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Disparities in Pain Management: Examining Cultural Inequities and the Critical Role of Behavioral Health Providers

For decades, pain management and the treatment of chronic pain (CP) have proven to be a complex, costly, and challenging area within the healthcare industry.

woman sitting at a desk and holding her back in pain

While advancements in best practices for treating CP have evolved to include multimethod and multidisciplinary team approaches that incorporate analgesics, physical therapy, psychotherapy, and complementary/alternative medicines, the traditional unimodal biomedical model is still apparent and often leads to poor outcomes (Edmond, Heapy, Kerns, 2019). Disparities in socioeconomic status, race, sexual orientation, and gender further affect access and opportunities for marginalized populations to receive the most effective treatments (Center for Disease Control; Cohen, Vase, Hooten, 2021). In addition, an individual’s experience of pain and the implications of ineffective treatment are impacted by sociocultural factors such as systemic discrimination, bias, and cultural stigma (NIH Heal Initiative).

In 2020, the International Association for the Study of Pain (IASP) revised its definition of pain. The new definition states that pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” The definition further clarifies that pain can be experienced without identifiable evidence of tissue damage.

Implications on Society

Chronic pain can have significant functional and financial implications for individuals, families, and society as a whole. According to the Centers for Disease Control and Prevention (CDC), an analysis of National Health Interview Survey data revealed that in 2021, an estimated 51.6 million people (20.9% of US adults) experienced CP, with 17.1 million (6.9% of US adults) experiencing high-impact CP, which significantly impacts day-to-day functioning.

Children also suffer from CP when it is not associated with a disease. Although research is more limited in this area, and prevalence rates vary, a systematic review noted 4% to 88% of children and adolescents experienced various areas of pain (King et al., 2011), and other research showed prevalence rates for a pediatric population of 25% (Perquin et al., 2000). In addition, COVID-19 has contributed to increases in CP cases related to stress about the pandemic and long COVID-19 symptoms (Abramson, 2022).

In addition to the substantial impact of CP on individuals and families, there is a considerable financial burden to society that results from healthcare costs and loss of work productivity. A study conducted by the Institute of Medicine’s Committee on Advancing Pain Research, Care, and Education concluded that the total financial burden to the US in 2010 ranged from $560 billion to $635 billion, which, at that time, was “nearly 30% higher than the combined cost of cancer and diabetes (Gaskin & Richard, 2011).” Those numbers also excluded the treatment of children and adults living in institutional settings (e.g., correctional facilities and psychiatric facilities).

History of Disparities

Prior to 1960, CP was thought of primarily as a physical health condition treated through medical interventions. This often led to only modest improvements in pain management. In addition, retrospective research studies examining the history of medication management for pain revealed significant differences in the administration of pain medication for Black and white patients in the US, highlighting systematic undertreatment of Black adults and children.

The disproportionately low rate of pain treatment was present even when Black patients were being treated for specific medical diagnoses that caused pain, such as the treatment of fractures in the emergency room and appendicitis (Hoffman et al., 2016).

Racially biased beliefs about biological differences between Black and white individuals have been historically documented by scientists and physicians, and for centuries, those beliefs were utilized to justify the inhumane treatment of Black people in medicine.

While advances in medical, psychological, and racial equity research have highlighted pervasive racial inequality and moved the field toward efforts to eliminate racial health disparities, current research reveals significant cultural bias in healthcare and in the treatment of CP (Hoffman et al., 2016).

Research between 2016 and 2021 exposes cultural disparities in the treatment and prevalence rates of pain issues in the U.S. Hoffman and colleagues published a study in 2016 that showed 50% of White medical students and residents endorsed at least one racially biased belief about biological differences between Black and white individuals (e.g., Black skin is thicker than white skin). The full sample of medical students was then shown case examples of a white and a Black patient experiencing pain. Those medical students who held at least one biased belief about racial differences rated the Black patient’s pain as lower than the white patient’s pain and provided treatment recommendations that were less accurate than their white counterparts.

In addition, CDC data from 2016 and 2021 revealed higher prevalence rates of chronic pain for cultural groups, including non-Hispanic American Indians or Alaskan Natives, Military veterans, women, adults who identify as bisexual, individuals living in rural areas, and individuals living in socioeconomic conditions where family income falls below the national poverty level.

A New Strategy

Additional research and advancements in understanding CP now view pain from a biopsychosocial perspective that focuses on the biological, psychological, and social influences on pain perception and the causes and effects of CP.

Given that CP is often comorbid with mental health and substance use disorders and the complex biopsychosocial interactions impacting them all, it became apparent that a biomedical framework alone was not an effective approach for pain management. Following devastating results from the over-use of opioid medications for pain and extensive research published in 2011 by the Institute of Medicine deeming chronic pain as a public health issue, in 2016, the US Department of Health and Human Services developed a national pain strategy proposing the need for health professionals across all disciplines to engage in treating pain management (Edmond et al., 2019).

Best practice standards for treating pain now encourage the use of non-pharmacological approaches when indicated and promote the involvement of behavioral health professionals and alternative and complementary therapies. While there has been an increase in integrated healthcare clinics and specialty mental health clinics for treating CP, the consistent use of multidisciplinary teams to address pain from a biopsychosocial perspective has been slow and continues to reveal significant disparities in access and treatment (Casio & Demyan, 2023).

The pain experiences that have accompanied COVID-19 present even more urgent and challenging needs for pain interventions that require medical professionals to understand how to validate and treat a patient’s experiences of pain, even when there is no evidence of physical pathology (Abramson, 2022).

The Role of Behavioral Health Professionals

Numerous psychological treatments and interventions for treating CP have been developed and researched since 1960. Cognitive behavioral therapy (CBT) is the most widely used psychological treatment, with ample research supporting its effectiveness in reducing pain and increasing psychological and physical health (Jensen & Turk, 2014).

Research also supports other effective interventions, such as mindfulness-based interventions and biofeedback (Casio & Demyan, 2023). In addition to providing psychological interventions, psychologists and other behavioral health professionals have expertise in assessing, conceptualizing, and treatment planning from a biopsychosocial perspective, which provides a complementary area of specialty to primary care physicians and other medical staff. Behavioral health professionals are typically well versed in facilitating and collaborating on multidisciplinary teams and can provide consultation on understanding the complex bi-directional biopsychosocial factors of mental health, substance use, and experiences of pain.

While there is little research on health disparities in pain management with behavioral health professionals specifically, we know all individuals harbor biased beliefs that can negatively impact behavior and interactions.

Psychologists and behavioral health professionals are often educated and trained in understanding bias and other identity and social factors related to culturally sensitive and responsive treatment. These areas of expertise are necessary for addressing the systematic cultural bias and discrimination identified through extensive research and would contribute to more appropriate and adequate treatment of all people suffering from CP.

Behavioral health professionals are also highly skilled in building rapport with individuals and their caregivers, allowing for the development of a trusting relationship where education for individuals and families may be better received.

Behavioral health professionals can assist systems of care through the following action items specifically related to addressing cultural disparities in pain management (Sabin, 2020):

  1. Conduct and facilitate educational programs with multidisciplinary teams on cultural bias, implicit bias and disparities in pain management to help professionals gain greater awareness of their own biases and implications related to treatment disparities.
  2. Develop data collection systems that track pain assessments and demographics related to race, gender, socioeconomic status, and other cultural factors to identify disparities within each system of care.
  3. Decrease the discretion of individual professionals in treating CP by following established best practices, guidelines, and system protocols.
  4. Develop protocols for engaging in comprehensive assessments of pain and comorbid mental health and/or substance use conditions that incorporate a biopsychosocial, cultural formulation for understanding presenting concerns that then facilitate treatment planning.
  5. Continue conducting research on developing standard objective measures for assessing pain that are not fully reliant on patient self-reports and subjective interpretations by providers.

Devereux Advanced Behavioral Health is one of the nation’s largest nonprofit organizations, providing services, insight, and leadership in the evolving field of behavioral healthcare. Founded in 1912, Devereux operates a comprehensive national network of clinical, therapeutic, educational, and employment programs that positively impact the lives of tens of thousands of children, adults – and their families – every year. The organization’s unique approach combines evidence-based interventions with compassionate family engagement.

With more than 6,000 employees working in programs across the country, Devereux is a trusted partner for families, schools, and communities, serving many of our country’s most vulnerable populations in the areas of autism, intellectual and developmental disabilities, specialty mental health, education, and foster care. For more than a century, Devereux Advanced Behavioral Health has been guided by a simple and enduring mission: To change lives by unlocking and nurturing human potential for people living with emotional, behavioral, and cognitive differences. www.devereux.org

References

Abramson, A. (2022). Patients turn to psychologists for new chronic pain strategies in the COVID-19 era. Monitor
on Psychology, 53(6). https://www.apa.org/monitor/2022/09/understanding-managing-pain

Center for Substance Abuse Treatment. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2012. (Treatment Improvement Protocol (TIP) Series, No. 54.) 3, Chronic Pain Management. Available from: https://www.ncbi.nlm.nih.gov/books/NBK92054

Cohen, S. P., Vase, L., & Hooten, W. M. (2021). Chronic pain: an update on the burden, best practices, and new advances. Lancet (London, England), 397(10289), 2082–2097. https://doi.org/10.1016/S0140-6736(21)00393-7

Cosio D, Demyan A. Behavioral Health Specialists in Chronic Pain Care: An Overlooked Asset. Practice Pain Management. 2023 January/February;23(1).

Edmond SN, Heapy AA, Kerns RD. Engaging Mental Health Professionals in Addressing Pain. JAMA Psychiatry. 2019;76(6):565–566. doi:10.1001/jamapsychiatry.2019.0254

Gaskin DJ, Richard P. The Economic Costs of Pain in the United States. In: Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. Appendix C. Available from: https://www.ncbi.nlm.nih.gov/books/NBK92521/

Jensen, M. P., & Turk, D. C. (2014). Contributions of psychology to the understanding and treatment of people with chronic pain: Why it matters to ALL psychologists. American Psychologist, 69(2), 105–118. https://doi.org/10.1037/a0035641

King, Saraa,*; Chambers, Christine T.b; Huguet, Annab; MacNevin, Rebecca C.b; McGrath, Patrick J.b; Parker, Louiseb; MacDonald, Amanda J.c. The epidemiology of chronic pain in children and adolescents revisited: A systematic review. Pain 152(12):p 2729-2738, December 2011. | DOI: 10.1016/j.pain.2011.07.016

Perquin, C. W., Hazebroek-Kampschreur, A. A., Hunfeld, J. A., Bohnen, A. M., van Suijlekom-Smit, L. W., Passchier, J., & van der Wouden, J. C. (2000). Pain in children and adolescents: A common experience. Pain, 87(1), 51–58. doi:10.1016/S0304-3959(00)00269-4

Rikard SM, Strahan AE, Schmit KM, Guy GP Jr.. Chronic Pain Among Adults — United States, 2019–2021. MMWR Morb Mortal Wkly Rep 2023;72:379–385. DOI: http://dx.doi.org/10.15585/mmwr.mm7215a1.

Sabin, A. (2020). How we fail Black patients in pain. https://www.aamc.org/news/how-we-fail-black-patients-pain

One Response

  1. Thank you for sharing this comprehensive article on the complex issue of chronic pain management and the disparities that exist in its treatment. The article highlights the need for a multidisciplinary approach, incorporating behavioral health professionals, to address the biopsychosocial factors that contribute to chronic pain.

    Key points from the article include:

    1. Chronic pain affects millions of people worldwide, with significant financial and functional implications.
    2. Disparities in socioeconomic status, race, sexual orientation, and gender affect access to effective treatments.
    3. The traditional biomedical model often leads to poor outcomes, and a biopsychosocial approach is necessary.
    4. Behavioral health professionals, such as psychologists, play a crucial role in assessing, conceptualizing, and treating chronic pain from a biopsychosocial perspective.
    5. Education and training in cultural sensitivity and responsiveness are essential for addressing systematic cultural bias and discrimination.
    6. Action items for behavioral health professionals include conducting educational programs, developing data collection systems, decreasing discretion in treatment, developing comprehensive assessment protocols, and continuing research on objective measures for assessing pain.
    Overall, the article emphasizes the need for a collaborative, multidisciplinary approach to address the complex issue of chronic pain management and reduce disparities in its treatment.
    Bankole-Phillip longe
    The Devereux Foundation
    Newyork center

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