**Transcript of Cyberseminar**

**Spotlight on Pain Management**

**Understanding and Reducing Racial Disparities in Pain**

**Presenter:  Diana J. Burgess, PhD**

**February 4, 2014**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact Diana.Burgess@va.gov*

Robin Masheb:Good morning everyone. This is Robin Masheb. I’m the Director of Education at the Prime Center. I will be hosting our monthly team call entitled, “Spotlight on Pain Management.” Today’s session is understanding and reducing racial disparities and pain. I would like to introduce our presenter for today, Dr. Diana Burgess. Dr. Burgess is an Associate Professor of Medicine at the University of Minnesota, a research scientist at The Center for Chronic Disease Outcomes Research, and Veteran’s Affairs Health Services and Development Center of Innovation and a Career Development Awardee. Dr. Burgess’ research applies social, psychological research and theory to understand and reduce health, and healthcare disparities, to focus on disparities in pain. 

Dr. Burgess received a Career Development Award to exam the provider contribution to racial disparities in pain management, and has conducted research examining the presence of and contributor of disparities in pain, and pain management. We will be holding questions for the end of the talk. At the end of the hour, there will be a feedback form to fill out immediately following today’s session. Please stick around for a minute or two to complete this short form, as it is critically important to help us provide you with great programming. Unfortunately, Dr. Bob Kerns, Director of the Prime Center will not be on our call today. But now, I’d like to turn things over to Dr. Diana Burgess. 

Dr. Diana Burgess:Thank you Robin, and thank you all for participating in the call. I am so happy to have this opportunity. I am going to get started, because we have a lot to cover. Let’s see, okay first poll question. Who is in the audience? Are you a researcher, clinician, or something else?

Robin Masheb:I did set this whole question up that if you’re a researcher clinician, you can click both of those buttons. 

Dr. Diana Burgess:Oh cool. 

Robin Masheb:Yeah. So don’t feel that you need to hold off, because I know a lot of people do have that dual role there. 

Dr. Diana Burgess:This is very cool. Oh, I hear it’s hard to hear. Is this better? Good. Okay great, oh it’s still coming in. 

Robin Masheb:That’s okay. It’s slowed down a bit. We could probably read through the results there. 

Dr. Diana Burgess:Okay so a nice mix. Well, I will be having some white-board participatory features and I’m so interested in hearing what everybody has to say as I go through each study. Thanks. Okay, and one more poll question. How would you rate your overall knowledge on the topic of racial/ethnic disparities in pain and pain treatment?

Robin Masheb:Okay so a nice distribution. Okay, I’m going to click through. This is very helpful. Okay, did I not give an overview? Oh, here is the outline of my talk. I’m going to begin by giving an overview of racial and ethnic disparities in pain and pain treatment, and then just try to unpack the idea of race/ethnicity, and talk about how this unpacking can help us understand really the myriad of causes of disparities. Then I’m going to talk about three studies. One focuses on racial discrimination and veterans’ pain. One will focus on how patient race affects opioid prescribing decisions. The third will focus on patient race and pain management in the VA. We’ll talk about implications for clinicians and policy makers actually throughout and then some future directions. 

Even though I live in Minnesota, I’m a New Yorker, so I am going to be—I am a fast talker but I will try not to go too fast. Okay, here are a couple of definitions. Health disparities have been defined in an NIH report as the differences in the incidence, prevalence, mortality and burden of disease, and other adverse health conditions that exist amongst specific population groups. Healthcare disparities are defined as racial and ethnic differences in the quality of health care that are not due to access related factors or clinical needs, preferences and appropriateness of intervention. And let’s keep these in mind, because I’m going to be talking about health disparities and healthcare disparities. 

Well, there is consistent evidence of racial and ethnic disparities in pain, and health disparity and pain treatment. So, I will be providing a bibliography of these references at the end and it’s on your hand out, but there have been three really good reviews recently that have looked at disparities in pain and pain treatment. What they found is a greater prevalence of pain and greater impairment and severity of symptoms among non-whites, and that non-whites receive poorer pain assessment and treatment than whites across just a variety of settings in all types of pain, acute, cancer, postoperative, chronic, nonmalignant pain, and end of life pain. Importantly, these racial and ethnic disparities exist outside of and within the VA healthcare system. 

I want to give the broader context. As many of you know, there has been research on disparities in general, and across disease conditions. What we find in pain treatment disparities are consistent with broader evidence of racial ethnic healthcare disparities. So, the Institute of Medicine published a very important report called, “Unequal Treatment.” Their broad conclusion was that across every therapeutic intervention, minorities receive fewer procedures and poorer quality medical care than whites. And the differences persist even after differences in health insurance, SES, stage and severity of disease, comorbidity and the type of medical facility you’re taking into account, and differences persist in context such as Medicare and VA where differences in economic status and insurance coverage is minimizes. 

Som Saha and colleagues did a very important systematic review looking at racial and ethnic disparities in the VA healthcare system. This paper that was published in *The Journal of General Internal Medicine* in 2008, reviewed studies from 1966 to October 9, 2006. And I am just presenting Table 2 which is basically a count of studies by disease condition in which disparities are present and not present. I’m highlighting the review of arthritis and pain management. So, at the time of their review, they have had had disparities present in six studies and not present in one. Just a brief review of what they found, one study found racial differences in joint replacement surgery and analgesic medication use with less aggressive management of osteoarthritis in African Americans and Latinos. This is a summary of all of the studies in this area. African Americans in the VA were less willing than whites to undergo joint replacement surgery due in part to less familiarity with the procedure, and worse expectations of surgical outcomes, including recovery, chronic pain and functioning. There is also evidence in this research that clinicians prescribe opioids less often for African Americans. All of which is consistent for what we find in the broader literature of studies conducted outside the 

VA. Now, I want to just unpack race/ethnicity, and I’m going to be using a definition by Ford and Harawa. Again, I’ll have the citations at the end. They talk about race as basically when people are assigned to one or more of the socially constructed categories established hundreds of years ago to divide humans into five major subpopulations. So, this is basically the technical category, but ethnicity is much broader. It encompasses aspects of social life such as culture and personal identity that people within some collective share. And what I think is very useful is how they have broken down ethnicity into two dimensions. And when I’m talking about race, I’m going to be talking about race/ethnicity, but I’d like to think about these two dimensions. 

The attributional dimensions describe unique sociocultural characteristics of a group. So, culture, diets, belief. In pain, we might say, this racial group tends to have a certain kind of coping style compared to this group. This group might be less trustful of healthcare. Then there is relational which captures the relationship between an ethnically designed group and the society in which it is situated, such as intragroup hierarchy. So when we’re talking about non-whites, African Americans, American Indians, Hispanics, Asian Americans, these groups have faced discrimination, historical, everyday discrimination, and so this definition is really useful in understanding how social stratification and social exposure such as discrimination in various realms contribute to health and healthcare disparities. 

Obviously there’s a relationship between the two. So we might think about a characteristic of a group such as this group doesn’t like interventions, or you know on average this group has a more negative attitude toward medication, but that could also be related, and we know there is a relationship between historical experience that group has within the healthcare system, and within a larger society. So, distrust in healthcare can be due to negative experience of oneself and one’s relatives in the healthcare system. 

So, in pain, there is a big literature on the contributors to disparities in pain and pain management, and I think this is a helpful framework. So we know that there is cultural variation in pain perception, expression, expectations, and response. So for example, there is research that African Americans are more likely to use prayer in response to pain. Then there are also cultural beliefs about pain management, so, attitudes towards opioids and attitudes toward surgical procedures, which researchers found in the VA, in terms of why African Americans were less likely to get joint replacement surgery or joint replacement for pain. But again, just because it is—you know there’s a relational piece too that affects the attributional piece. 

So, some of the relational contributors to disparities in pain and pain management are lack of access to healthcare and medication, unconscious or conscious provider bias, which I’ll talk about. So, stereotypes that may, that affect people even outside of consciousness that could inadvertently affect the likelihood of prescribing opioids, poor assessment and poor communication, all of which we know occur for non-whites. That assessment, there is some research showing assessment tends to be poorer. We know in the broader literature on healthcare disparities, communication tends to be worse for non-white patients with white providers. Then there is just greater exposure to life stressors such as poverty and discrimination, and those contribute to pain, also potentially working in workplaces that where pain and injury are more likely to occur. 

So, I’m going to talk about a study I conducted with my colleagues in the Minneapolis VA, looking at the effect of perceived discrimination on bodily pain among older African American men. And just for some background, there’s a huge literature documenting the greater rates of discrimination experienced by African American compared with whites. And more important showing that these repeated experiences of discrimination both lifetime discrimination and discrimination experience day-to-day are a source of chronic stress, and are associated with poor physical and mental health behaviors, so, cardiovascular disease for example, depression, lower-mental health, and negative health-related behaviors such as smoking, delaying healthcare, and poor adherence to treatment. And the time of this study there wasn’t anything published looking at the relationship between discrimination and pain that we thought this was plausible given the larger literature. 

So, we wanted to ask the question, is discrimination would be associated with greater physical pain among African Americans? So, we put some questions on a national survey of colorectal cancer screening among VA patients, 50 to 75. Melissa Partin was the PI. And we looked at the sample of all African American patients, and we focused on men, because the sample was almost all men. What we used was a dependent variable comprised of two questions, how much did pain interfere with your normal work, including both work outside the home and housework, and how much bodily pain have you had during the past four weeks? 

The independent variable was the experiences of discrimination scale which measures discrimination over a lifetime. The key question asked, how often have you experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following situations, because of your race, ethnicity or color. Then there are a variety of situations, at school, hiring, getting a job. At work, getting housing, getting medical care, getting service in a store or restaurant, getting credit, bank loans or mortgage, on the street or in a public setting, from the police or in the courts. And I wanted to vent the unadjusted association of the different types of discrimination with pain and also provide an overview of what the distribution was. 

So, if you look at the first column which let’s see, looks at people who’ve never experienced these types of discrimination, except for medical care, over half of the sample has experienced discrimination in these different domains, and remember these are older veterans. So it’s not surprising. I highlighted getting medical care, because it is somewhat good to know that people experience less discrimination getting medical care than in other settings. Although we can still say it’s high, and you know there is a lot, if you look at on the street, in a public setting, from the police, or in the court. And importantly, all of these were associated with pain, the largest being from the police or n the courts. 

And now, I’m going to present the multivariate analysis where we created—we averaged according to the algorithm, we created a composite measure. And what you see is that perceived discrimination, let me get this green arrow, oh here we go. So, perceived discrimination was highly associated with pain in the multivariate analysis. And it was one of the only things in our analysis that was associated with pain. And what I think is very important is that much of this discrimination happened outside the healthcare setting. So, it really points to the importance of what goes on in what you could think of as the patients’ life space and life history as affecting what one might see in the clinic and in our epidemiological studies. 

So, the results suggest that racial discrimination is a potential contributor to the greater burden of pain experienced by African Americans. And since this came out, there has been another study that found similar results. Again, they are consistent with numerous studies demonstrating an association between racial discrimination and poor health. But of course it’s a cross sectional design, so we can’t make causal statements. So people who had more pain might for example, view the world more negatively, and therefore be more likely to report discrimination. Although there have been more longitudinal studies where people have found that discrimination at time one, predict certain health outcomes, and time two even after controlling for present day discrimination. 

So, some implications, I think it really highlights the importance of a biopsychosocial approach to pain that addresses psychological and environmental factors. It’s likely that this measure also is a proxy for a number of other experiences that African Americans of this generation have faced and continue to face. And there are multiple pathways by which discrimination affects health. Discrimination may affect chronic pain through any of these pathways and these pathways may be potential targets for intervention, although we need more work. So we know that pain affects chronic stress and discrimination affects chronic stress, and stress contributes to pain. Also poor mental health, discrimination has been found to contribute to lower quality sleep, to anger. 

There have been a number of studies including studies conducted in the VA that discrimination is associated with avoidance of healthcare and poor adherence to treatment, and it’s also associated with poor provider and patient communication. So, again, all of these are areas that could contribute to what we find with pain, these disparities. Again, I think some people are writing in. It really does point to sort of the whole person approach. So now this is a white board, and I am really interested in your thoughts about implications for research policy and practice, other thoughts. 

Robin Masheb:Sorry, I pulled up the wrong white board here. Give me just a second. 

Dr. Diana Burgess:No problem.

Robin Masheb:Now, for the audience, when this comes up at the top of your screen, you have some annotation tools. There is a capital T there. Just click on that and then bring your cursor down to the white board and you can type in free text on the white board. You will need to click off of your text for us to see it, but feel free to send in your responses to the question. 

Dr. Diana Burgess:Yes, and I, as Robin said, I am not a clinician. So I’m always fascinated to hear what people in other areas of research, policy and clinicians think about this research and how it might apply to what they do. So Heidi it says white board 10, am I supposed to be seeing—oh now, I’m seeing things. 

Robin Masheb:Somebody is writing something on there. But no, people, I’m assuming are typing. 

Dr. Diana Burgess:Oh okay.

Robin Masheb:And haven’t clicked off of it for us to see. Now, you guys don’t need to free text on there. I think somebody is using the pencil tool. If you click on that capital T, that will allow you to type in your answers on the screen rather than trying to draw it with a pencil. 

Dr. Diana Burgess:This is good, has potential, mediators and our moderators can specifically exam that could further explain, I’m guessing the relationship between discrimination and pain. And I haven’t checked the literature in the last couple of years, but there has been work on this idea of allostatic load that discrimination is such a stressor. So, it would be really interesting to look at these potential mediators. Also to just add this discrimination question on a survey there, or shorter question, it could be something that you could put in if you have these potential mediators. If you’re looking at for example other factors that might contribute to pain is something that you could look at. 

I wonder if there is a difference in communication between providers of the same racial or ethnic background, and there is a literature looking at concordance and looking at the fact that communication for non-whites, and most of it has been done with African Americans does seem to do better with providers of the same race. And that is looking at codes of the observer rating of the interaction quality and also patient ratings. 

Yes, and I think the experience in the military, I think age, we didn’t see an interaction with age, but this was an older, everybody was older was 50 or older, because of our interest in colorectal cancer screening. So, I think that would make a difference. I think this is really interesting looking at other groups. And for immigrant, ethnic roots has the level of the acculturation been accounted for? Yes, we’ve done a lot of work with Asian Americans, and I am not—I cannot recall off the top of my head what acculturation, how that weighs in, but definitely there is a type of language discrimination that people who don’t speak the language feel a certain amount of discrimination. 

Okay, this is really helpful and something that comes up a lot that I will be talking about at the end is this issue of communication, and how can that fit in, because, a lot of the issues that come up about treatments, especially could hinge on communication, and discrimination is one factor that might make past discrimination, communication in the encounter more difficult. Okay I am going to move on, although does this get captured Heidi, so I can—because I’d love to spend more time on this. 

Moderator:Yes, actually I will make a screen print of each of these are we’re going through so that you have that information. 

Dr. Diana Burgess:Thanks. 

Moderator:Yep.

Dr. Diana Burgess:I know we have a lot to talk about, but that was really great. It’s great to have some input when I’m alone in my office. Okay, now I’m going talk about a study that’s an experimental survey looking at patient race and physicians’ decisions to prescribe opioids for chronic low-back pain. And I did this with a number of my colleagues including Dr. Kern who was super helpful and people within and outside the VA. The research question here was, does provider stereotyping contribute to racial disparities in decisions to prescribe opioids for chronic non-cancer pain? This came from a real—a large literature looking at the potential impact of stereotypes on racial disparities. And this was something that was identified in The Institute of Medicine report “Unequal Treatment,” and came from the larger literature on stereotypes. 

So, just some background, stereotypes are concepts that contain our knowledge, beliefs, expectations and feelings about a social group. Salient are really obvious patient characteristics such as race, also gender and age can activate stereotypes which can influence providers interpretations of behaviors and symptoms, expectations about patients’ behaviors, and behaviors toward patients which can influence patients’ behaviors themselves, and it also can influence prescribing decisions. Importantly, there is research showing that this can occur automatically or implicitly without conscious intent, even among people who are very egalitarian and have the best of intention. 

This is a great slide that my colleague Michelle Van Ryne put together showing how everybody engages in unconscious stereotyping. Here are two news articles about Hurricane Katrina, and it’s the same picture of somebody, you know people in water with stuff, but this one. The one on the top talks about a young man—look at the one at the top, looting a grocery store in New Orleans on Tuesday. And the one below talk about residents wade through chest-deep water after finding bread and soda. So, again, the writers themselves probably weren’t even aware of what they were doing, because just like you see an individual patient, you don’t see necessarily a bunch of article, and it’s unconscious. You don’t necessarily know that you’re doing it. Then you also have stereotypes like this that get reinforced. Associations get reenforced because we are in the presence of the larger media culture. So, I thought this was really illustrative. 

But in pain treatment, the reason why we wanted to look at stereotype was there is a body of research showing that non-whites are less likely than whites to be prescribed opioids. And my colleagues and I published a conceptual paper looking at how decisions to prescribe opioids for pain have several features that in social psychology have been shown to increase the likelihood that providers, racial stereotypes will affect their clinical decision making. So, it’s a very complex decision. Providers need to weigh the risk and the benefits of opioids, and there is a lot of contradictory information, and there are a lot of risks. In that we find from surveys conducted inside and outside the VA that providers lack knowledge in this area and find this to be a very difficult area. And where there is a lack of knowledge and decisions are ambiguous and difficult, stereotypes are something we naturally use to help us make sense, and sort things out. 

So, we all speculated that certain types of what we called “red flag” patient behaviors, verbal and nonverbal behaviors might activate or make legitimate negative stereotypes of African Americans. So, you know this person might be more likely to be a criminal, such as looting, a drug user. He might divert opioids that might leave physicians to be concerned about prescribing opioids. So, the hypothesis here is that providers are more reluctant to prescribe opioids to black versus white patients, particularly among patients who manifested these “red flag” behaviors. And I don’t know if you know Megan Crowley-Matoka, but she had been doing some ethnographic work looking at providers in VA, and looking at how certain behaviors might trigger reactions in providers. 

So, this is a Vignette study where physicians read Vignettes. It was a mail survey, and between-subjects factorial design was used. So, we systematically varied patient characteristics. So you were randomly assigned to read either about a black or a white patient with chronic pain who is always male. Verbal behavior, what they said in this kind of cartoon which we call the photonovella was either challenging, you know demanding. I want opioids, or non-challenging. And then we also looked at nonverbal behavior. So was the person angry? Were they dejected? Were they calm? And we’re going to just not focus on that, because we didn’t really get anything clear on the non-verbal behavior. But our primary dependent measure was, when we asked providers how they might treat the patient, we looked at the decision to switch the patient to a higher dose or stronger type of opioid. 

So, we made these photo novella stimulus materials where we had four photos and a script depicting a chronic pain patient, accompanied by a clinic note. At the time, we really wanted to make this more realistic than previous Vignette studies that might just have a brief paragraph, and we created scripts based on Dr. Crawley took his ethnographic research to evoke these patient behaviors that would or would not raise red flags among physicians about the advisability of prescribing opioids, and I have an example of this. Then the red flag and challenging verbal behaviors were belligerence, demanding behavior, asking for an opioid by name, and using the opioids that are relative. 

So, here is an excerpt, the pain in my back is killing me. You’ve got to do something. This is the worst pain I’ve ever had, and the doctor says when do you have the pain? All the time, I’m telling you it’s terrible. I just can’t stand it anymore. You’ve got to do something for the pain. I’ve tried some of my wife’s Percocet she had from her surgery and that stuff really worked. I want some of that. And we spent a lot of time pilot testing the people we used as models; making sure the white and the blacks were equally rated in attractiveness. We used a young or an older model, and we tested to make sure that dialog scenes were credible to physicians. 

This was a national sample of 1,000 general internal medicine physicians, and we described it as a study of pain treatment, and we didn’t mention race, and we got a 40% response rate which isn’t great. We had $10.00 in the envelopes, but it’s pretty good for physicians. So, just quickly our sample, mostly male, the ethnicity is mixed, 40% white, 23% Asian American Pacific Islander, only 4.7% African American or American born black. Then if you look at the bottom two rows, so they were asked to estimate the percentage of patients who were non-white. So they estimated, on average, 37% of their patients were non-white, and the percentage of their patient with chronic non-cancer pain, they estimated about 20%. It would be much higher likely in the VA, because we have a pretty high percentage of patients with chronic pain. 

We used logistic regression to determine the effects of patient characteristics on physicians prescribing decisions. And in our model, it included the main effects of patient characteristics, so race, verbal behaviors and nonverbal behaviors. And we looked at the interaction between race and verbal behaviors and race and nonverbal. And then we looked at physician age, because there was when we looked at our exploratory analyses, physician age made a difference. So here is our main result I want to highlight. We’re looking at the percentage of physicians who prescribe patients a higher dose or stronger type of opioid, and if you look on the left two columns this isn’t statistically significant, but it approaches significance. 

For the white patient, you are more likely to prescribe opioids to the non-challenging patient which is kind of what you would expect and less likely to the challenging patient. Counter to our hypotheses, for African American patients, physicians were more likely to prescribe patients a higher dose or stronger type of opioid for patients who were challenging, who was belligerent. That is very interesting, and we didn’t expect it, but it’s something that we thought a lot about. And on the next page, I’m going to provide some explanations. So, I will just flash back so you can see, it’s the opposite of what you expected, and it is also a little bit counterintuitive. 

The challenging script, although it was designed to raise red flags, it was unambiguous in stating the patient’s desire. So we have this communication difficulty between often black patients and their non-black doctors. But there might have been a lack of uncertainty which is common in physicians when treating patients of another race, and it is consistent with the Vignette study in which assertive behavior led to full staging of breast tumors among black, but not white women. And also, of course these Vignette studies might not capture the actual decision making processes that occur in clinical settings. 

Some implications, it points to the larger issue of the unconscious use of factors such as race and ethnicity and there is some current research underway in VA to minimize provider implicit bias. That’s being led by Dr. Leslie Hausmann with partnership with The Office of Health Equity. So, since these data were collected in 2005, I think there really has been a stronger legislative and regulatory push to address the issue of opioid diversion and misuse. And certainly you know there is mounting evidence of the harm. So some questions are, how might racial biases operate within this context? And something I’m going to return to on my next study how might positive biases potentially lead to inappropriate prescribing among groups stereotyped as unlikely to misuse or abuse opioids? Such maybe as women, white, higher SES people, perhaps, older people. 

And I think there really is a tension between addressing disparities in opioid prescriptions and also acknowledging the public health crisis caused by increased opioid prescribing, particularly in light of incomplete evidence about its benefits. So, it’s very tough, and you know as my colleagues and I were talking on the pain call yesterday, we also didn’t want to focus so much on opioids. We want to focus on other things, but I think it just points to this issue that you know race is powerful. Stereotypes are powerful, and they seem to affect decisions. 

So now I have another white board, and I’m very curious about what you all think. And I’m looking at some about gender as a moderator, and I think that’s very interesting, because there is some research that African American men in particular are more likely to be the victims of racial discrimination, although there is also this famous human studies of cardiovascular treatment, and it was black women who were less likely to receive treatment. So, I think it’s important. And there is racial bias. I’m looking at some of the questions with regards to racial differences in psychotic disorders. And I believe that African Americans are more likely to be diagnosed with psychotic disorders especially on children. There is some work on how race influences mental health diagnoses of children. 

That’s interesting, a study of wrongly prescribing antibiotics where parents of young children push for it. So, yes, it gets tricky because also when I started this study, the climate around opioids was somewhat different. But nonetheless, I think the issue is factors that we might not want—we don’t want to influence decision making, having an influence. And one of my colleagues Janis Savin measured people’s unconscious bias through something called, “the implicit association test” and found that greater unconscious bias through this kind of cognitive test was associated with people being less likely to prescribe opioids for pain patients. 

Okay so if I click on can I see the whole—how to tease out disparities. So, yes, I think this issue, which I can’t see the whole question. But you know, is it considered a disparity if maybe it’s not considered appropriate treatment, and this comes from sort of a large literature looking at the undertreatment of pain, of African Americans in situations where they’re on strong painkillers. You know there is no question it was appropriate. So, there is research showing that blacks are less likely and Hispanics to get treated with opioids and certain types of treatments with long-bone fractures in the emergency department. So, it comes from a larger literature looking at consistent undertreatment of cancer patients who are black. 

Is there some type of cause or an effect or observer bias in the use of a yes with race in attempting to overcompensate? Yes, I think that is definitely an issue that people here were able to you know at their leisure look at what was happening and make decisions, and try to overcompensate. So I think that is really important. Also only 40% of people responded. So maybe the people who responded to the survey were more likely to be those types of people who wanted to correct for potential racial bias. And to look at how non-white refugee populations are treated, which is very interesting in this clinic because we have a very large Minneapolis Somali population. So that’s an area of particular interest here. Okay great, I’m going to move on, because we still have a lot to cover, but I like the white board feature. I like getting some feedback and I’m in my office. 

So, this next study that I’m going to talk about is a VA HSR&D funded study with many people in the pain community in the VA pain research community who participated. And it’s looking at presence and correlative racial disparities in the VHA. The research question here that I’m going to focus on was, do racial disparities in pain management, so screening, prescription of pain medication for chronic pain, and perceived effectiveness of chronic pain treatment exist in the VA healthcare system?

So, this is a secondary data analysis. The sampling frame was the ambulatory care model of the 2007 Survey of Healthcare Experiences of Patients, which is a large national survey that used to be administered. And I’ll say a little more, in all analyses we have accounted for clustering by site and whether the patient was new or established. And that’s just because this is part of how the sampling frame for the SHEP was constructed. 

So, here are the key measures. We looked at pain screening, which is the presence of a pain score in the patient’s record at the SHEP index visit. So basically you were eligible to be in this SHEP sample, because you were—you visited. You had this visit in your VA, and then we wanted to see at the SHEP index visit, did they ask you to rate your pain as was the requirement at that point in the VA. We wanted to look at pain treatment. Primarily, we looked at pain medication including whether an opioid was prescribed, and we used the pharmacy benefits management data base for that. Pain screening above was the corporate data warehouse. 

Then we looked at pain outcomes. This was why it was really useful to be looking at the SHEP, because we had two survey questions. We had a question on the perceived effectiveness of their chronic pain treatment and a rating of their functional interference due to pain. So, I’ll be talking about this a little more. I also have a couples of cites of papers we published. So, if you’re interested in the methodological detail, I can provide you with those. But the first question, looking at whether there are racial disparities in pain screening, looked at what we call the pain screening cohort. So this was about 28,000 blacks and 233,000 white SHEP responders and non-responders whose index visit was in primary care. 

So, it didn’t matter whether they responded to the survey. We captured them. What we found was that blacks were less likely than whites to be screened for pain, in our adjusted and unadjusted analysis. And this analysis adjusts for demographic, medical, and psychological comorbidities and active—so once we adjusted, any active prescription of pain medication, outpatient utilization and facility characteristics, because we had a facility survey. It still reduced the odds ratio only to .86. So, it reduced it from .79 to .86, but it was still significant. And I’m sorry, in this one the facility characteristics were I think we looked at percentage of African Americans in the facility. And these the 78% to 82% were estimated for black and white established primary care patients at a typical VA facility. And if you have some questions about the details, you can write those down. 

But basically, we did see differences in screening between blacks and white. Oh and one more thing sorry. The reduction, we looked at what of these factors accounted for the reduction in the odds ratio. It was primarily due to the fact that black patients were more likely to visit the VA as outpatients in the two years prior to their index visit. So, potentially some of that difference is that the more you keep going to the VA, you may be less likely to be asked, because you know you’ve been seen more often. 

So, the next question was, are there racial disparities in pain treatment? And here we focus on opioids which again, I think we should be focusing more broadly, but it was something we could measure. And there was a lot of concern at the time we put this together about racial disparities in opioid use. So, we looked at the subset of the screening cohort who had diagnoses of low back, neck or joint pain. So, this was 9,831 black, and 71,471 white patients. We stratified the analyses by age, under 65 and 65 and older. Since we know that 65 and older are more likely to show racial differences in who is a dual user. So, white people are more likely to have another source of care outside the VA, where 65 and older black patients are more likely to have the VA be their source of care. Now we find that under 65 but the difference is particularly high for 65 and older, and because we’re trying to look at prescriptions in the VA, this is pretty important. 

So, we looked at—the analyses I’m going to represent incorporated race, their pain intensity rating, new or established primary care patient status, interaction between race, and the most recent pain intensity rating, and I’ll talk about that. Basically, we thought it was important to look at people with different levels of pain, self-reported. And then we also looked at healthcare facility and race within facility. And what we looked at was the prescription of opioids in the year following the first pain diagnoses. 

So, we went back and we looked at the first pain diagnosis in this time period and then we looked at opioids in that following year. And what we found was for patients under 65, blacks with moderate or high levels of pain were less likely to receive opioids than whites, but there were no differences between black and white patients with low levels of pain intensity and those with pain intensity rates of zero. So, we found the disparities that we expected, but really at higher and moderate levels of pain. 

Interestingly for patients 65 and older, we didn’t find differences except for patients with pain intensity rates of zero where blacks are more likely than whites to receive opioid prescriptions, which again, you could argue this is very odd. Should people be receiving this? But that’s what we found, but again, this is very difficult to interpret, because older whites are more likely to have a dual source of care, and therefore, they may be more likely to get prescription for opioids outside the VA. So just methodologically this is important to kind of share with people who use these data that you know we really want to make sure we capture outside data when we’re looking at things like disparities, because you can have some misleading findings. 

So, we have not published this. We did something that I think Steve Dobscha is an the call... something similar where we looked at the SHEP and we looked at whether African Americans were less likely than whites to report that their pain treatment was good, very good, or excellent. And in the unadjusted analyses, this is what we found. Blacks were less likely to believe that their pain treatment was good, very good, or excellent, and it was pretty low overall. But when we adjusted for non-response bias, because there was a fairly large response—there was lower than optimal response rates and blacks were less likely to respond than whites. We used propensity score methods and then the effect of race and perceived effectiveness of pain treatment was non-significant.

So, that’s hard to interpret. We haven’t published this yet, but we’ve been doing some exploratory analyses looking—we next want to stratify by veterans less than 65, and greater than 65 and look at the impact of these prior opioid prescriptions on satisfaction with pain treatment and functional interference due to pain. Our preliminary results are not stratified by age do suggest that having a prior prescription of opioids was no associated with greater perceived effectiveness of pain treatment or lower pain interference for most black and white patients with pain, except for whites with pain levels of 1-3 perceived treatment effectiveness, was higher for those who received opioids. 

So, again, we need to put some caveats here. We’re using self-report data and we have some issues in response rate, but it is interesting that we did not, even though we saw these disparities in blacks being less likely to get opioids, it didn’t seem like this was associated with differences on these outcomes we care about. And I think this is important because every move to sort of the next generation of disparities research, we really want to dig and see what these differences that we documented mean. So we are going to again, caveat, we haven’t published this and fully digested it, but I thought I would share it with this group. 

So, implications, I think we need more research in general on whether disparities in opioid prescribing contributes to disparities in musculoskeletal pain. And more broadly to test strategies to improve pain management among populations that experience disparities. So, the current VA pain strategy focuses on self-management as a foundation of chronic pain management. And we just got a study funded that we’re working on getting our, just in time documents for that a proactive walking trial to reduce pain in black veterans. And what we’re doing is testing the effectiveness of a proactively delivered counseling program. So, basically, we reach out to patients that we know have pain in a way that we’ve done in other studies looking at delivering smoking cessation treatment. And we give people the opportunity to participate in a program to promote walking to decrease pain. So, this is really focusing on nonpharmacological self-management approaches. And I have a lot of great co-investigators; some of who I think are on the call. 

And now, because I know we’re getting close to the end, just a couple implications, and then we’ll take questions. I am pretty interested in the role of communication in reducing disparities. So, nonwhites have encounters with providers that are shorter, less positive, less participatory, and less what’s called psychosocial talk, so kind of chit chatting. And that stuff is really important therapeutically and in terms of coming up with a good treatment plan, making sure people follow the plan, and there is some research showing that discussing the use of prescription pain in arthritis medications with pharmacy staff did differ by race and gender. So, you know white men and white women discussed it more than black men and particularly black women. And there was a small study of cancer patients, very small that found that short education and coaching with a communication component eliminated racial disparities in pain, but it was a tiny study, although I do have the site. So, right now, I know I went pretty quick toward the end, but I’m really interested in your questions, your thoughts. 

Moderator:Diana, do you want to do questions or white board?

Dr. Diana Burgess:Yeah, let’s do questions. 

Moderator:Okay, sounds good. We do have a few questions out here. Okay, I’m just going to start from the top here. So, are bio-psychosocial, spiritual wholeness in health can and will be affected by social discrimination including outside VA which affects pain?

Dr. Diana Burgess:So, I think it’s really important to think about what goes on in the life space outside the VA, but I think this does really point to you know communication and the stuff that we really all care about, patient-centered care. 

Moderator:Thank you. Next question here, in VA, is there a difference in those VAs with a larger proportion of nonwhite providers, either African American, or those of Asian or Middle Eastern background?

Dr. Diana Burgess:You know we did not look at that. That is a really good question. I would be interested. 

Moderator:And the next question, what about gender as a moderator?

Dr. Diana Burgess:We have not been able to look at gender as a moderator, unfortunately, but I think as the VA population changes and there are a lot of younger African American female veterans, I think it really will be important, because in other studies certainly gender has played a role, and gender does influence the type of exposures that racial minorities experience such as discrimination by the police and so forth. So, I think that’s really important.

Moderator:Great thank you. The next question here, given the paucity of race or ethnicity in the VA data, how were you able to fill in the missing unknown? How much of the missing unknown were you able to recover and is there a standard algorithm for people to use for this?

Dr. Diana Burgess:That is a really good question. I think I can direct you towards a paper, but basically we use the SHEP, because there is a self-report question which is really good, and then black and whites, there have been some nice papers about the reliability of race data in the VA. It’s getting better. It’s a lot better for looking at black and white versus other racial ethnic roots. There was a [inaud.] from an administrators reported the race of patients that wasn’t as reliable toward patients reporting their race, but the reason why we only looked at blacks and whites because it was more reliable at that point. We also had an unknown category that we looked at, unknown race.

Moderator:Great thank you. The next question here, Dr. Burgess, I know that your work is addressing great care for all, and that your work doesn’t excessively depend on opioids, but as opioid appropriateness in chronic pain is now questioned and in transition, how might you be able to tease out appropriate pain care from opioid use?

Dr. Diana Burgess:I think that’s really important. I think there was definitely aside when I was doing this where we really worried a lot about under medication. Now there has just been more about questions about this. And I think focusing less on opioids is a big piece, because I think that can be somewhat of a diversion and then I think more details, you know, understanding of what is, I think a lot of people now in the VA are doing more work on opioid safety. And I think it becomes part of the larger package. Leslie Hausmann has done work looking at some racial disparities and sort of opioid monitoring and opioid safety issues. So, perhaps you have to look at race as one of the categories that might extraneously influence decision making but there is also a larger issue of appropriate use and treatment. 

Moderator:Great thank you. Diana, I wanted to check in with you. It looks like we have about seven pending questions. We are at the top of the hour here. I wasn’t sure if you were able to stay on a little bit later. 

Dr. Diana Burgess:Oh, I can definitely stay on the line. 

Moderator:Okay sounds good. 

Dr. Diana Burgess:Absolutely, and I really appreciate everybody participating in the call. It’s been so interesting. 

Moderator:Fantastic, and for the audience, I know a lot of you can only dedicate an hour to this. We are recording the call, and so these questions will be captured in the recording, and we will send you the link to that as soon as it is posted. 

Robin Masheb:Oh, is there time for people to do the feedback form?

Moderator:I actually. I can’t put up the feedback form until I close the meeting. 

Robin Masheb:Until we close, okay good. 

Moderator:I will put that up. Unfortunately we’re not going to be able to get it from everyone but we will—there are definitely a lot of people who do hang out for the rest of the session. So the next question that we have here. Has racial bias been investigated with regards to racial differences in psychotic disorders?

Dr. Diana Burgess:Yes it has ...

Moderator:Like bipolar and schizophrenia?

Dr. Diana Burgess:Yes, so it has been. I can’t recall the entire, the literature, but there have been these differences, and I think I mentioned this on the call especially among children. 

Moderator:Great, thank you. The next question is anyone going to do a study in Colorado or Washington State VA to see if initial or followup visits for chronic pain issues decreases over time due to availability of marijuana to self-medicate?

Dr. Diana Burgess:Oh that is really very interesting. This is not my area, but yeah it’s an interesting question. 

Moderator:Great thanks.

Dr. Diana Burgess:A great area for natural experiments. 

Moderator:Yes it is. The next question here, any videos to role model chatting which is perceived as engaging and helpful by most African American with veterans?

Dr. Diana Burgess:I would direct you toward the work of Lisa Cooper. She is at Johns Hopkins and she is really the pioneer in this area, and I know she has an intervention with CD ROMs which really focuses—it’s a really great interactive piece to try to improve communication skills with patients and nonwhite, with physicians and nonwhite patients. I’m not sure which of her materials she’s published, but it’s Lisa Cooper. On the PDF, I have some of her citations. 

Moderator:Great thank you. The next question here, what about the gender of the provider?

Dr. Diana Burgess:You know that is interesting. There have been, the few studies, Vignette studies have that female providers are less likely to have the same, manifest the same racial biases in pain disparities, but not all studies. And we did a study that is just coming out where we found—we also had people do this Vignette task either under when they were busy, when they were doing another task, or when they weren’t busy. And we found that women were more likely to prescribe opioids to blacks than whites, and they were even more so when they were under kind of time pressure. But for men, they were more likely to prescribe opioids towards blacks when they weren’t under time pressure, but when they were they reverted. 

So this kind of—so when they were under time pressure, they couldn’t correct for their initial response. They were more likely to prescribe to whites, and that was the hypothesis. And it’s hard to know what to make of it, but at least the men in the study kind of support something that one of the other participants said that maybe people overcompensate in these Vignette studies. So, it looked like for the men that if you gave them all the time to do the Vignette they were more likely to favor blacks or at least prescribe opioids to blacks, but then under time pressure whites. Although in real life, I don’t know if people have looked at the gender differences. 

Moderator:Okay great, thank you. The next question, I wonder about the role of health literacy in general regarding pain management. 

Dr. Diana Burgess:That is a really good question. I think some of this might come up in some of the work on joint replacement. I don’t know if Said Ibraham is on the call, but you know they’ve done some really great work looking at why people decide to go for joint replacement or not. And some of it does seem to be beliefs about surgery and so forth. And this stuff, I think could be affected by health literacy. I don’t know off the top of my head, but I think it’s a really interesting area and points to this kind of interactive between you know your own beliefs about pain treatment and these larger factors. 

Moderator:Great thank you. And I don’t see Said on the call right now. We’re not able to get any feedback from him on that. 

Dr. Diana Burgess:Okay.

Moderator:But the next question here, as a health psychologist, how can I help physicians and nursing staff improve communication and reduce disparities in care for a small pain clinic?

Dr. Diana Burgess:Oh that is a really good question. I am not a clinician, but it seems like the literature on patient-centered care really shows that sort of, that warmth, that kind of psychosocial talk, and building trust, all of those things go a long way. And there has been one study with medical students in standardized patients showing that providers or medical students in this case with a much more patient-centered approach were less likely—didn’t treat black and white standardized patients, you know acted differently with those who weren’t as patient-centered did. So, I think communication in patient-center-ness and establishing trust is really going to be one of the keys here. 

Moderator:Okay great, thank you. The last question I have, with the current state of evidence regarding pain and racial disparities, are we at a point where we can discuss implications for policy? Do we know enough?

Dr. Diana Burgess:I think with the opioid question, that is so complicated. So, that is very tough. I think with the other piece we really—I think the focus, we know so much now about communication and feelings of how important that is, and the self-management component. And we know that these stressors that are experienced at higher rates by African Americans, discrimination and so forth affect pain. And I think as somebody said on the call the sort of wholistic, you know patient-centered approach in dealing with psychosocial issues that may be occurring. I would say that that is a very—it’s very difficult, but that is going to be important in dealing with some of these disparities. 

Moderator:Okay great, thank you. That does conclude our questions for today’s session. Dr. Burgess, I really want to thank you for taking the time to prepare and present for today’s session. We really do appreciate it. For the audience, if you guys could hold on for just a minute. When I close out the session here, I am going to be putting up a feedback form. We do love to get your feedback. We really do read through all of it. Use it on our current and upcoming sessions. Our next session in this series is scheduled for March 3rd. Jodie Trafton will be presenting. I don’t have a topic yet, but as soon as we have that, we will be sending that out to everyone. You can register for that session. Thank you everyone for joining us for today’s HSR&D cyber seminar, and we hope to see you at a future session. Thank you. 

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