Addressing Pain Treatment Disparities Through Health Education

Trends in Addressing Pain Treatment Disparities Through Health Education

April 26, 2017

 For medical providers and patients alike, education plays an integral role in the effectiveness of pain treatment and management. It may be assumed as common sense or even taken for granted that it is important for comprehensive education to be available to patients in pain and the clinicians treating them. However, pain education in medical schools and patient service settings has traditionally been limited to a very narrow scope (Hartrick et al. 593). Clinicians, policymakers and researchers are now calling for new approaches that account for the multi-factorial, “intersubjective” nature of pain to address the full experience of the patient, with an emphasis on the value and power of education to propel this change.

In Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, the authors emphasize:

Enhanced continuing education and training are needed for healthcare professionals to address gaps in knowledge and competencies related to pain assessment and management, cultural attitudes about pain, negative and ill-informed attitudes about people with pain, and stereotyping and biases that contribute to disparities in pain care. (Pizzo et al. 8)

Examples of the all too prevalent “ill-informed attitudes” are highlighted in the New York Times article, “Minorities Seeking Pain Relief Are Shortchanged in Treatment” by Abby Goodnough. Goodnough points out that, not only are black people and other minorities actively being discriminated against but that, statistically speaking, black people are also significantly less likely to abuse prescription drugs than white populations, even in the same economic and geographic brackets.

As Goodnough notes of one study published in August 2016 showing that the likelihood of receiving opioids when visiting the emergency room for certain kinds of pain is “significantly lower” for black patients as compared to whites,

…researchers say the reasons may include false stereotypes, such as the assumption that blacks are more likely to abuse drugs, as well as a tendency for doctors to empathize less with patients whose race is different from their own—perhaps subconsciously—and to underestimate the severity of their pain. (2)

Even so, while substantial data documents the prevalence of racial bias and disparity in the treatment of pain, little is being done to address it. To change these prejudices, proactive clinician education emphasizing “unlearning” biases and taking the whole patient into account is critical.

Pain medicine specialists, such as Rollin M. Gallagher, Pain Medicine Editor-in-Chief, and Daniel B. Carr, Tufts Medical Center Professor of Pain Research, are also championing increased multidisciplinary education, including teaching topics such as empathy and compassion, not only to increase effectiveness and patient satisfaction, but also because they are finding that it makes their jobs easier (Gallagher 213). For example, the authors discuss how underprepared medical students are when confronted by a combination of chronic pain that is “superimposed” by acute pain, despite the fact that this is a common occurrence (Hartrick et al. 593).

Yet, unlike other learned technical skills, skills such as compassion and empathy require a broader, multidimensional scope of education. As Carr points out, “There are unique barriers to appropriate pain assessment and treatment, that perhaps reflect a fundamental discordance of instincts to nurture vs stigmatize” (Carr 183). Carr goes on to say,

…teaching about pain in the same fashion as education about other topics such as anatomy or biochemistry misses something fundamental. Pain education from a reductionist perspective, which ignores its intersubjective and moral dimensions, may actually be counter-productive. […] Material that emphasizes mechanisms at the expense of exploring the meaning and experience of individual suffering could actually lead to the unintended negative consequence of over-intellectualization. (183)

Relieving Pain in America echoes the necessity for better education “…about pain and its diversity, and that people with chronic pain should be recognized by family, employers, health insurers, and others as having a serious condition” (Pizzo et al. 4). In “Pain Education: Getting An Early Start,” the authors advocate for medical school faculty working with pain educators so that medical students get an advanced start in understanding the complexities of treating pain (Hartrick et al. 593, Pizzo et al. 42). Significant data support improvement in outcomes with increased education, which also shows promise for decreased cost as a result (Gallagher 213, Pizzo et al. 5). Historically, however, multiple political, economic, social, and organizational factors have inhibited acting on this research to improve pain education in practice. As Relieving Pain in America asserts, “Remediating the mismatch between current knowledge and its application will require a cultural transformation in the way clinicians and the public view pain and its treatment” (Pizzo et al. 4, 20).

The “mismatch” between the information readily available about stigmas, routine under-treatment, and disparities in how people in pain are evaluated, and how this information is applied, is where pain education is “sorely” (pun intended) needed. It is imperative that health education is expanded to encompass an examination of underlying principles, values, and beliefs about pain. “Public health education can help counter the myth, misunderstandings, stereotypes, and stigma that hinder better care” (Pizzo et al. 22). Furthermore, this education needs to take a broad approach to address clinicians and patients alike. To paraphrase disability activist, playwright and author, Susan Nussbaum, whom I interviewed, even within the disability rights movement pain is largely misunderstood and there often exists a heightened pressure from within disability community to push oneself, which can be in direct conflict with the needs and rights of people with pain disabilities.

In a New York Times editorial “Becoming Disabled,” Rosemarie Garland-Thomson underscores that the lack of a widespread disability movement hinders disability being seen as a legitimate identity. As Garland-Thomson puts it, “Roughly one in five Americans live with a disability. So where is our pride movement?” (SR1). The experience of pain, often an “invisible” disability, is prone to being minimized and dismissed which has a direct impact on how patients in pain are treated and how they are (or more often, are not) prepared to advocate for themselves.

While pain education is not a well-defined field in and of itself, the broader field of Health Educators and Community Health Workers is expanding: according to the Occupational Outlook Handbook the job outlook is projected at 13%, which is faster than average. Health Education is predicted to be a continually growing field because of the emphasis on disease prevention and in an effort to increase cost control (Seltzer pg not available). In my interview with Dr. Ellen Barnett, Medical Director of the Integrative Medical Clinic of Santa Rosa, Barnett confirmed that there is an under-met, growing need for patients to have support to implement physician recommendations to manage pain effectively.

More and better pain education stands to benefit all involved: patients, clinicians, and economic stakeholders. There is no question that there exists a need for pain education—the challenge I foresee is promoting recognition of the value of pain education from social, political, and personal dimensions. As a person with pain disease and disabilities, the studies and reports about how people in pain are treated—or, rather, as is all too often the case, mistreated—reflect much of my lived experience. Utilizing my grassroots activism background, I am combining pain studies and social justice so that I may make the greatest impact to influence change.

Works Cited

Barnett, Ellen, MD PhD. Telephone Interview. 20 December 2016.

Bureau of Labor Statistics, US Department of Labor, Occupational Outlook Handbook,  2016-17, Health Educators and Community Health Workers, on the internet at http://www.bls.gov/ooh/community-and-social-service/health-educators.htm. Visited 19 December 2016.

Carr, Daniel B., MD. “Twenty-First Century Pain Education: The Rediscovery of

Compassion.” Pain Medicine, vol. 12, 2011, pp. 183-185.

Gallagher, Rollin M., MD, MPH. “Empathy: A Timeless Skill for the Pain Medicine

Toolbox.” Pain Medicine, vol. 7, no. 3, 2006, pp. 213-214.