancer or Sickle Cell Disease

BACKGROUND

Patients with sickle cell disease (SCD) report pain scores that appear greater than those reported in a meta-analysis for patients with cancer, but statistical comparisons of the pain scores from both populations have not been published.

AIMS

The goal of the study described here was to compare pain outcomes reported by outpatients with cancer or SCD.

DESIGN

Descriptive comparative study.

SETTING

Outpatient oncology or sickle cell clinics.

SUBJECTS

The participants were outpatients (N = 415) from three studies: (1) 106 patients with SCD, 93% African-American (referent group); (2) 140 patients with cancer, 90% Caucasian (race discordant); (3) 169 patients with cancer, 20% Caucasian, 65% African-American (race concordant).

METHODS

Patients completed the PAINReportIt including pain location, quality, pattern, intensity, expectation, satisfaction, and demographic questions. Analyses included the χ² test, analysis of variance, and regression.

RESULTS

Outpatients with SCD reported more pain location sites than the race-discordant (p < .001) and race-concordant (p < .001) cancer groups; higher pain quality than the race-discordant (p < .001) and race-concordant (p < .001) groups; and greater pain pattern scores than the race-discordant (p < .001) and race-concordant (p < .001) groups. The race-concordant group reported higher worst pain intensity than the SCD (p < .001) and race-discordant (p = .002) groups. The three groups did not differ significantly on pain expectation (p = .06). Regarding satisfaction with pain level, there was a significant difference between the race-concordant and SCD (p = .006) groups, but not between the race-discordant and SCD (p = .12) groups or between the race-discordant and race-concordant (p = .49) groups.

CONCLUSIONS

Outpatients with SCD reported three of four sensory pain parameters that were greater than those reported by outpatients with cancer. A better understanding of these differences is pertinent to improving pain outcomes.

Living with Symptoms: A Qualitative Study of Black Adults with Advanced Cancer Living in Poverty

Cancer is associated with disease-related and treatment-related symptoms. Little is known about the symptom experience of black individuals with advanced cancer especially those with limited financial resources. Therefore, the purpose of this study was to explore the symptom experience of black adults with advanced cancer living in poverty. This qualitative descriptive study focused on the perspectives of the participants experiencing at least two symptoms related to cancer. A purposive sample of 27 individuals receiving care at a public hospital in a southeastern city participated in the study. Semi-structured audiotaped interviews were conducted by two research interviewers. Content analysis was used to develop themes to describe the symptom experience. Two main themes emerged in terms of the participants' symptom experiences: (1) "living in pain," which included the overwhelming experience of pain, both physical and emotional, and (2) "symptoms associated with functioning in everyday life." Participants frequently used the context of activities in their daily lives to explain symptoms, including the effect of symptoms on the activities of eating, moving and doing, and communicating. People with advanced cancer work to negotiate a high frequency of multiple distressful symptoms of severe-to-moderate severity. Information gained from this study can help guide research in symptom science and provide direction for clinicians working with this minority group.

How Do Demographic, Surgical, Patient, and Cultural Factors Affect Pain Control After Unicompartmental Knee Arthroplasty? A Multivariable Regression Analysis

BACKGROUND

Controlling pain after unicompartmental knee arthroplasty (UKA) is essential for improving patient satisfaction, minimizing complications, and early rehabilitation. There is little literature available evaluating the effect of both treatment and patient characteristics on in-hospital pain after UKA. The purpose of this study was to examine the effect of patient and treatment characteristics on in-hospital pain after UKA. This study also evaluated the role of analgesic cocktail (traditional periarticular injection cocktail "[PAI]" vs cocktail including liposomal bupivacaine "[LBUP]").

METHODS

The study sample included 442 consecutive UKA cases performed between December 2011 and August 2013. The primary outcome measures were the average Visual Analog Scale pain score and the percent of pain scores during hospitalization that were 0, that is, "no pain." Multivariable regression analyses were implemented to investigate associations between patient demographics and analgesic group with the outcomes. For the analgesic groups, the "PAI" group received injections of a cocktail including Marcaine, ketorolac, and morphine, the "LBUP" group received injections of LBUP.

RESULTS

Postoperative pain was higher in females (P < .001) and younger patients (P = .002). The patient group treated with LBUP injection technique had similar overall average Visual Analog Scale pain scores to patients in the PAI group (P = .729); however, there was also a significant improvement in pain scores over time (as the study progressed) for patients in the LBUP group relative to the PAI group (P = .003), potentially indicating better outcomes with more experience with the injection technique. When compared individually by day, the LBUP group had lower pain scores from day 1 to 3 (P < .024).

CONCLUSION

The results showed that in patients undergoing UKA, postoperative pain was lower in males, older patients, patients with lower body mass index, and those treated with LBUP over the study period. Understanding these associations is necessary to effectively manage pain and encourage earlier ambulation and physiotherapy after UKA.

Assessment of pain in a Norwegian Emergency Department

Background

Although pain management is a fundamental aspect of care in emergency departments (EDs), inadequate treatment of pain is unfortunately common. There are multiple local protocols for pain assessment in the ED. This study evaluated whether the initial assessment and treatment of pain in the ED are in accordance with the in-hospital protocol of the ED at a Norwegian University Hospital.

Materials and methods

Prospective data on pain assessment and initial treatment in the ED were collected from nursing and physician documentation. The patients’ perceptions of subjective pain were recorded using a numerical rating scale (NRS) that ranged from 0 to 10.

Results

Seventy-seven percent of the 764 enrolled patients were evaluated for pain at arrival. Female patients had a higher probability of not being asked about pain, but there was no difference in the percentage of patients asked about pain with respect to age. Additionally, patients with low oxygen saturation and systolic blood pressure were less likely to be asked about pain. Of those with moderate and severe pain (58 %), only 14 % received pain relief.

Discussion

Assessment and treatment of pain in the ED are inadequate and not in line with the local protocols. A focus on strategies to improve pain treatment in the ED is a necessary aspect of developing optimal acute patient care in Norway in the future.

Ethical pain management in the emergency department: the canary in the coal mine

SUMMARY 

The emergency department serves as the gateway to the acute healthcare system. In the USA and increasingly worldwide, patients view the emergency department as the venue where both diagnostic and therapeutic modalities will be brought to bear regardless of condition or socioeconomic status. At the same time, the emergency department is the canary in the coal mine – the warning location for difficulties in how healthcare is delivered to patients in both the outpatient and inpatient settings. In no area is this more apparent than pain management. Emergency departments are expected to treat patient's pain aggressively, often in the face of incomplete or contradictory histories and the inability to ensure outpatient follow-up. These factors create an ethical challenge for emergency departments in how to approach pain treatment. This paper will provide a framework for how emergency departments can address the ethical challenges posed by pain management.

Adherence to Analgesics for Cancer Pain: A Comparative Study of African Americans and Whites Using an Electronic Monitoring Device

Despite well-documented disparities in cancer pain outcomes among African Americans, surprisingly little research exists on adherence to analgesia for cancer pain in this group. We compared analgesic adherence for cancer-related pain over a 3-month period between African Americans and whites using the Medication Event Monitoring System (MEMS). Patients (N = 207) were recruited from outpatient medical oncology clinics of an academic medical center in Philadelphia (≥18 years of age, diagnosed with solid tumors or multiple myeloma, with cancer-related pain, and at least 1 prescription of oral around-the-clock analgesic). African Americans reported significantly greater cancer pain (P < .001), were less likely than whites to have a prescription of long-acting opioids (P < .001), and were more likely to have a negative Pain Management Index (P < .001). There were considerable differences between African Americans and whites in the overall MEMS dose adherence, ie, percentage of the total number of prescribed doses that were taken (53% vs 74%, P < .001). On subanalysis, analgesic adherence rates for African Americans ranged from 34% (for weak opioids) to 63% (for long-acting opioids). Unique predictors of analgesic adherence varied by race; income levels, analgesic side effects, and fear of distracting providers predicted analgesic adherence for African Americans but not for whites. Perspective: Despite evidence of disparities in cancer pain outcomes among African Americans, surprisingly little research exists on African Americans' adherence to analgesia for cancer pain. This prospective study uses objective measures to compare adherence to prescribed pain medications between African American and white patients with cancer pain.

Prevalence of migraine in a diverse community--electronic methods for migraine ascertainment in a large integrated health plan

INTRODUCTION

The growing availability of electronic health data provides an opportunity to ascertain diagnosis-specific cases via systematic methods for sample recruitment for clinical research and health services evaluation. We developed and implemented a migraine probability algorithm (MPA) to identify migraine from electronic health records (EHR) in an integrated health plan.

METHODS

We identified all migraine outpatient diagnoses and all migraine-specific prescriptions for a five-year period (April 2008-March 2013) from the Kaiser Permanente, Northern California (KPNC) EHR. We developed and evaluated the MPA in two independent samples, and derived prevalence estimates of medically-ascertained migraine in KPNC by age, sex, and race.

RESULTS

The period prevalence of medically-ascertained migraine among KPNC adults during April 2008-March 2013 was 10.3% (women: 15.5%, men: 4.5%). Estimates peaked with age in women but remained flat for men. Prevalence among Asians was half that of whites.

CONCLUSIONS

We demonstrate the feasibility of an EHR-based algorithm to identify cases of diagnosed migraine and determine that prevalence patterns by our methods yield results comparable to aggregate estimates of treated migraine based on direct interviews in population-based samples. This inexpensive, easily applied EHR-based algorithm provides a new opportunity for monitoring changes in migraine prevalence and identifying potential participants for research studies.

Racial differences in opiate administration for pain relief at an academic emergency department

INTRODUCTION

The decision to treat pain in the emergency department (ED) is a complex, idiosyncratic process. Prior studies have shown that EDs undertreat pain. Several studies demonstrate an association between analgesia administration and race. This is the first Midwest single institution study to address the question of race and analgesia, in addition to examining the effects of both patient and physician characteristics on race-based disparities in analgesia administration.

METHODS

This was a retrospective chart review of patients presenting to an urban academic ED with an isolated diagnosis of back pain, migraine, or long bone fracture (LBF) from January 1, 2007 to December 31, 2011. Demographic and medication administration information was collected from patient charts by trained data collectors blinded to the hypothesis of the study. The primary outcome was the proportion of African-Americans who received analgesia and opiates, as compared to Caucasians, using Pearson's chi-squared test. We developed a multiple logistic regression model to identify which physician and patient characteristics correlated with increased opiate administration.

RESULTS

Of the 2,461 patients meeting inclusion criteria, 57% were African-American and 30% Caucasian (n=2136). There was no statistically significant racial difference in the administration of any analgesia (back pain: 86% vs. 86%, p=0.81; migraine: 83% vs. 73%, p=0.09; LBF: 94% vs. 90%, p=0.17), or in opiate administration for migraine or LBF. African-Americans who presented with back pain were less likely to receive an opiate than Caucasians (50% vs. 72%, p<0.001). Secondary outcomes showed that higher acuity, older age, physician training in emergency medicine, and male physicians were positively associated with opiate administration. Neither race nor gender patient-physician congruency correlated with opiate administration.

CONCLUSION

No race-based disparity in overall analgesia administration was noted for all three conditions: LBF, migraine, and back pain at this institution. A race-based disparity in the likelihood of receiving opiate analgesia for back pain was observed in this ED. The etiology of this is likely multifactorial, but understanding physician and patient characteristics of institutions may help to decrease the disparity by raising awareness of practice patterns and can provide the basis for quality improvement projects.

Practice recommendations for pain assessment by self-report with African American older adults

Despite decades of education and clinical practice guidelines underscoring disparities in pain management, pain continues to be inadequately managed in older African American adults as a result of patient, provider, and systems factors. Critical factors influencing pain assessment in older African American adults has not been extensively examined, contributing to a lack of data to inform health care providers' knowledge on culturally-responsive pain assessment in older African Americans. Assessing pain in older African Americans is unique because differences in language, cultural beliefs, and practices moderate how they report and express pain. This paper presents an overview of patient-provider factors that affect pain assessment in older African Americans with a focus on this population's unique cultural beliefs and practices. Recommendations for best practices for performance of a culturally-responsive pain assessment with older African Americans are provided.

A longitudinal linear model of patient characteristics to predict failure to attend an inner-city chronic pain clinic

Patients often fail to attend appointments in chronic pain clinics for unknown reasons. We hypothesized that certain patient characteristics predict failure to attend scheduled appointments, pointing to systematic barriers to accessing chronic pain services for certain underserved populations. We collected retrospective data from a longitudinal observational cohort of patients at an academic pain clinic in Newark, New Jersey. To examine the effect of demographic factors on appointment status, we fit a marginal logistic regression using generalized estimating equations with exchangeable correlation. A total of 1,394 patients with 3,488 total encounters between January 1, 2006, and December 31, 2009, were included. Spanish spoken as a primary language (alternatively Hispanic or other race) and living between 5 and 10 miles from the clinic were associated with reduced odds of arriving for an appointment; making an appointment for a particular complaint such as cancer pain or back pain, an interventional pain procedure scheduled in connection with the appointment, unemployed status, and continuity of care (as measured by office visit number) were associated with increased odds of arriving. Spanish spoken as a primary language and distance to the pain clinic predicted failure to attend a scheduled appointment in our cohort. If these constitute systematic barriers to access, they may be amenable to targeted interventions.

PERSPECTIVE

We identified certain patient characteristics, specifically Spanish spoken as a primary language and geographic distance from the clinic, that predict failure to attend an inner-city chronic pain clinic. These identified barriers to accessing chronic pain services may be modifiable by simple cost-effective interventions.

Different patient-reported outcomes in immigrants and patients born in Sweden: 18,791 patients with 1 year follow-up in the Swedish Hip Arthroplasty Registry

BACKGROUND AND PURPOSE

Some patients have persistent symptoms after total hip arthroplsty (THA). We investigated whether the proportions of inferior clinical results after total hip arthroplasty-according to the 5 dimensions in the EQ-5D form, and pain and satisfaction according to a visual analog scale (VAS)-are the same in immigrants to Sweden as observed in those born in Sweden.

METHODS

Records of total hip arthroplasties performed between 1992 and 2007 were retrieved from the Swedish Hip Arthroplasty Register (SHAR) and cross-matched with data from the National Board of Health and Welfare and also Statistics, Sweden. 18,791 operations (1,451 in immigrants, 7.7%) were eligible for analysis. Logistic and linear regression models including age, sex, diagnosis, type of fixation, comorbidity, surgical approach, marital status, and education level were analyzed. Outcomes were the 5 dimensions in EQ-5D, EQ-VAS, VAS pain, and VAS satisfaction. Preoperative data and data from 1 year postoperatively were studied.

RESULTS

Preoperatively (and after inclusion of covariates in the regression models), all immigrant groups had more negative interference concerning self-care. Immigrants from the Nordic countries outside Sweden and Europe tended to have more problems with their usual activities and patients from Europe and outside Europe more often reported problems with anxiety/depression. Patients born abroad showed an overall tendency to report more pain on the VAS than patients born in Sweden. After the operation, the immigrant groups reported more problems in all the EQ-5D dimensions. After adjustment for covariates including the preoperative baseline value, most of these differences remained except for pain/discomfort and-concerning immigrants from the Nordic countries-also anxiety/depression. After the operation, pain according to VAS had decreased substantially in all groups. The immigrant groups indicated more pain than those born in Sweden, both before and after adjustment for covariates.

CONCLUSION

The frequency of patients who reported moderate to severe problems, both before and 1 year after the operation, differed for most of the dimensions in EQ-5D between patients born in Sweden and those born outside Sweden.

An ethical framework for the management of pain in the emergency department

Pain is a ubiquitous problem, affecting more than 100 million individuals in the United States chronically and many more in the acute setting. Up to three-quarters of patients presenting to the emergency department (ED) report pain as a key component of their reasons for requiring acute care. While pain management is a fundamental component of emergency medicine (EM), there are numerous attitudinal and structural barriers that have been identified to effectively providing pain control in the ED. Coupled with public demands and administrative mandates, concerns surrounding ED pain management have reached a crisis level that should be considered an ethical issue in the profession of EM. In this article, the authors propose an ethical framework based on a combination of virtue, narrative, and relationship theories that can be used to address the clinical dilemmas that arise in managing pain in ED patients.

Chronic pain management strategies used by low-income overweight Latinos

OBJECTIVE

The objective of this study is to examine the strategies used to manage chronic pain from the perspective of the individual in group interviews.

METHODS

Sixteen low-income overweight Latino adults participated in two group interviews facilitated by a trained moderator who inquired about the type of chronic pain suffered by participants, followed by more specific questions about pain management. Interviews were audio-recorded, transcribed verbatim (Spanish), back-translated into English, and analyzed using thematic analysis.

RESULTS

Participants' pain varied in type, location, and intensity. Participants discussed pain-related changes in activities and social life, and difficulties with health care providers, and as a result, we discovered five major themes: pain-related life alterations, enduring the pain, trying different strategies, emotional suffering, and encounters with health care system/providers.

DISCUSSION

Findings indicated that there are opportunities for providers to improve care for low-income overweight Latinos with chronic pain by listening respectfully to how pain alters their daily lives and assisting them in feasible self-management strategies.

Psychosocial, cultural, and spiritual health disparities in end-of-life and palliative care: where we are and where we need to go

Although health disparities are well documented, the extent to which they affect end-of-life care is unknown. Limited research funding leads to sparse and often contradictory palliative care literature, with few studies on causal mechanisms. This article explores the psychosocial, cultural, and spiritual health disparities existing in palliative and end-of-life care with the goal of identifying future research needs. This article reports efforts to determine knowledge gaps related to health disparities in psychosocial, cultural, and spiritual aspects of end-of-life care in which the authors draw upon recent literature from multiple databases. Although few data are available, studies show that minorities make little use of hospice, often because of lack of knowledge about hospice or palliative care, family-centered cultures, and preferences for more aggressive end-of-life care than hospice allows. The authors conclude that future research should include a search for theoretical and causal mechanisms; prospective longitudinal investigations; diverse patients, conditions, contexts, and settings; methodological diversity and rigor; and interdisciplinary, culturally sensitive interventions.

Pain and symptom management in palliative care and at end of life

The purpose of this review is to provide a literature update of the research published since 2004 on pain and symptom management in palliative care and at end of life. Findings suggest that pain and symptoms are inadequately assessed and managed, even at the end of life. Although not pervasive, there is evidence of racial/ethnic disparities in symptom management in palliative care and at end of life. There is a need for a broader conceptualization and measurement of pain and symptom management as multidimensional experiences. There is insufficient evidence about mechanisms underlying pain at end of life. Although there are advances in the knowledge of pain as a multidimensional experience and the many symptoms that occur sometimes with pain, gaps remain. One approach to addressing the gaps will involve assessment and management of pain and symptoms as multidimensional experiences in people receiving palliative care and at end of life.

Is socioeconomic status a risk factor for stiffness after total knee arthroplasty? A multicenter case-control study

Socioeconomic factors may play a role in the development of arthrofibrosis following total knee arthroplasty. Using manipulation following total knee arthroplasty as a surrogate for stiffness, this multicenter case-control study found that African American and young patients (<45 years of age) had twice the odds for manipulation compared with Caucasian and older-age patients.

Challenges and opportunities in pain management disparities research: implications for clinical practice, advocacy, and policy

Due to high profile initiatives at the national level, awareness of inadequate pain care affecting many groups in our society has never been greater. Nevertheless, increased awareness of pain disparities and the initiatives to address these disparities have yielded only modest progress, most notably in the form of growing appreciation that pain disparities likely result from multiple factors, including biological, psychological, environmental, health system, and cultural factors. Much less progress has been made in developing interventions that target these multiple determinants to reduce pain management disparities. In this paper we discuss key ethical and methodological challenges that undermine our capacity to investigate and develop meaningful interventions to improve pain outcomes among vulnerable populations. Key challenges in the areas of research engagement, recruitment, design, and measurement are discussed from both scientific and normative standpoints. Specific opportunities within emerging research paradigms to improve designs and measures are also discussed. Finally, we conclude with identifying potential synergies between the pain management disparities research agenda and the broader areas of clinical practice, advocacy, and policy that could help to move the field forward.

PERSPECTIVE

Researchers studying disparities in pain care face a number of ethical and methodological challenges that must be addressed to advance the field towards eliminating disparities. We discuss these ethical and methodological challenges and propose opportunities for paradigmatic revisions in areas of research engagement, design, measurement, advocacy, and policy.

Pain outcomes of inpatient pain and palliative care consultations: differences by race and diagnosis

BACKGROUND

Pain management disparities exist among patients not receiving palliative care. We examined pain outcomes for disparities among patients receiving palliative care.

METHODS

At a 542-bed teaching hospital in Honolulu, The Queens' Medical Center Pain and Palliative Care Department collected patient characteristics and pain severity (initial, final) for each consultation from 2005 through 2009. Analyses compared pain levels by race (white, Asian, Hawaiian/Pacific Islander [PI], other) and consultation diagnosis (cancer, noncancer medical, surgical [59% orthopedic], other). Multiple regression models analyzed factors associated with lower final pain levels and pain reduction.

RESULTS

Study population included 4658 patients. No final pain was reported by more non-white patients (33%-39%) than white (27%, p<0.0001) and more cancer and noncancer medical patients (45%-54%) than surgical/other patients (20%-31%, p<0.0001). Asian (adjusted odds ratio [aOR] 1.24; 95% confidence interval [CI] 1.06-1.46; p=0.007) and PI (aOR 1.46, 95% CI 1.20-1.77, p=0.0001) races had increased likelihoods of lower final pain severity versus whites, controlling for age, gender, Karnofsky score, preconsult length of stay, and initial pain severity. Surgical diagnoses had decreased likelihood of lower final pain levels versus cancer (aOR 0.38, 95% CI 0.32-0.46, p<0.0001). Among 2304 patients reporting moderate/severe initial pain, 1738 (75.4%) reported pain reduction to mild/no final pain. PI race was associated with pain reduction versus whites (aOR 1.57, 95% CI 1.17-2.10, p=0.003). Surgical diagnoses had decreased likelihood of pain reduction vs. cancer (aOR 0.52, 95% CI 0.39-0.71, p<0.0001).

CONCLUSION

Pain outcomes were similar or better among non-white races than whites. Surgical patients reported more final pain than cancer patients.

The management of cancer pain

The experience of pain in cancer is widely accepted as a major threat to quality of life, and the relief of pain has emerged as a priority in oncology care. Pain is associated with both the disease as well as treatment, and management is essential from the onset of early disease through long-term survivorship or end-of-life care. Effective relief of pain is contingent upon a comprehensive assessment to identify physical, psychological, social, and spiritual aspects and as a foundation for multidisciplinary interventions. Fortunately, advances in pain treatment and in the field of palliative care have provided effective treatments encompassing pharmacological, cognitive-behavioral, and other approaches. The field of palliative care has emphasized that attention to symptoms such as pain is integral to quality cancer care.

Ethnic and gender differences in the functional disparities after primary total knee arthroplasty

BACKGROUND

The benefits of TKA have been well documented. Whether these benefits apply equally across gender and ethnic groups is unclear. Given the underuse of TKA among certain demographic groups, it is important to understand whether gender or ethnicity influence pain and function after TKA.

QUESTIONS/PURPOSES

We determined (1) the influence of race, gender, and body mass index (BMI) on primary TKA functional scores and ROM before gender-specific implants; and (2) whether comorbidities influenced ROM and functional scores.

PATIENTS AND METHODS

We reviewed all 202 patients who underwent primary TKAs in 2004. We contacted 185 of the 202 patients, including 90 African-Americans, 87 Caucasians, four Asians, and four Hispanics (55 men, 130 women). Their average age was 66 years, and average BMI was 34.4 (range, 20-55). Knee Society scores (KSS) and ROM, patient demographics, and the Charlson Comorbidity Index (CCI) were recorded. Minimum followup was 24 months (average, 29.1 months; range, 24-60.3 months).

RESULTS

African-Americans had longer delays to presentation, higher BMI, and worse 2-year KSS. Women (all races) had higher BMI and worse preoperative flexion/arc ROM. African-American women had worse final ROM and had similar final gains in ROM (postoperative minus preoperative ROM) after controlling for confounders.

CONCLUSIONS

Gender and race affected functional KSS and ROM variables. The worse results experienced by African-American women may be attributable to a longer delay to presentation. However, the scores and motion were high for all subgroups, and underuse of TKA in women and African-Americans cannot be justified based on a perception of lesser functional gains.