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Pain Management Across Cultures

Authors: Andrew N. Wilner, MD, FAAN, FACPFaculty and Disclosures

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To host this year's conference, "Cultivating a Community of Care," the American Academy of Pain Management partnered with Meharry Medical College, Nashville, Tennessee. The forum united doctors, nurses, psychologists, pharmacists, social workers, dentists, acupuncturists, and others to address conventional and traditional healing techniques and unique needs of patients with pain. The meeting focused on disparities of care in pain management that affect special populations, such as American Indians, women, minorities, the elderly, the 47 million uninsured in the United States, and others.

The conference drew on the strengths of Meharry Medical College, founded in 1876 as the medical division of Central Tennessee College, established by the Freedmen's Aid Society of the Methodist Episcopal Church. Its mission is to "improve the health and health care of minority and underserved communities by offering excellent education and training programs in the health sciences; placing special emphasis on providing opportunities to people of color and individuals from disadvantaged backgrounds, regardless of race or ethnicity; delivering high-quality health services; and conducting research that fosters the elimination of health disparities." This mission includes training healthcare professionals to provide "culturally competent" medical care, which takes patients' bio-psycho-social and cultural perspectives into account during the process of clinical assessment, decision making, and treatment.

Ethnic and Gender Disparities in Pain Management

Carmen Green, MD, Associate Professor of Anesthesiology, Director of Pain Research, and Director of the Health Disparities Research Program, University of Michigan Medical School, Ann Arbor, Michigan, delivered the keynote address, "Pain, Disparities, and Practice: Opportunities to Improve Health Policy and Healthcare Quality."

As the "proud great granddaughter of slaves, free people of color, Irishmen, and Indians," Dr. Green related that she grew up listening to stories of her ancestors, "They paid a price for something that they could not yet see, and it's those stories that have really been instrumental in the work that I do as a pain medicine doctor."

Dr. Green raised several issues: "Why do we take care of different people in different ways? Why are there differences in outcomes based on gender or class? Do these things influence our access to care? Pain is the perfect model to try and improve these very large disparities. Quality healthcare should be safe, timely, effective, efficient, equitable, and patient-centered."

Healthcare in the United States is not the same for everyone, according to Dr. Green. Disparities in care based upon gender, race, age, class, and lack of insurance are important factors in the delivery of healthcare. Historically, healthcare for black Americans after the end of slavery was so poor that some recommended re-enslaving them to improve their health. As late as 1984, the Heckler Report identified 85,000 excess deaths for black Americans due to suboptimal care. Native Americans and Chinese Americans have also traditionally received poor care. A study published in 1999 in The New England Journal of Medicine[1] had male and female actors of different racial backgrounds complain of chest pain. The study authors concluded that race and sex influenced how physicians managed care: In this simulation, women and blacks were less likely to be referred for cardiac catheterization than were men and whites.

Dr. Green observed, "This paper was important because the authors couldn't explain why women and blacks were treated differently."

The prevalence of pain will continue to grow as people are treated for diseases that previously were fatal. Most of the top 10 causes of death, such as heart disease, cancer, and chronic lower respiratory diseases, are associated with pain. Presently, 7% to 50% of Americans suffer from some type of pain, and 1 in 6 live in chronic pain. This prevalence increases to 1 in 3 in the elderly. Chronic pain is estimated to cost $90 billion per year in the United States; however, only 1% of the National Institutes of Health budget is allocated to pain research.

"Healthcare professionals aren't uniformly trained in the treatment of pain," stated Dr. Green. Factors such as age, ethnicity, family history, sex roles, anxiety, depression, cognitive factors, behavioral factors, and sociocultural differences influence pain and how it is treated. In particular, women are at risk of having their pain undertreated and poorly assessed. Women have a higher prevalence of most chronic pain conditions, including widespread pain, regional pain, fatigue, irritable bowel syndrome, migraine, and tension headache. Physical and sexual abuse, more common in women, also play a role in the development of chronic pain.

Dr. Green observed that minorities report more pain, increased severity of pain, and are more likely to be disabled from pain. Minorities with cancer pain are less likely to receive treatment for their pain and have less access to specialty care and opioids. In a recent study completed in Michigan, pharmacies in minority-predominant zip codes were 52 times less likely to carry sufficient opioid analgesics than were pharmacies in white-predominant zip codes regardless of income.[2]

Dr. Green recommended that patients be asked about the impact that pain has had on their lives, jobs, and ability to afford treatment. The goal is to provide culturally sensitive care for all patients.

Dr. Green concluded, "The willingness to listen to the patient, who may relate a 'different story' than expected, may be very important. It may make you uncomfortable to provide culturally sensitive care for people with disabilities, women, and minorities. Knowing is not enough; we must apply. Willing is not enough; we must do. We need to think of pain as a social justice issue. Pain is a good model [for thinking] about healthcare reform."

Pain Management in American Indian Communities

American Indians are the only Americans with a legal right to health insurance, which is provided by the Indian Health Service, according to Donald Warne, MD, MPH, Health Policy Research Director, InterTribal Council of Arizona, Inc. However, the Indian Health Service suffers from severe underfunding relative to other government healthcare agencies, receiving only $2130 per person (pp) compared with $3985/pp for the Bureau of Prisons, $5010/pp for Medicaid, $5234/pp for the Veterans Administration, and $7631/pp for Medicare.

"We are not getting an adequate deal in exchange for our land," complained Dr. Warne, "There is only one pain clinic in the entire Indian Health Service."

The disparity in funding for the Indian Health Service is particularly poignant when examining the relatively poor health of American Indians. Death rates for preventable diseases in American Indians are significantly higher than among non-Indians: alcoholism, 638%; accidents, 215%; diabetes, 291%; and suicide, 91%. The average age of death in Arizona is 72.2, but is 54.7 in Arizona's American Indian population. Dr. Warne stressed the importance of the "diabetes-depression-alcoholism" triad that he often witnessed as a primary care physician. "Alcohol worsens blood sugar, and diabetes worsens depression," observed Dr. Warne. "But it's hard to treat, because Medicaid will address the diabetes and depression but not the alcoholism."

Dr. Warne outlined important issues regarding disparities in American Indian pain management. These include influence of culture on pain response, tolerance and communication, current utilization trends and need, disparities in access and funding, differences in health beliefs, and provider communication and cultural competence.

In the American Indian culture, medicine is seen as a healing power and not something in the control of man. Medical providers were known as traditional healers, and they channeled healing energy but did not own it. A medicine man touched the patient, prayed with the patient, meditated with the patient, and included the family and community in the healing process. Unfortunately, the modern focus on confidentiality loses sight of the power of the community to effect healing.

"One of the biggest advantages that the traditional healers have is that they are members of the community," observed Dr. Warne, "While the goal of modern care is cure or control of the individual disease, the traditional healer focuses on community health. We will never be effective in the healthcare of any population until we are culturally sensitive."

Dr. Warne emphasized the humility of the traditional healer. One healer, Black Elk, wrote, "Of course it was not I who cured. It was the power from the outer world, that the visions and ceremonies had only made me like a hole through which the power could come to the two-leggeds. If I thought that I was doing it myself, the hole would close up and no power could come through."

In addition to being underfunded, the Indian Health Service is understaffed by about 15%. "We pay people less to see patients who are sicker," Dr. Warne wryly observed.

"We need to eliminate the funding disparities. What we spend in a week on wars could correct the problem," concluded Dr. Warne.

Spiritual Assessment and Healing in the African American Culture

"We need a 'narrative competence' in listening to our patients; they are not just a problem list," declared Richard Payne, MD, Professor of Medicine and Divinity, Duke University, Durham, North Carolina. "The notions of healing and spirituality are very important in dealing with people within the context of their culture."

Dr. Payne emphasized that race and culture are distinct attributes. Just because people have a common phenotype -- black skin, for example -- does not mean that they maintain the same views and perspectives regarding spirituality, pain, and healing.

Dr. Payne explained that healing needs to involve not just the absence of disease, but also the restoration of all 3 spheres of body, mind, and spirit. Many blacks believe that only God can decide life and death, that God is responsible for health, that spiritual beliefs are the most effective way to influence healing, and that divine intervention and miracles occur. They may hold contradictory beliefs, for example, that only God can decide on health, but that the doctor can be God's instrument, acting legitimately and appropriately in issues of pain and health.

Chronic pain, defined as pain lasting more than 2-3 months, is important to treat because it can interfere with one's ability to communicate with God and all the critically important aspects of life. In one study, 50% of patients who were terminally ill reported moderate-to-severe pain, emphasizing that chronic pain is often not adequately treated at the end of life.[3] In that study, blacks were more likely to seek additional pain therapy, see a pain specialist, and refuse more pain treatment because of fear of addiction.

Pain may have several components, such as emotional, spiritual, financial, and physical. Patients may refuse pain treatment because they would rather deal with pain on their own, or because they see pain as a struggle that needs to be overcome. As such, denying treatment may represent a type of nobility. Black patients may also be more mistrustful that their pain will be treated adequately, based on historical disparities in healthcare treatment and abuses such as the Tuskegee syphilis experiments.

There is little disagreement between blacks and whites that the following are important at the end of life: spiritual peace, not being a burden, knowing what medications are available, honest answers from doctors, settling family issues, physical comfort, understanding treatment options, freedom from pain, getting finances in order, visits from family and friends, and knowing how to say goodbye.

With respect to the role of prayer as medicine, Dr. Payne commented, "I think that persons in religious communities get social support and lifestyle benefits that may be translated into better health outcomes. I am not convinced that there are any specific outcomes that one can assign to an intervention of a higher being."

Dr. Payne concluded, "Disparities in healthcare are not due to just simple racism. For example, the lack of opioid availability to minorities is a complex issue; pharmaceutical companies admitted that they didn't detail as much in those areas; physicians didn't write opioid prescriptions in as much volume, and some physicians worried about abuse. There is an effect of people's perception of race and unfairness, regarding how they perceive pain and their relationships with their providers."

Conclusions

Disparities in healthcare exist related to gender, race, minority status, and other factors. One such affected group is American Indians, who have significantly increased rates of alcoholism, accidents, diabetes and suicide, as well as premature death. Federal funding for the Indian Health Service is lower than for other types of government health insurance.

Chronic pain interferes with quality of life and is undertreated in many people. Disparities exist in the treatment of chronic pain among people of different racial backgrounds and will grow as the population ages and becomes more infirm. Comprehensive treatment includes not only alleviating physical pain, but also addressing emotional, spiritual, and financial consequences of pain. Clinicians should strive to provide culturally sensitive care and adequate pain control.

This activity is supported by an educational grant from PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC.

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