Julie Posey, a 65-year-old retiree, said her arthritis caused her to live with debilitating, chronic pain for nine years before her primary-care physician prescribed her any pain medication stronger than Tylenol.
Posey, who developed arthritis in 1998, said she suffered with severe arthritis pain for several months until she was diagnosed with breast cancer in 1999.
After her diagnosis, Posey was offered narcotics to treat the pain associated with her cancer. But the narcotics did little to ameliorate the arthritis pain in her lower back, the swelling in her joints and the constant agony of simple activities such as walking.
Posey's breast cancer went into remission in 2004. But what should have been happy news also meant that she would no longer have the narcotics prescribed to her for breast cancer treatment.
Her arthritis pain became excruciating. She was forced to use a cane to walk and had to depend on her friends and family to help her with day-to-day chores.
"I've been seeing my [primary-care physician] every three months for the past nine years, and each time I was there he'd ask me why I'm walking with a cane, and I'd tell him it's because of the pain in my back, that the arthritis pain kept getting worse and Tylenol and physical therapy didn't help me," she said.
"But he wouldn't change my medication. I'd talk to other arthritis patients who were taking opioids, but all I could get was Tylenol, and I knew there had to be something better."
A number of factors may have contributed to Posey's doctor's decision not to prescribe her a more powerful painkiller. But a growing body of evidence suggests that one of the reasons she may not have received proper pain treatment is because Posey is black.
And the latest addition to this body of research shows that these discrepancies in care may be present not only in the family physician's office, but also in the emergency department.
A study released Tuesday reveals racial and ethnic minorities may be less likely to receive pain medication by emergency department doctors than white patients, despite the fact that opioid prescribing for patients making pain-related visits to the emergency department increased over the past 15 years.
Researchers at the University of California, San Francisco, analyzed data from 1993 to 2005 gathered through the National Hospital Ambulatory Medical Care Survey (NHAMCS) of U.S. emergency department visits.
After reviewing nearly 400,000 pain-related visits to emergency departments across the country, they found that emergency department physicians prescribed opioids — a class of pain drugs that have morphinelike effects — to 37 percent of patients in 2005, compared with 23 percent of patients in 1993.
But the researchers also found that striking disparities still exist in the quality of pain management between white and nonwhite patients, despite national initiatives to improve and standardize pain-related care.
"The good news is this study shows that opioid-prescribing rates increased over the past decade, and that appears to be partially in response to national quality improvement programs to improve pain treatment in U.S.," said lead study investigator Dr. Mark Pletcher, assistant adjunct professor of epidemiology and biostatistics at the University of California, San Francisco.
"But there appears to be this persistent gap in prescribing [of opioids] for whites and nonwhites, and the disparity is just as large now as it was a decade ago; it didn't shrink with the increase in prescribing opioids."
Specifically, over the 13-year survey period, the likelihood that a white patient complaining of pain would receive the pain medications from an emergency room doctors was 31 percent, while black and Hispanic patients only received the drugs 23 percent and 24 percent of the time, respectively.
In 2005, opioid-prescribing rates in the emergency department were 40 percent for white patients and 32 percent for all other patients.
Pam Kedziera, clinical director of the Pain and Palliative Care Center at Fox Chase Cancer Center in Philadelphia, Pa., says the findings underscore an inherent prejudice within the medical system.
"Nonwhites going to an ER are often labeled as drug seekers and their pain is ignored," Kedziera said. "Unfortunately, all nonwhites — even the affluent, educated, employed group— have reported that they are viewed differently than white [patients]."
"There is a bias in our health system to be more concerned with potential diversion problems than to be concerned about good pain management."
Miscommunication May Color Pain Drug Discussions
Although a standardized pain assessment tool is used by physicians in determining which patients should be prescribed pain medication, much of the pain-management decision-making remains subjective and therefore vulnerable to the influence of racial bias.
According to Ferdinando Mirarchi, medical director and director of operations of the department of emergency medicine at Hamot Medical Center in Erie, Pa., each patient visiting the emergency department with a complaint of pain is asked to rate their pain on a scale from zero to 10, with 10 being the worst pain.
"But just because a patient complains of 10 out of 10 pain does not mean that the use of narcotics is warranted," Mirarchi explained. "I once had a patient tell me he needed a shot of Demerol just so he could get a tetanus shot for an abrasion."
"Couple pain management with abuse potential, and physicians are more reluctant to prescribe narcotics."
Another point of subjectivity in assessing a patient's pain is based on how well a minority patient can communicate their pain to a white doctor.
"Racial differences between patient and physician have been shown to affect assessment, treatment and compliance with [pain-related treatment] recommendations," said Dr. Sabine Kost-Byerly, director of the pediatric pain management in the department of anesthesiology and critical care medicine at Johns Hopkins University in Baltimore.
"I wonder how well providers of a particular race can read nonverbal cues, such as facial expressions, of another race. … If a patient states that their pain is severe, but [their] facial expression does not support this, or the physician cannot read the patient's facial expression, then no treatment or less treatment will be offered."
Additionally, some doctors believe that certain minority groups may be reluctant to express their pain to doctors because their culture holds a negative stigma on displaying such signs of weakness.
"As a Hispanic professional, in my Mexican culture it is a sign of weakness to feel pain. Many of my white patients ask me for pain medicine," said Dr. Elda Ramirez, assistant professor of nursing in the emergency care division at the University of Texas, Houston. "Many of my nonwhite patients actually refuse pain medicine."
Reversing the Trend
Other research in the past has pointed to racial discrepancies in pain drug prescription rates in other medical sectors.
However, despite major campaigns undertaken by the Joint Commission on Accreditation of Healthcare Organizations and the Veterans Health Administration in the late 1990s to introduce national standards for pain treatment and management, several studies have affirmed that major inequalities still exist in the quality of pain treatment offered to patients of different racial and ethnic backgrounds.
And previous studies based on the NHAMCS survey of U.S. emergency department visits also revealed alarming disparities in opioid prescribing between racial and ethnic groups suffering from back pain and migraine between 1997 and 1999.
Dr. Carmen Green, director of the Pain Research Division and associate professor of anesthesiology at the University of Michigan, conducted a number of studies comparing the differences in prescription rates of opioids to minority and white patients between 2003 and 2007.
What she and other researchers learned was that many doctors lacked familiarity with certain aspects of pain treatment.
"We found in a study several years ago that most doctors don't have pain education," Green said. "Pain is the No. 1 reason a patient sees an emergency department doctor, but they aren't well equipped to deal with these pain complaints."
In 2005, Green and her team of researchers at the University of Michigan published a report in the journal Pain that found great variability in physician's decision-making process for pain management.
According to the study, physicians across the country reported "lesser goals for chronic pain, and their prescribing habits differed on the basis of race, ethnicity, age, and gender, with the pain complaints of minorities, elderly persons, and women receiving less attention than the complaints of white men."
Among the additional barriers faced by minorities seeking adequate pain care, Green found that Michigan pharmacies in minority zip codes were 52 times less likely to carry an adequate supply of opioid analgesics than pharmacies in predominately white zip codes, regardless of income.
And the study released Tuesday suggests that many could be affected. Researchers noted the majority of all emergency department visits are pain-related visits, accounting for 156,729 of the 374,891 trips to the emergency department during the survey years.
And the National Center for Health Statistics reported in 2006 that 26 percent of Americans age 20 years and older — an estimated 76.5 million Americans — say that they suffer from pain.
Until six months ago, Posey was one of these million. It wasn't until her breast cancer returned in the middle of last year that her physician finally prescribed her a generic form of morphine to manage her pain.
For the first time in nine years, Posey said she was free from the pain of her arthritis.
"I don't have to use the cane all the time now," she said. "The swelling has gone down and I can walk on my own. Now I don't need people to constantly assist me to walk and I don't have to hear people always tell me they feel so sorry for me.
"But no one should have to wait until they get cancer to get chronic pain treatment."