Ensuring Access to High Quality, Multidisciplinary Pain Care for Everyone: Tackling Barriers of Policy, Bias & Inequality

It's time for a cultural transformation in the treatment of pain. 

The American Academy of Pain Medicine (AAPM) and World Health Organization (WHO) have declared pain relief a human right.

Most people with pain receive initial care in a primary care setting. Compared with physicians who have completed extensive specialization (eg, fellowships) in pain management, primary care physicians receive much less formal training in managing chronic pain.

It has been demonstrated that for pain management prior to specialty pain care, blacks and women had less adequate pain care at referral. These results suggest the need for interventions and education in the primary care arena to improve pain care.

Outcomes

Learners completing this activity report improved abilities in:

• Addressing unconscious and implicit biases
• Truthful and honest pain assessment of both gender and race in pain management
• Ensuring equitable access to care for all persons

Learning Objectives

As a result of participating in this activity, learners will be able/better able to:

• List the demographic trends changing the patient population in the United States
• Account for these trends when formulating long-term practice, policy or organizational decisions 
• Deconstruct ways in which clinical decision making is subject to biases of gender, race, and ethnicity
• Categorize the ways in which the phenotypes of gender, age, race, and ethnicity influence healthcare disparities
• Modify clinical care to account for implicit bias

Desirable Physician Attributes

• Patient Care [ACGME/ABMS] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
• Provide Patient-centered Care [IOM] Identify, respect, and care about patients’ differences, values, preferences and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health
• Professionalism [ACGME/ABMS] As manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
• Systems-Based Practice [ACGME/ABMS]  as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • 1.4: Describe the impact of pain on society
    
  • 1.5: Explain how cultural, institutional, societal, and regulatory influences affect assessment and management of pain

• 2. Pain assessment and measurement: How is pain recognized?
  • 2.3: Assess patient preferences and values to determine pain-related goals and priorities
  • 2.4: Demonstrate empathic and compassionate communication during pain assessment

• 4. Clinical conditions: How does context influence pain management?
  • 4.1: Describe the unique pain assessment and management needs of special populations
  • 4.4: Implement an individualized pain management plan that integrates the perspectives of patients, their social support systems, and health care providers in the context of available resources
  • 4.5: Describe the role of the clinician as an advocate in assisting patients to meet treatment goals

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships

Neither the speaker, peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity has, or has had within the past 12 months, any relevant financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Additional Reading

• Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US); 2003. EXECUTIVE SUMMARY. Available from: https://www.ncbi.nlm.nih.gov/b...
• Green, C. R., Anderson, K. O., Baker, T. A., Campbell, L. C., Decker, S., Fillingim, R. B., ... & Todd, K. H. (2003). The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Medicine, 4(3), 277-294.
• Poleshuck, E. L., & Green, C. R. (2008). Socioeconomic disadvantage and pain. Pain, 136(3), 235.
• Green, C. R., Wheeler, J. R., Marchant, B., LaPorte, F., & Guerrero, E. (2001). Analysis of the physician variable in pain management. Pain Medicine, 2(4), 317-327.
• LaVeist, T. A., Gaskin, D. J., & Richard, P. (2009). The economic burden of health inequalities in the United States.
• Green, C. R., Baker, T. A., Sato, Y., Washington, T. L., & Smith, E. M. (2003). Race and chronic pain: A comparative study of young black and white Americans presenting for management. The Journal of Pain, 4(4), 176-183.
• Schulman, K. A., Berlin, J. A., Harless, W., Kerner, J. F., Sistrunk, S., Gersh, B. J., ... & Eisenberg, J. M. (1999). The effect of race and sex on physicians' recommendations for cardiac catheterization. New England Journal of Medicine, 340(8), 618-626.
• Green, C., Todd, K. H., Lebovits, A., & Francis, M. (2006). Disparities in pain: Ethical issues. Pain Medicine, 7(6), 530-533.
• Green, Carmen R., John RC Wheeler, Frankie LaPorte, Beverly Marchant, and Eloisa Guerrero. "How well is chronic pain managed? Who does it well?." Pain Medicine 3, no. 1 (2002): 56-65.
• Sewell, J. L., & Velayos, F. S. (2012). Systematic review: the role of race and socioeconomic factors on IBD healthcare delivery and effectiveness. Inflammatory Bowel Diseases.
• Fuentes, M., Hart-Johnson, T., & Green, C. R. (2007). The association among neighborhood socioeconomic status, race and chronic pain in black and white older adults. Journal of the National Medical Association, 99(10), 1160.
• Elder, C. R., DeBar, L. L., Ritenbaugh, C., Rumptz, M. H., Patterson, C., Bonifay, A., ... & Deyo, R. A. (2017). Health care systems support to enhance patient-centered care: lessons from a primary care-based chronic pain management initiative. The Permanente Journal, 21.
• Baker, T. A., & Green, C. R. (2005). Intrarace differences among black and white Americans presenting for chronic pain management: The influence of age, physical health, and psychosocial factors. Pain Medicine, 6(1), 29-38.
• Kaplan, G. A. (2004). What’s wrong with social epidemiology, and how can we make it better?. Epidemiologic Reviews, 26(1), 124-135.
• Green, C. R., & Hart-Johnson, T. (2010). The adequacy of chronic pain management prior to presenting at a tertiary care pain center: the role of patient socio-demographic characteristics. The Journal of Pain, 11(8), 746-754.
• IOM (Institute of Medicine). 2011. Patients charting the course: Citizen engagement and the learning health system: Workshop summary. Washington, DC: The National Academies Press