Living in Agony
Pain goes untreated for many minorities
Lack of insurance, pharmacies that don't carry potent drugs add to health care gap.
When the pain gets unbearable during his morning shave, Don Dillard grabs onto the sink to steady himself. He has been in severe pain since a loaded dump truck rolled over his body 15 years ago.
Pain specialist Linda Vanni, right, visits with lung cancer patient Geneva Smith, 45, in her room at the Karmanos Cancer Institute. Smith tried to ignore her back pain because she was afraid to find out its cause, she said.
"Pain is fundamentally a human rights issue and a civil rights issue," says Dr. Carmen Green, who is helping Don Dillard deal with chronic pain following an accident.
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Donald Dillard counted himself lucky to survive when a loaded dump truck rolled over his body, crushing his pelvis and thighs and shredding a football-sized chunk of flesh in his torso.
But the 15 years since then have been a nightmare of agonizing days and nights made worse by the lack of potent pain medications at pharmacies near his Detroit home, struggles to get proper care and workers' compensation red tape. "It's really depressing when you know there are things out there that can help you, and you can't get them," Dillard said.
Dillard's problems illustrate a pervasive inequity in our nation's health care system: Hispanics and African-Americans are consistently undertreated for pain across a range of conditions, from cancer to chest pain to broken bones.
As pain management emerges as a growing medical specialty, a mounting body of evidence shows minorities are far less likely than whites to receive medicines, physical therapy and care they need. Extensive studies from the University of Michigan and Wayne State University show the problem is especially acute in southeast Michigan.
The impact can be devastating, sapping quality of life, interrupting sleep and eating patterns, and triggering depression. Chronic pain can even prevent some from working.
Many experts say disparate treatment can be traced to deep-seeded racial stereotypes, such as the assumption that minorities are more likely to abuse or sell potent drugs, or the archaic belief they don't feel pain as acutely as whites.
Economic factors pay a large role as well. In 2002 and 2003, nearly 60 percent of Latinos and more than 40 percent of African-Americans nationwide were without health insurance, cutting them off from proper treatment.
And pharmacies in low-income, minority neighborhoods are less likely to carry strong pain medicines.
The issue of pain treatment fits into a troubling overall health picture for minorities. A federal study in 2002 found minorities generally receive lower-quality health care than white patients, even when their income, insurance and medical conditions are similar.
For Dillard, it was only when a U-M pain specialist took up his cause that life started to improve. State-of-the-art treatments allow him to perform small tasks such as walking to the corner grocery store with a cane or tidying the kitchen.
"Looking back, I can see how I used to be withdrawn and disgruntled with the way things were," he said. "Slowly but surely, I'm doing more. It's a long, hard process."
But even with help from a leading pain expert, Dillard still struggles. There are times when he can't get his prescriptions filled and his worker's compensation insurance won't pay for the physical therapy his doctors say could help.
Dillard's doctor, pain specialist Carmen Green, has studied the issue and believes the racial disparities are more than a glitch in the U.S. health system.
"Pain is fundamentally a human rights issues and a civil right issue," she said. "The people are suffering and disenfranchised and they're literally fighting for pain relief."
A nationwide crisis
Uncontrolled pain is a growing problem that straddles racial lines. More than 50 million Americans suffer from chronic pain, costing more than $100 billion in reduced productivity, sick time and medical costs, estimates the American Chronic Pain Association and the National Institutes of Health.
As Americans live longer, they're more likely to suffer from painful, chronic conditions such as arthritis and diabetes.
Pain management is a relatively new field, only becoming a specialty in the late 1980s. It wasn't taught in medical schools until the 1990s. Dozens of studies, including several in Michigan, have found that African-Americans and Hispanics receive less pain treatment than the general population.
A 2003 study found that African-Americans who sought treatment at a Michigan pain clinic reported significantly more pain and distress and were more likely to be depressed. Another national study found that whites who came to hospital emergency rooms with broken legs were twice as likely to get pain medication as Hispanic patients with broken legs.
"You can't get into the heads of individual physicians to see what they're thinking, but on the whole it's clear they're not managing pain as aggressively in minority populations," said Gary A. Puckrein, president of the National Minority Health Month Foundation.
Hard to measure
The root of the issue, many doctors say, is personal biases in the treatment of patients -- especially people complaining of severe pain.
There is no medical test to measure pain levels. And while some doctors look for physical cues such as restlessness or an elevated pulse, experts say people with chronic pain often adapt and don't show symptoms.
"It's a tough situation because when someone comes in complaining of severe pain, you don't know how they feel," said Dr. Felix Valbuena, medical director of the Community Health and Social Services clinic in southwest Detroit, which primarily serves Hispanic patients.
That's where stereotypes come into play, such as the belief that African-Americans have a higher threshold to tolerate pain, said Dr. Winston Price, president of the National Medical Association, which represents African-American doctors.
While pain tolerance does vary widely between different people, there is no credible research to suggest race is a factor that should be considered.
It's also discriminatory and wrong to assume that minorities are more likely to abuse painkillers or sell them on the street, experts say.
"There's no scientific basis for that," Price said. "But the bias, whether overt or covert, is to undermedicate African-Americans."
Doctors hestitant
Beyond judging patients, doctors face the risk of federal investigation for prescribing large amounts of painkillers.
Last year, the U.S. Drug Enforcement Agency said doctors could be investigated based on how many of their patients get narcotics, the number of pills patients receive and how long they stay on the drugs.
This type of enforcement can enter into the thinking of doctors as they prescribe drugs. Most states, including Michigan, have automated systems that track how many narcotic prescriptions doctors write.
"There's a very small number of physicians who get prosecuted, but when it happens, it certainly catches everyone's attention," said Dr. Jeffery Kimpson, a pain specialist at Providence Hospital in Southfield. "There are barriers built into the system to make you a little more hesitant to prescribe."
At Kimpson's practice, doctors have a policy not to write prescriptions for narcotics on a patient's first visit. Kimpson also uses Michigan's prescription tracking system to see if patients are getting narcotics from another doctor.
"We like to develop a relationship with the patient because we don't want people coming in off the street to get medications," he said. "We like them to follow a complete pain management program. If they're really in pain, they'll work with us."
Lack of access to drugs
Even when minority patients find a pain specialist to work with, they're often denied the drugs they need because pharmacies in minority neighborhoods are less likely to carry potent painkillers.
Studies by the University of Michigan and The Detroit News document the problem in Michigan. In 2002, a Detroit News survey of 200 of the 700 retail pharmacies in Oakland, Macomb and Wayne counties found that filling prescriptions for painkillers is much easier in suburbs than poorer communities. Some pharmacists in Detroit say they're deterred from stocking heavy-duty painkillers because of the danger of robberies and opportunity for abuse. A string of high-profile killings in 2000 and 2001 spurred some drugstore chains to stop stocking OxyContin. Others say there isn't sufficient demand for the drugs.
"We have been broken into, and that is a factor," said Mary Frazier, owner and pharmacist at M & D Pharmacy on Mack Avenue in Detroit, which carries Vicodin but not OxyContin or any immediate-release morphine products. "But we really don't have much demand, and if we get phone calls, we will send them to another pharmacy that carries what they need."
In Detroit, hospital pharmacies often are the only choice for many patients.
The pharmacy in Harper University Hospital carries a wide selection of pain relievers, and doctors there work closely with pharmacists to ensure patients get proper drugs.
"I tell the docs all of the time -- when you prescribe a pain medication for someone, you better make sure they can get it," said Linda Vanni, pain specialist at the Karmanos Cancer Institute.
Fear and doubt
Geneva Smith tried to ignore the throbbing pain in her back for two months before it finally got so bad that she had to see a doctor.
"I didn't pay no attention and just took Tylenol and Advil, but it got so severe I couldn't cope," said Smith, 45, a former waitress from Detroit.
Tests showed Smith was suffering from advanced lung cancer that spread to her back. Six months later, she is a hospice patient at the Karmanos Cancer Institute, where nurses and doctors try to keep her pain under control with a pump that delivers liquid pain medication to her spine.
There's a chance doctors could have offered Smith more treatment if she had come in earlier. But she hesitated to see a doctor, she said, because she was afraid to find out what was causing her pain.
Fear and doubt from patients, especially minorities, is another barrier to pain care, studies show. Some patients who ignore their pain or refuse treatment suffer needlessly. The most common fear of patients in pain is that they'll become addicted to narcotics, pain experts say. Some patients confuse addiction with tolerance, U-M pain specialist Green said.
Addiction is a psychological dependent on a drug. Tolerance is simply the body getting used to a particular substance, which occurs with most prescriptions, including drugs for hypertension and diabetes.
"Just because their body gets used to seeing a certain molecule does not mean they're addicted," Green said.
Fear is an excuse heard often by Linda Vanni, the pain specialist at Karmanos.
"I ask them right out front, 'What are you afraid of?'" she said. "Sometimes it's 'I'm afraid to take my medicine home because someone in my family will take it.' Sometimes they're afraid of the side effects.
"A lot of people believe that if you suffer here, you pave your way to heaven."
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The Detroit News.
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