Study: Cancer pain undertreated in minorities

More than a communication problem

Yet another study suggests that minorities are poorly cared for at the end of life. Cancer pain among minorities often goes undertreated compared to cancer pain among whites, according to the study, which was published in the the April 15 issue of the journal Cancer (2002; 8:2295-2304).

Researchers talked with 31 cancer outpatients, 17 of whom were Hispanic and 14 African-American. Many of the participants told researchers that they didn’t understand the best way to use pain medications or that they hadn’t been warned in advance about possible side effects and how to control them.

Researchers also found that 75% of the patients said they experienced severe pain. While they got information from many sources, patients told the researchers that doctors are the most frequent and most trusted sources for information regarding cancer and cancer-related pain.

"There seems to be a problem in communication," said lead author Karen O. Anderson, PhD, at M.D. Anderson Cancer Center in Houston. "Patients may be reluctant to talk about their pain. Doctors and nurses don’t always do a good job of asking about it."

In this study, some patients didn’t want to discuss their pain because they felt they should be able to bear it. Others were concerned about the potential for addiction. Some patients stopped taking their medicine because of unpleasant side effects. For example, pain medicine often causes constipation. "They should have been warned about this [constipation]," Anderson said. "They should have been given steps to prevent it. Often [doctors] use a high-fiber diet, mild laxative, or stool softeners to prevent these problems."

Communication is only part of the problem, says John Finn, MD, medical director for Hospice of Michigan in Detroit and a pain management expert. "The issue is fairly more complicated than lack of communication," he says. "What is evident is that minorities do get worse treatment than everyone else."

The study alludes to two other important factors: patient reluctance to take pain medication and physicians’ lack of training in pain management. Finn suggests that understanding cultural differences among African-Americans, Hispanics, Asians, and whites leads to an appreciation of the complexity of addressing pain management among minority groups.

For example, among African-Americans, there often is a mistrust of the health care system. He suggests that communication between African-Americans and their physicians may be hampered by an assumed mistrust. Physicians must make a stronger effort to explain courses of treatment and listen to patient concerns in order to gain their trust.

Inner-city pharmacies contribute to the pain management divide. Many pharmacies in impoverished neighborhoods do not stock narcotic drugs out of fear of being robbed or burglarized. This contributes to reduced access to pain management drugs among minorities, who often are the majority in such neighborhoods. In addition, people living in high-crime neighborhoods are reluctant to keep these drugs at home for the same reasons pharmacies do not stock them.

Also, the way health care providers measure pain is an issue. Rather than arbitrarily choosing an unacceptable level of pain for the entire population, health care providers need to gauge pain on individual preferences. For example, if five of 10 people report pain of more than a 5 on a 1-to-10 scale, it would be reported that half the patients were made to endure moderate to severe pain. Instead, providers should consider an individual’s tolerance for pain, which is often based on cultural factors. For example, Hispanics, with their deep roots in Catholicism, may be willing to endure higher degrees of pain. Also, fear of addiction is prevalent among minorities.

Not the first study

This study follows another study that concluded that minorities are significantly less likely to receive appropriate pain medication for a number of painful conditions, including cancer-related pain. Literature suggests that physicians evaluate pain equally, whether you’re African-American, Hispanic, or white, but for some reason, there appear to be differences in prescribing practices, says Stacie Pinderhughes, MD, assistant professor of geriatrics at the Mount Sinai School of Medicine in New York City.

Pinderhughes says a 1997 study on undertreatment of cancer pain, published in the Annals of Internal Medicine, found that 65% of minority patients did not receive guideline-recommended analgesic prescriptions, compared to 50% of non-minority patients.

She also points to a 2000 study published in the Annals of Emergency Medicine that examined African-American patients and non-Hispanic white patients who presented to the emergency room with fractures. African-American patients were 66% more likely to receive no pain medication for their fractures than their white counterparts, she says.

Pinderhughes says three types of factors can affect access to opioids for minority patients: patient factors, provider factors, and system factors. Two examples of patient factors are fears of addiction and fears of judgment. Typical patient fears might be "Will I become a drug addict?" or "Will my sister or daughter think I’m a drug addict?" Pinderhughes explained.

There are also fears of not wanting to distract a physician from the primary problem. "If I’m an elderly African-American woman with cancer, I may not want to tell my doctor about my pain, because I may be fearful that my doctor will not focus on treating my cancer," Pinderhughes says.

Limited access to opioids in neighborhood pharmacies is yet another major patient factor for minorities, according to Pinderhughes. In the 2000 study, a group led by Sean Morrison, MD, at the Mount Sinai School of Medicine, examined the percentage of pharmacies in New York City neighborhoods that stocked adequate opioid pain medications. The group found that residents of predominantly minority neighborhoods were much less likely to have access to pain medications, because the neighborhood pharmacies did not stock them.

While the variability pharmacy stocks of opioids is considered a patient factor, Pinderhughes says it also can be considered a system factor. A negative personal experience with addiction in family members is another example of a patient factor that may affect willingness to request pain treatment.

Pinderhughes characterizes the medical community’s lack of education and discomfort associated with prescribing pain medications as provider factors. Medical students only recently started receiving mandatory training in the principles of pain management, she says. "I graduated from medical school in 1994, and I didn’t get one class on the benefits of pain management," she notes.

Today, more programs teach clinical competencies in pain management and palliative care. Still, Pinderhughes says some physicians may be reluctant to prescribe pain medications because they may not know how to prescribe them, or they may be uncomfortable with managing potential side effects.