Faculty Bibliography

UNLABELLED:Due to high profile initiatives at the national level, awareness of inadequate pain care affecting many groups in our society has never been greater. Nevertheless, increased awareness of pain disparities and the initiatives to address these disparities have yielded only modest progress, most notably in the form of growing appreciation that pain disparities likely result from multiple factors, including biological, psychological, environmental, health system, and cultural factors. Much less progress has been made in developing interventions that target these multiple determinants to reduce pain management disparities. In this paper we discuss key ethical and methodological challenges that undermine our capacity to investigate and develop meaningful interventions to improve pain outcomes among vulnerable populations. Key challenges in the areas of research engagement, recruitment, design, and measurement are discussed from both scientific and normative standpoints. Specific opportunities within emerging research paradigms to improve designs and measures are also discussed. Finally, we conclude with identifying potential synergies between the pain management disparities research agenda and the broader areas of clinical practice, advocacy, and policy that could help to move the field forward. PERSPECTIVE/CONCLUSIONS:Researchers studying disparities in pain care face a number of ethical and methodological challenges that must be addressed to advance the field towards eliminating disparities. We discuss these ethical and methodological challenges and propose opportunities for paradigmatic revisions in areas of research engagement, design, measurement, advocacy, and policy.

BACKGROUND:Unlike pain practitioners, health care insurers in the United States are not expected to function according to a system of medical ethics. Rather, they are permitted to function under the business "ethic" of cost-containment and profitability. Despite calls for balancing the disparate agendas of stakeholders in pain management in a pluralistic system, the health insurance industry has continued to fail to take the needs of suffering chronic pain patients into consideration in developing and enacting their policies that ultimately dictate the quality and quantity of pain management services available to enrollees. This essay examined these self-serving strategies, which include failure to reimburse services and certain medications irrespective of their evidence-bases for clinical efficacy and cost-efficiency; "carving out" specific services from interdisciplinary treatment programs; and delaying and/or interrupting the provision of medically necessary treatment. Blatant and more subtle strategies utilized by insurers to achieve these ethically questionable goals are examined. Additionally, this essay addressed some of the insurance industry's efforts to delegitimize chronic pain and its treatment as a whole. CONCLUSION/CONCLUSIONS:The author concludes that the outlook for chronic pain sufferers is not particularly bright, until such time that a not-for-profit single-payer system replaces the current treatment/reimbursement paradigm.