New research results on pain differences between blacks and whites show that, for example, black women are much more likely than white women to have severe pain and related mental health effects when they finally seek treatment from pain specialists. Blacks also had more barriers to getting effective pain care.
Those findings, from pain researchers at the University of Michigan who are among the first to study racial disparities in chronic pain and its treatment, are being presented this week at the annual meeting of the American Pain Society.
And although the researchers have not yet found precise reasons for the differences between blacks and whites in how they perceive and handle pain, they suspect that many factors, including economic and cultural ones, are at work. They have additional studies under way to further explore the impact of chronic pain on racial and ethnic minorities.
"Overall, African Americans with chronic pain have significantly more symptoms than whites when they first seek pain treatment, as well as more pain, depression and impairment in their physical, emotional and social health," says lead researcher Carmen Green, M.D., an anesthesiologist and assistant professor in the U-M Health System's Department of Anesthesiology and pain specialist at the U-M's Multidisciplinary Pain Center. "This has tremendous implications for their quality of life and overall health."
Green and her colleagues studied African American and Caucasian men and women who were seen at the U-M pain center for chronic pain in recent years. Using standardized survey questionnaires, 3,132 white and 345 black women were asked about their pain, emotional health and disability level.
In a separate study, the team tallied the answers of 136 white and 101 black patients with chronic pain from a 50-item questionnaire about their pain treatment patterns, perceptions and payment.
The results parallel disparities that other researchers have found between blacks and other races in other diseases and their treatment, such as cancer and heart disease.
"Although the health of the U.S. population has improved substantially over the past fifty years, racial and ethnic minorities continue to lag behind non-minorities on many key health indicators," Green notes. "We're starting to understand that chronic pain, which can interfere greatly with a person's work, social and personal life, and emotional and physical health, may be no different from what others have found in other conditions."
Green and her colleagues on the Michigan Pain Outcomes Study Team began their research after noticing differences between patients of different races who came to the pain center for treatment. Black patients coming to the center for the first time tended to have much more severe symptoms than new white patients, Green explains.
Pain treatment for both acute and chronic pain has improved tremendously in recent years, with better medications and pain-controlling devices to choose from and better understanding of how pain affects a patient's life. So, Green says, no patient should have to suffer without treatment for pain that interferes with their ability to work, play, exercise, or care for themselves or others.
But the results of their studies to date suggest that many patients, especially African Americans, are going without treatment until their symptoms become severe and affect their functioning.
In the study of black and white women with chronic pain, the team found that even after correcting for age, marital status, education level and pain duration, blacks had greater levels of pain, depression, disability and symptoms of post-traumatic stress disorder than whites.
All four measures of pain and its effects on mental and physical functioning were much higher in the black women than in the white women, based on their answers to standardized questionnaires that have been designed and validated to provide consistent measurement.
White women, for example, were 66 percent less likely than black women to score high on the McGill Pain Questionnaire, and 61 percent less likely than black women to score high on the Beck Depression Inventory. The differences between the races were somewhat smaller on the Pain Disability Index and the Post Traumatic Chronic Pain Test. Chronic pain is known to cause or worsen problems with both psychological well-being and overall health.
In the survey of white and black pain patients of both genders regarding their health care utilization patterns and attitudes, Green and her colleagues noted several significant differences between the races, along with trends that did not reach statistical significance.
African Americans were more likely than Caucasians to use the emergency room for regular health care services, and reported more visits to the ER for chronic pain. African Americans also waited longer than whites to see a health care provider of any type about their chronic pain.
Economic factors seem to play a strong part in producing these disparities, Green says. Although the vast majority of all the patients surveyed had health insurance and prescription drug coverage, African Americans were more likely to be covered by Medicaid, and reported more difficulties in affording or paying for their health care in the past year.
The survey asked patients about their perceptions of how well pain medication controlled pain, and whether gender, ethnicity or culture affected access to pain treatment. Although the differences between the races were not statistically significant, except for black women, Green says she suspects that perceptions of the health care system, attitudes toward pain itself, and cultural norms about expressing pain may play a role in African Americans' pain behavior.
To explore pain's racial disparities further, Green and her team are now conducting the first-ever prospective study of chronic pain in African Americans under 50 years of age, following them for six months after they first visit the pain clinic. Funded by a grant from the Aetna Foundation, they hope to finish recruiting participants this summer and report results early in 2004.
Meanwhile, the team has also just received a grant from the Blue Cross Blue Shield Foundation of Michigan to study the quality of cancer pain management in African Americans, focusing on a type of pain that occurs in 80 percent of cancer patients before their death but is grossly under-treated. The study will enroll patients who are receiving care at the U-M Comprehensive Cancer Center, and several of its community-based cancer care partner locations, for advanced lung, breast, prostate, or colon cancer.
In addition to Green, the study team includes Tamara Baker, Ph.D., a postdoctoral research fellow in Anesthesiology and the U-M Center for Research on Ethnicity, Culture and Health; research associates Khady Ndao-Brumblay, PharmD, MSc. and Andrew Nagrant, M.P.H.; and research assistant Tamika Washington, B.S.
The U-M Multidisciplinary Pain Center provides comprehensive services for the evaluation and treatment of patients with chronic, disabling pain. The team-based approach is especially suited for patients who have not responded to other pain treatments. A referral from a physician is required.
Visit http://www.med.umich.edu/anes/sections/pain/default.htm or call 734-763-5459.