Download Pain Report 7 Focus on Long-Acting Opioids

Pain Report 7 Focus on Long-Acting Opioids
Editorial Faculty Board
Veeraindar Goli, MD, FAAPM
Medical Director, Pain Evaluation & Treatment Services and Assistant
Medical Director, Duke Pain & Palliative Program
Assistant Clinical Professor of Psychiatry; Assistant Clinical Professor of Anesthesiology
Chief, Neuropsychiatric Services
Duke University Medical Center
Rebecca S. Finley, PharmD, MS, FASHP
Chair and Associate Professor
Department of Pharmacy Practice and Pharmacy Administration
Associate Dean for Pharmacy
Philadelphia College of Pharmacy
Supported by an educational grant from Purdue Pharma, L.P.
Reviewed and Updated: March 2007
Selection and Use of Long-acting Opioids
Management of chronic pain constitutes a significant clinical challenge not only because of its enormous impact upon the lives of
those who suffer from it, but also because of the complexities physicians face in addressing it. Chronic pain may originate from
disease processes, such as cancer, AIDS, rheumatoid arthritis, or osteoarthritis, or may result from conditions with a multifactorial diagnosis such as back pain. Unlike acute pain, which is generally nociceptive (i.e. a direct response to a noxious
stimulus, such as a trauma) and short in duration, chronic pain persists for months, sometimes years, and may be either
nociceptive or neuropathic (i.e. caused by a lesion or dysfunction in the nervous system) or a mixture of both. 1
Opioids have been central in treating pain since ancient times, and are the current standard of care for the treatment of moderate
to severe pain. However, although they are generally accepted in addressing cancer-related pain, the use of opioids in chronic
nonmalignant pain (CNMP) remains somewhat controversial. Such controversy hinges on questions of efficacy, safety, and the
dangers of addiction. The difficulty in dealing with the pain itself, and with addressing objections to the use of opioids, is made
more difficult because patient response to opioids can vary greatly. Thus, treatment of chronic pain is not simply a matter of
choosing the most appropriate analgesic, but also requires a full understanding of appropriate dosing regimens, titration, possible
adverse effects, and routes of administration. 1
Numerous studies, surveys, and case series have evaluated the efficacy of opioids in treating CNMP, but the quality of many of
these evaluations leaves much to be desired. That said, randomized trials have shown opioids to be effective in relieving CNMP,
although their efficacy in addressing issues such as disability, quality of life, and functional improvements are more variable. 2
Clinical surveys show fairly consistent favorable outcomes with opioids in CNMP, while retrospective case series have viewed
opioids in a much less positive light. Although these findings are somewhat ambiguous, it is clear that a subpopulation of patients
suffering from CNMP do benefit from opioid use. 3
Clinical experience has shown that long-acting opioids provide a number of specific advantages over short-acting opioids in
CNMP.4 For continuous pain, the around-the clock analgesia provided by long-acting opioids is more effective than dosing on an
as-needed basis, and is likely to result in fewer side effects. While opioids with a short half-life may be administered on an
around-the-clock schedule, such a method is not only less convenient, but is also distracting, since frequent dosing serves as a
constant reminder of the patient’s pain and a disruption in daily activities. Use of a long-acting opioid for baseline pain,
supplemented by a short-acting opioid for breakthrough or episodic pain, is considered optimal therapy for persistent chronic
pain.4
Long-acting opioids are available in a number of different formulations. Controlled-release formulations of morphine and
oxycodone, as well as transdermal fentanyl are most commonly used, although opioids with long half-lives, such as methadone
and levorphanol, are also available. However, opioids with longer half-lives may pose a problem with delayed toxicity if the
interval between doses is shorter than the drug’s half-life. It is important to note that for the sake of safe administration,
controlled-release oral opioid formulations must not be altered or damaged. Tablets should not be crushed, broken or chewed,
but swallowed whole, otherwise large doses intended for slow absorption will be absorbed in a considerably shorter time period,
risking overdose and possible death. Similarly, capsule preparations containing pellets may either be swallowed whole, or
opened up so that the pellets can be sprinkled on soft foods. Destruction of the pellets by crushing, chewing, or dissolution may
cause overdose and can be lethal.
Morphine
Morphine has long been considered the gold standard of opioid agents, and is the most commonly used in treating pain.
Controlled-release morphine is available for 8-, 12- and 24-hour dosing. A review of 10 different studies examining 257 cancer
pain patients who received 12-hour dosing of controlled-release morphine (at a variety of dosing levels, from 90 mg to 330
mg/day) found that 98% of the patients completed a successful course of treatment, with effective pain relief, minimal side
effects, and limited requirements for rescue medication. 5 Data for morphine use in CNMP is not as prolific as for cancer pain,
however a study of 100 patients, mostly suffering from neuropathic or back pain, who were treated with controlled-release
morphine found an excellent rate of success: 79 patients experienced partial or good pain relief, with side effects largely limited
to constipation and nausea (typical of all opioids) and no instances of either respiratory depression or addiction. 6 Since
neuropathic pain is generally harder to treat with opioids than nociceptive pain, these numbers may represent a more difficult to
treat patient population.
It is worth noting that the pharmacokinetics of morphine vary quite considerably in its different formulations. Short-acting
(immediate-release) morphine has a half-life of 2-4 hours and reaches peak plasma concentration in the first hour after
administration. By contrast, twice daily morphine (12-hour dosing) has a 3-6 hour half-life, a somewhat lower peak plasma level,
but a more evenly sustained level of plasma concentration. This trend continues in the once-daily formulation, in which the halflife is about 10 hours, peak plasma levels are somewhat reduced, and the pharmacokinetic profile is generally less changeable.
The pharmacokinetics of the twice-daily formulation and variability in patient response may require 8-hour dosing in some cases
instead of 12-hour dosing. A comparison of the once-daily and twice-daily formulation has shown both to be safe and effective
analgesics.7
Dosing requirements with morphine varies according to the degree of pain and a patient’s prior experience with opioids. For
patients who are likely to require 120 mg/d or less, a 30 mg tablet is recommended for initial titration, followed by conversion to
60 mg or 100 mg, and with upward titration continuing until the desired analgesia level is reached. Use of the 200 mg morphine
dose is recommended only for opioid-tolerant patients. Morphine use in older patients should be approached with somewhat
greater caution due to a higher degree of risk in that patient population, as should patients with severe renal or hepatic
impairment.8
Oxycodone
A semi-synthetic opioid, oxycodone has a higher oral bioavailability than morphine, with a half-life between 3.5 and 5 hours in its
short-acting formulation.1 Controlled-release oxycodone, available in a twice-daily formulation, has a biphasic absorption profile.
The first stage involves a rapid onset, followed by a prolonged release phase. 9 Half-life for the controlled-release formulation is
4.5 hours.
Oxycodone has been shown in clinical studies of osteoarthritis patients with moderate to severe pain to be superior to placebo in
reduction of pain intensity, as well as reduction in pain interference with mood, sleep, and enjoyment of life. 10,11 A further study
examined titration of both immediate-release and controlled-release oxycodone in cancer and noncancer low back pain patients
converting from other opioids.12 No significant difference was seen between the two formulations in achieving stable pain control,
degree of pain control achieved, or in time to achieve pain control. One may infer from these results that titration of controlledrelease oxycodone is achievable without undue difficulty.
For the opioid-naïve patient, 10 mg every 12 hours is an appropriate starting dose. 7 Should greater levels of analgesia be
required, the dosage amount should be increased, but the frequency of dosing should not. Clearance of oxycodone in older
patients may also be somewhat reduced.
A dosing ratio of 2:1 for oral morphine to oral oxycodone is suggested in package inserts for controlled release oxycodone.
Clinical experience suggests that for some opioid-tolerant patients, a 1:1 ratio may be appropriate. 1 1:1 and 1.3:1 ratios of oral
oxycodone to oral morphine has also been safely and effectively used in treating chronic cancer pain.13
Hydromorphone
While long-acting formulations of hydromorphone are not presently available in the United States, development of controlledrelease hydromorphone is currently underway for the American market. Hydromorphone in other formulations has long been
available in this country, and has been used in the treatment of chronic pain.
Hydromorphone is a semi-synthetic opioid, more potent than morphine, and which, like oxycodone, has been used as an
alternative to morphine in patients who have experienced intolerable side-effects from morphine.14 Hydromorphone’s high
solubility allows it to be prepared at high levels of concentration for parenteral injection, making it ideal for patients who require
high opioid doses to treat their pain. Hydromorphone is frequently used for continuous subcutaneous infusion.
A number of studies have been conducted on the safety and efficacy of controlled-release in comparison to other opioids,
although most of these studies have involved treatment of cancer pain. Results from these studies suggest that hydromorphone
is quite similar to other opioids in terms of efficacy, safety, and patient preference. 14 One such study, employing a crossover
design, compared controlled-release hydromorphone with controlled-release morphine in 100 patients, and assumed a 7.5:1
hydromorphone to morphine potency ratio. Results showed no significant difference in experience of pain, adverse events, or
drug preference between the two groups.15 Another crossover study, of 44 patients, compared controlled-release hydromorphone
with controlled-release oxycodone.9 No significant difference was found between the two opioids for overall pain intensity (as
measured by the Visual Analogue Scale), categorical pain intensity, need for rescue medication, incidence of sedation or nausea,
or patient preference.
Transdermal Fentanyl
A semi-synthetic opioid 100 times more potent than morphine, the transdermal fentanyl formulation provides a near constant
release rate, and is designed for a duration of action of up to 72 hours, although this might extend for a longer period in older
patients. Serum concentration levels accrue gradually upon application, with leveling off occurring after 12-24 hours, followed by
a slow decline. A potential drawback seen with the transdermal formulation is poor adhesion to the skin of some patients.
Transdermal fentanyl has been shown to be effective in treating both nociceptive pain (such as diabetic ulcer, osteoporotic
vertebral fracture, and ankylosing spondylitis) as well as neuropathic pain (such as radicular pain brought on by intervertebral
disk protrusion, and herpetic neuralgia).
Transdermal fentanyl has been successfully used to treat CNMP, and showed improved pain relief compared with oral opioid
analgesics in a study of 50 patients with lower back pain. 12 Another study of 212 patients suffering from CNMP compared
transdermal fentanyl with controlled release oral morphine for level of pain control and quality of life after treatment: 65%
expressed a preference for the transdermal fentanyl, 28% preferred the controlled release morphine, and 7% had no
preference.16 Preference for the transdermal fentanyl occurred for both pain relief and quality of life.
A recent open-label study of 529 noncancer pain patients receiving long-term treatment with transdermal fentanyl measured
changes in quality of life over the course of treatment. Median therapy duration was 10 months, and patients in the study
included those experiencing both nociceptive and neuropathic pain. Results showed a significant improvements in quality of life
within 28 days and in pain management within 48 hours. The study is particularly notable for demonstrating no significant
differences in effectiveness of transdermal fentanyl between patients with nociceptive and neuropathic pain. 17
Methadone
Methadone is a synthetic opioid long used to treat opioid addiction, and best known for its use in the treatment of heroin
addiction. Its oral bioavailability is higher than that of morphine, and it shares a similar duration of action of 4-8 hours. Methadone
has an exceedingly long half-life that varies between 15 and 48 hours (with some estimates putting its half-life at up to 128
hours), and a high degree of variability in clearance. These properties make titration difficult, and methadone should be
prescribed on an as needed basis during the titration period.
In contrast to the difficulties of titration and risk of toxicity, methadone does present several advantageous characteristics. It is
potentially useful in treating neuropathic pain as a result of its non-competitive antagonistic activity at N-methyl-D-aspartate
(NMDA) receptors, and it has no known active metabolites, making it well suited to those for whom metabolite accumulation
poses a risk of toxicity.18 It is available in formulations for multiple routes of administration, although risk of skin irritation makes
the subcutaneous route undesirable. It is one of the least expensive opioids therapies available, which, in long-term treatment
may be a significant consideration, and if used with caution, can be used safely and effectively in treating chronic pain.
Clearly, differences in pharmacokinetic profiles, routes of administration, bioavailability, and available formulations, among other
criteria, may provide advantages for one opioid over another. Moreover, patient response to any given opioid may be highly
variable, and the availability of multiple opioid agents provides clinicians with an array of alternatives that increase the likelihood
of achieving successful analgesia.
While numerous studies have been conducted comparing opioids for efficacy and safety, results have been disparate: the
majority of studies have been of inadequate quality, and the heterogeneity in study designs has made comparisons and metaanalyses difficult if not impossible. Chou et al recently reviewed 16 randomized trials (1427 patients) and 8 observational studies
(1190 patients) which sought to establish differences between opioid analgesics for safety and efficacy.19 Their conclusion was
that no conclusion was possible with the available data.
Guidelines and Consensus Statements on the Use of Long-acting Opioids
in the Treatment of Chronic Nonmalignant Pain
While the use of opioid analgesia in chronic cancer pain and acute pain has been widely accepted for many years, questions
about the appropriateness of long-term use of opioids for chronic nonmalignant pain (CNMP) has meant that formalization of
guidelines has occurred only relatively recently. Perhaps the most widely recognized approach to the subject is the consensus
statement published jointly by the American Academy of Pain Medicine (AAPM) and the American Pain Society (APS), “The Use
of Opioids for the Treatment of Chronic Pain,” which was originally issued in 1996. Additional guidelines have been published by
a variety of national organizations, such as the American Academy of Family Physicians, the American Geriatrics Society, the
American Society of Anesthesiologists, the American Medical Directors Association, and the Federation of State Medical Boards.
In some cases these guidelines are addressed directly to the subject of opioid use in CNMP, and in other cases, the guidelines
deal with the subject of pain more broadly, with opioid use in CNMP part of a more comprehensive project.
AAPM/APS Consensus Statement (1996)20
The AAPM/APS consensus statement is simply that, a consensus statement, rather than detailed guidelines on treatment
modalities or the specifics of opioid selection in CNMP. Its purpose is, in part, to lend credibility and official sanction to the use of
opioids in CNMP. It points out that while national guidelines for the treatment of acute and cancer pain have been available, this
has not been the case for noncancer chronic pain, despite significant social as well as economic costs — costs in the vicinity of
tens of billions of dollars annually.
The timing of the statement is also significant. At the time it was formulated, and continuing into the present, state laws were and
are being developed and revised to reflect the evolving understanding and attitudes of the role opioids play in chronic pain
management. State legislatures and boards of medical examiners have been engaged in creating laws and regulations (e.g.
intractable pain treatment acts) that significantly impact the availability and use of opioids in CNMP. Attitudes have varied widely
from state to state, and where policymakers lack a clear scientific and clinical background, or may be influenced by opinions not
based on medical evidence, the possibility of counterproductive policy is great. Thus, the AAPM and APS saw it as important to
lend their experience in helping such lawmaking and regulatory bodies to create sound policy.
The consensus statement points out that since chronic pain is not a single entity, but a multifaceted issue with diverse causes,
approaches to treatment are necessarily varied, and include pharmacologic interventions (including, but not restricted to, opioids)
and non-pharmacologic approaches. Treatment for pain represents one of the most common reasons patients consult doctors,
and the non-treatment of pain is not only unnecessary, but leads to enormous suffering, lost productivity, and an increased
burden on the healthcare system.
Resistance to the use of opioids is based on concerns in several domains, including fears of addiction, side effects, diversion of
drugs. At the same time, physicians themselves are concerned about prescribing opioids for fear of regulatory action against
them.
Concerns about addiction are based, in part, on misconceptions about the nature of addiction and frequently involve
misidentification of patients as addicts. The medical literature provides strong evidence that new addiction among patients who
use opioids for treating pain is quite rare. And even among those patients who are addicts, opioids can be safely used for treating
pain from cancer, surgery and recurrent illnesses such as sickle cell disease, so long as they are carefully supervised and
opioids are appropriately prescribed.
Concern about side effects from opioid use is most strongly focused on respiratory depression. However, pain specialists now
understand that respiratory depression is mainly a short-term symptom that generally manifests among opioid-naïve patients and
that is exacerbated by pain. Barring access to opioids for effective pain relief could, therefore, provoke a worsening of the very
symptoms that prompted the restrictions. Lesser side effects, such as sedation and nausea, usually dissipate with continued
opioid use, while constipation can be treated with stool softeners and laxatives as well as dietetic intervention.
Tolerance to opioids, once considered a significant barrier to their long-term use, has proven to be much less prevalent than
previously assumed. Long-term use of opioids in treating cancer pain has shown that what appeared to be tolerance was more
often than not simply symptoms of disease progression. Moreover, prior assumptions regarding arbitrary upper dosage limits for
opioids appear to be unfounded.
With regard to possible diversion of opioids for illicit purposes, while such risks do exist, they should not be regarded as grounds
for withholding a medication crucial for the treatment of pain. Risk of diversion can certainly be addressed by attention to
prescribing patterns, and by maintaining a clear record of what medications a physician prescribes for a given patient.
In order to deal with physician anxiety about regulatory scrutiny, clear guidelines on the use of opioids in CNMP should go a long
way toward reducing the ambiguity surrounding appropriate treatment modalities. This would not only aid the physicians
themselves, but would help regulatory and legal bodies distinguish between appropriate and inappropriate use of opioids.
While the AAPM/APS consensus statement does not draw out detailed guidelines for prescribing opioids, it does suggest that
such guidelines should be based on sound medical practice, which it summarizes as follows.
1) Patient evaluation: This should include both a pain history and an assessment of how pain has affected the patient. A physical
examination should be performed, as well as a review of previous diagnoses, previous interventions, a drug history, and an
evaluation of concomitant diseases or conditions.
2) Treatment plan: The plan should take into consideration all available treatment options, including pharmacologic and
nonpharmacologic treatment modalities, which may be suited to the patients’ particular needs. Where opioid treatment is
selected, the patient should be informed of all applicable risks and benefits, and be made well acquainted with the course of
treatment.
3) Consultation: A consultation with a pain specialist or psychologist may be useful in some cases, particularly when a complex
case is involved or when the treating physician has limited experience in managing pain.
4) Review: Periodic review should occur in order to evaluate the efficacy of the pain treatment, and to assess the patient’s
functional status, side effects, requirements for further analgesia, and quality of life.
5) Documentation: Documentation is necessary to track the course of treatment, to aid in patient evaluation, and support the
choice of treatment.
American Society of Anesthesiologists (2002) 21
The ASA guidelines address pain management in general, and discussion of opioid therapy in chronic pain deals mainly with
routes of administration and recommendations about when opioid therapy is appropriate. Both systemic delivery (oral,
transdermal, and intravenous) as well as neuraxial delivery (epidural, intrathecal) are seen as providing effective analgesia. The
guidelines state that medical literature suggests adverse sequelae (such as pruritus, nausea, respiratory depression,
dependence, and tolerance) are more likely to occur with systemic delivery as compared to neuraxial delivery.
Recommendations for the use of opioids largely parallel those of the AAPM/APS consensus statement. They additionally
recommend that opioid therapy be initiated once other analgesic therapies, such as non-steroidal anti-inflammatory drugs
(NSAIDs) or transcutaneous electrical nerve stimulations (TENS), prove inadequate to address chronic pain.
American Academy of Family Physicians (2000) 22
The AAFP statement, titled “Treatment of Nonmalignant Chronic Pain,” points out the limitations of NSAIDs and short-acting
opioids in addressing CNMP. Continuous use of NSAIDs may be associated with significant adverse events, and has led to endstage renal disease in 0.2% of patients who have taken them on a daily basis for five or more years. Hepatoxicity or
coagulapathy have also been seen with chronic use of NSAIDs, aspirin, and acetaminophen, while NSAIDs are associated with
ulcer formation in 2-4% of chronic users. Short-acting opioids are associated with sedation and euphoric side effects, while the
necessity of frequent dosing inherent in the use of these drugs may encourage tolerance. Chronic use of benzodiazepines have
also been associated with adverse events such as sedation and impaired cognitive skills. By contrast, studies suggest that longacting opioids are not associated with organ toxicity or cognitive impairment, and have good efficacy in treating chronic pain.
While studies report a rate of 3-19% of drug abuse, dependence, or addiction in chronic pain patients 23, according to the AAFP,
true addiction (i.e. psychological dependence) is rare in chronic pain patients who use long-acting opioids, and tolerance is also
seen as less likely with long-acting analgesia. It is further pointed out that patients with a history of addiction are no more likely to
abuse opioids than the general population. A study of patients in a clinical setting using opioids to treat CNMP were prescreened
for history of drug or alcohol abuse and psychosocial indicators in an effort to predict future opioid abuse. 24 No correlation was
seen between those possessing assumed indicators of future abuse and those who would actually go on to abuse opioids.
The AAFP recommends educating patients who will be prescribed long-acting opioids that they are not to be used in the same
manner as short-acting opioids. The goals of long-acting opioids should be pain reduction and increased function with limited
adverse effects, and not total pain elimination, or reduction of such psychological issues as stress, depression, anxiety, or life
dissatisfaction.
American Geriatrics Society (2002)25
The AGS has published extensive guidelines for “The Management of Persistent Pain in Older Persons,” which deals with many
facets of pain treatment. With regard to opioid use in chronic pain, the guidelines point out the increasing acceptance of such
medications, and note that addiction is even rarer among older patients than the general population, while tolerance to opioids is
slow to develop in stable disease states. Furthermore, concerns about dependency and addiction do not justify withholding
opioids for the relief of pain.
Older patients respond to analgesia of all kinds more readily than younger patients, and tend to be more susceptible to adverse
reactions. Subsequently, the AGS advocates using two or more drugs with complementary mechanisms, when possible, in order
to achieve greater relief with reduced risk of toxicity that may arise from higher doses of a single agent. Close monitoring of older
patients is particularly crucial, both because of the greater likelihood of adverse reactions, and to ensure there are no drug-drug
interactions.
Finally, the AGS advises caution in the use of methadone for pain relief due to methadone’s long and variable half-life. This issue
is particularly pertinent to older patients whose hepatic metabolism may already be under strain from use of other medications for
other persistent conditions.
American Medical Directors Association26
The AMDA has drawn up extensive guidelines for “Chronic Pain Management in the Long Term Care Setting.” With regard to
long-term opioid use, their approach largely parallels that of the AAPM/APS consensus statement. Issues of addiction, tolerance,
and loss of control, once considered significant barriers to opioid use, are now understood to occur with much less frequency
than previously assumed. Long-term use of NSAIDs is not recommended because of risk of systemic damage, and use of
benzodiazepines is discouraged concomitantly with opioids because of the possibility of adverse interaction.
The AMDA guidelines recommend against the use of several opioids for chronic pain. Specifically, use of butorphanol,
propoxyphene, meperidine, nalbuphine, and pentazocine are discouraged, although propoxyphene may be acceptable for those
patients who have used it over a long time period and who have had difficulty achieving satisfactory analgesia with other
medications.
Federation of State Medical Boards27
The Federation of State Medical Boards of the United States (FSMB) released their “Model Guidelines for the Use of Controlled
Substances for the Treatment of Pain” in 1998. This statement, appropriate to the FSMB’s function, focuses on limiting abuse
and diversion of opioids.
Among their recommendations, the FSMB suggests the use of a written agreement, also known as a “narcotic contract,” for
patients seen as posing a higher risk for abuse. Such contracts commit the patient to having all of their pain medication
prescribed by a single physician, and to not seek other sources of pain medication without the physician’s permission. In return,
the physician promises to provide all necessary and reasonable pain medication that the patient may require. Violation of the
contract by the patient would lead to termination of pain treatment by the contracting physician. State prescribing records may be
used to confirm that the contract is being honored.
The advantage of such a contract, apart from the obvious barrier to opioid abuse, is that it allows a single physician to take full
responsibility of the patient’s analgesic needs, while eliminating concern that the patient is augmenting their pain treatment from
other sources. The FSMB also suggests periodic drug screening of serum and urine levels for patients at risk for medication
abuse.
The Role of Race, Ethnicity, and Gender in the Treatment of Pain
It is widely understood by those who study the subject that pain is significantly undertreated in the United States. This is true for
all kinds of pain, including acute pain, chronic pain from cancer, chronic nonmalignant pain (CNMP), post-operative pain, and
various other manifestations of pain. The reasons for this undertreatment are complex, having to do with the healthcare system,
insurance coverage, legal and regulatory issues, views on the virtues and vices of analgesics — particularly opioids — and
perceptions about pain itself. The difficulty of addressing these issues is compounded when variables of race, ethnicity, and
gender are entered into the equation.
A clear preponderance of the medical literature indicates that people belonging to racial and ethnic minorities are, on average,
significantly less likely to receive treatment for pain, including opioid therapy, compared to non-Hispanic White people.28-32 The
reasons for this difference are manifold. Putting aside those reasons cited above — which are, to some extent, applicable to
patients of all races and ethnicities — one is still faced with an issue that defies easy categorization. Which does not mean that
the subject is beyond comprehension, or cannot be dealt with; it does mean that it may manifest in multiple ways at the same
time, and cannot be simply attributed to societal racism. To be sure, racism plays a role, but it would be inaccurate and
counterproductive to describe all instances of undertreatment of racial and ethnic minorities as a consequence of bigotry.
Studies that have sought to measure the degree and nature of undertreatment for pain in minority populations are revealing, if
not entirely revelatory, of the diversity of the issues involved. Numerous studies, a majority conducted in emergency medicine
settings, have shown that African-Americans and Hispanics are less likely to receive analgesia for pain than Whites. A typical
cross-section of such studies may be seen in a recent review by Bonham that looked at eight separate studies of prescribing of
analgesic medications in different settings.28 Three of the studies dealt with emergency department pain treatment, two of the
studies looked at treatment for cancer pain, two studies addressed post-operative pain, and one study looked at treatment for low
back pain. Of these eight studies, six found significant undertreatment of pain in minority patients. Of the two studies that found
no difference in treatment, one occurred in an emergency department and the other dealt with low back pain.
Details of these studies suggest that several forces were at work. Perhaps most obvious was the notion that some physicians
hold stereotypical views of racial minorities that causes them to underestimate pain in these patient populations. More subtly,
differences in treatment may result from poor communication between physician and patient, in which racial or ethnic difference
may play a role, but in which racism itself is not the guiding factor. 28 Differences in race and ethnicity may create cultural barriers
between physician and patient; this may simply be a lack of familiarity or comfort level, or it may manifest as a sense of not being
understood. Of course, these feelings can come from either or both parties. Even a small degree of discomfort, or an inability to
accurately read verbal cues or body language, can contribute to a less engaged relationship between physician and patient.28
Such disengagement is likely to have an impact on treatment. It is not hard to see that physicians are more likely to pay greater
attention to, and be more engaged in the treatment of, patients with whom they feel a closer connection. This issue may be
regarded with some optimism, since physician behavior is more likely to be modifiable if effective communication is the problem
rather than racial bias.
To be sure, differences in race and ethnicity are not the only grounds for poor communication between physician and patient.
Differences in socioeconomic status can also be a strong influence on communication, and patients with fewer economic
resources are known to receive poorer medical treatment in general, and are more likely to be undertreated for pain, than those
with greater resources. Since members of some racial and ethnic minorities are, on average, more economically disadvantaged
— and possess, on average, a lower level of education — multiple social forces may be at work in lessening the quality of
medical treatment.28
It is important to note that different approaches to studying the impact of race, ethnicity and gender in treatment for pain have
yielded different results. A recent study by Tamayo-Sarver et al employed a survey, delivered and returned by mail, to evaluate
emergency physicians’ inclinations toward prescribing opioids in hypothetical pain presentations. 33 The survey used three
different vignettes, alternating the race and ethnicity of the patients, to see if treatment recommendations would vary. Race and
ethnicity was conveyed by using identical color photographs of the areas of complaint — ankle, back, and head — in which skin
tones were digitally altered to suggest a patient was African-American, Hispanic, or White. Patients names were supplied that
would further cue racial/ethnic background (e.g. Shaquil Robinson, Luis Martinez, Sean O’Connor). Results of the survey, in
which 2872 physicians participated, showed no significant difference in inclination to prescribe opioids based on race or ethnicity.
Knowing that a patient had a higher-prestige occupation or a primary care provider increased the likelihood of an opioid
prescription to a small degree.
A similar survey of 111 primary care physicians was conducted by Weisse et al to establish differences in pain treatment for
patients of different race, ethnicity, and gender. 34 Of those physicians surveyed, 55% were male, 79% were white, 13.5% were of
Asian descent, and 2.7% were African-American. No overall difference was seen in decision to treat or in maximum permitted
doses on the basis of ethnicity, race, or gender. There were, however, differences in treatment. In hypothetical kidney stone pain,
male doctors prescribed twice as much hydrocodone for White patients as they did for African-American patients, while female
doctors did the opposite, prescribing twice as much hydrocodone to African-American patients. For hypothetical back pain, male
doctors prescribed twice as much hydrocodone to male patients versus female, and female doctors prescribed twice as much
hydrocodone to female patients versus male patients.
These surveys may be seen to have a certain advantage over studies of prescribing behavior in clinical settings in that they
eliminate some of the variables that might tend to skew results. By using identical photographs with only skin tone altered, the
Tamayo-Sarver study would appear to even the playing field and eliminate the inconsistencies and variables inherent in particular
patient interaction. Indeed, such studies may have a lot to say about the pervasiveness of outright racism in physician behavior.
But by eliminating the patient interaction factor, these studies risk missing a central cause of treatment inequity: flawed physicianpatient communication.
While many studies have revealed a disparity in pain treatment among different racial and ethnic groups, much work needs to be
accomplished in addressing the issues that such studies describe. Taking note that the problem exists is no doubt helpful, but
ultimately strategies must be consciously created to overcome such disparities. For example, development of pain assessment
measures which take into account cultural and linguistic differences in patient populations could help bypass some of the
communication issues that currently hinders proper diagnosis and treatment. Similarly, intervention strategies based upon an
understanding of the various factors — racial, ethnic, cultural, gender, economic — associated with treatment disparities would
go a long way toward closing the gap in quality of care for all patient populations.
References
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Nicholson B. Responsible prescribing of opioids for the management of chronic pain. Drugs. 2003;63(1):17-32.
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Dickinson BD, Altman RD, Nielsen NH, Williams MA. Use of opioids to treat chronic, noncancer pain. West J Med.
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