Advocacy
Racial and Ethnic Identifiers in Pain Management: The Importance to Research, Clinical Practice, and Public Health Policy
A Position Statement from the American Pain Society. Approved by the APS Board of Directors, October 22, 2004
An emerging literature is documenting racial and ethnic differences in pain management for acute, chronic, and cancer-related pain. The theme that has emerged from much of the research is that racial and ethnic minorities are at risk for problematic access to pain care, poor pain assessment, and often receive inferior treatment for their pain complaints for all types of pain and across all kinds of treatment settings. As a result, the quality of pain treatment is becoming an important topic in the national debate about health and healthcare disparities.
Although significant progress has been made in documenting disparities in pain care and differences in pain perception, much work remains to be done to understand and eliminate pain management disparities in the U.S. healthcare system. Presently, at the highest levels of research, data on race and ethnicity are required to demonstrate sufficient racial and ethnic diversity in research samples so they can support generalization of results to the entire population. Despite the demonstrated value of racial and ethnic data for pain disparities research, continued access to these data cannot be taken for granted.
This paper has three aims:
- to discuss the importance of continued access to data on race and ethnicity so the government can document and publicize disparities (Institute of Medicine, 2002)
- to discuss the implications of several national health disparities initiatives
- to address the significance of racial and ethnic identifiers for clinical health services, experimental pain research, and healthcare policy making.
The Status of Health Disparities: What Do Racial and Ethnic Identifiers Tell Us?
Several government agencies have compiled comprehensive reports on the status of health disparities. For example, the Institute of Medicine of the National Academy of Sciences (2002) reviewed extensive literature and identified two major sources of disparities: (1) disparities endemic to healthcare systems and (2) disparities that stem from the clinician-patient interaction. The first annual National Healthcare Disparities Report (2004), released by the Agency for Healthcare Research and Quality (AHRQ), provided a national overview of racial, ethnic, and socioeconomic disparities in health care in the general U.S. population. Consistent with the report by the Institute of Medicine, the AHRQ report concluded that racial, ethnic, and socioeconomic disparities are national problems that are pervasive in our healthcare system. Unfortunately, the AHRQ report gave minimal attention to inequities in pain care.
National Health Disparities Initiatives
In addition to forming the basis of comprehensive reports documenting widespread health disparities experienced by racial and ethnic minority groups, racial and ethic identifiers are also necessary to evaluate progress toward eliminating these disparities. A number of national initiatives are underway to eliminate these disparities (e.g., Healthy People 2010, a well-known initiative of the U.S. Department of Health and Human Services, and the NIH Strategic Plan to Address Health Disparities). The latter initiative led to the development of the National Center on Minority Health and Health Disparities, an agency that will coordinate, support, and assess the NIH’s efforts toward eliminating health disparities.
Significance for Pain Research
Green et al. (2003) presented a review paper that documented the presence of significant racial and ethnic disparities in pain assessment and treatment across all settings and for all types of pain. With national attention now focused on health disparities, pain clinicians, researchers, and policy makers have a greater opportunity than ever before to raise awareness about inequities in pain management and the need for comprehensive pain research. The ability to collect and access racial and ethnic identifiers is crucial to the continuation of the critically important work of providing optimal pain care for all.
Using Racial and Ethnic Identifiers in Pain Research
Racial and ethnic identifiers are needed in the clinical and health services research arena to
- document pain disparities in clinical settings based on retrospective data
- plan and implement prospective studies with sufficient sample and ethnic diversity to detect existing pain disparities
- develop and evaluate pain assessment instruments that reflect cultural, ethnic, and linguistic diversity
- understand the role of both patients’ and clinicians’ ethnicity in pain management decision-making
- examine racial and ethnic differences in clinical pain perception, beliefs, attitudes, and behaviors that may underlie differences in the pain experience and in clinical pain conditions as well as disparities in treating such conditions
- develop culturally sensitive models for assessing and treating pain as well as methods to disseminate this information while enhancing pain education for all clinicians and patients alike
- document progress toward eliminating disparities in pain management
- evaluate and document pain management outcomes.
Experimental Research
Racial and ethnic identifiers are needed in experimental pain research to
- examine racial and ethnic differences in experimental pain perception, beliefs, and behaviors that may explain disparities in the experience of clinical pain conditions
- plan and implement studies with sufficient sample diversity to detect racial and ethnic differences when they exist.
Public Policy and Pain Management
Racial and ethnic identifiers are necessary in the public policy arena to
- develop evidence-based pain management standards/guidelines for pain assessment, documentation, and effective pain treatment to ensure adequate care for all patients
- evaluate implementation of pain management standards/guidelines.
References
Green, C. R., Anderson, K. O., Baker, T. A., Campbell, L. C., Decker, S., Fillingim, R. B., et al. (2003). The unequal burden of pain: Confronting racial and ethnic disparities in pain. Pain Medicine, 4, 277–294.
Institute of Medicine. (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington DC: National Academies Press.
National Healthcare Disparities Report: Summary. (2004, February). Rockville, MD: Agency for Healthcare Research and Quality.
This document was prepared by the Organizing Committee of the Pain Disparities Special Interest Group of the American Pain Society.