WEST LAFAYETTE, Ind. — A 62-year-old with stage IV lung cancer that has spread to his bones, causing unspeakable pain, is trying to convince his physician to prescribe pain medicine. What happens next?

It actually could depend on if the patient is black or white. Or if the physician is a primary care provider or an oncologist.

Yes, race and other factors could play a role, according to a new study conducted by researchers and recently published in the Journal of General Internal Medicine.

Historically, black patients report greater pain, mostly due to undertreatment, and are less likely to receive adequate pain management, said Cleveland Shields, a professor in Purdue University’s College of Health and Human Sciences’ Department of Human Development and Family Studies, who specializes in physician-patient communication, as well as health disparities due to race, poverty and geography.

Dr. Ronald Epstein, of the University of Rochester School of Medicine, who served as the co-principal investigator said, “We know that race affects the quality of care that patients receive. Our study clarifies when, how and under what circumstances racial bias enters into the picture. Our findings will help train the next generation of physicians to be more aware of their biases and provide more equitable care.”

Shields added, “Racial disparities in pain control are well-documented. There is plenty of evidence that black patients receive less adequate pain management than white patients.”

To conduct the five-year study, the group enlisted and trained standardized patients or “secret shoppers” who visited 96 primary care physicians and oncologists in urban and rural settings across Indiana, Michigan and New York. The physicians participating in the study did not know on what topics or aspect of patient care they were being observed.

As the study proceded, researchers also found that some physicians were increasingly reluctant to prescribe opioids as the nation found itself debating the use and amount of pain medication.

According to Shields, the use of standardized patients is a common technique used in medical schools as a way for medical students to learn how to interact with people in a patient care setting.

The group assigned either two black patients or two white patients to a physician’s office. The visits were separated by four or more months and were mixed in with new and regular patients.

Half of the standardized patients were activated or trained to interact, ask questions, express opinions with the physicians involved in the study. The other half were not activated. Activated patients saw an improvement in the physicians’ communication and interaction.

“When you have improved communication about pain control, it increases appropriate prescribing,” Shields said. “We expected to find direct racial differences, but we only found racial differences with the oncologists.”

The study was conducted by a group of researchers from Purdue, the University of Michigan School of Medicine, the University of Rochester School of Medicine, the University of California Davis School of Medicine and West Virginia University.

The work aligns with Purdue's Giant Leaps celebration, acknowledging the university’s global advancements made in health, longevity and quality of life as part of Purdue’s 150th anniversary. This is one of the four themes of the yearlong celebration’s Ideas Festival, designed to showcase Purdue as an intellectual center solving real-world issues

The National Cancer Institute (1R01CA155376) funded this study.

Writer: Matthew Oates, 765-496-2571, oatesw@purdue.edu; @mo_oates

Sources: Cleveland Shields and Dr. Ronald Epstein. To schedule an interview, please contact Matthew Oates.

Note to Journalists: For a copy of the research paper contact Matthew Oates at 765-496-2571 or oatesw@purdue.edu

ABSTRACT

The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment

Cleveland G. Shields; Jennifer J. Griggs, M.D.; Kevin Fiscella, M.D.; Cezanne M. Elias; Sharon L. Christ; Joseph Colbert; Stephen G. Henry, M.D.; Beth G. Hoh; Haslyn E. R. Hunte; Mary Marshall; Supriya Gupta Mohile, M.D.; Sandy Plumb; Mohamedtaki A. Tejani, M.D.; Alison Venuti; and Ronald M. Epstein, M.D.

BACKGROUND: Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer.

OBJECTIVE: To examine the effect of race on physicians’ pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation.

DESIGN: Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles—a 62-year-old man with advanced lung cancer and uncontrolled pain—differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions.

PARTICIPANTS: Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians’ mean age was 52 years (SD = 27.17), 59% male, and 64% white.

MAIN MEASURES: Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment. KEY RESULTS: SPs completed 181 covertly audio-recorded visits that had complete data for the model co-variates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81).

CONCLUSIONS: Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain.

TRIAL REGISTRATION: NCT01501006