Opioids: Race, Class, and Gender Discrepancies Johnathan Goree, MD Director of Chronic Pain Division Chair of Opioid Stewardship Committee Assistant Professor Department of Anesthesiology University of Arkansas for Medical Sciences

Disclosures I have no financial interests to disclose related to this presentation

Outline What does our physician/provider work force look like Are pain outcomes different for under-represented groups? What are the factors that affect these outcomes? What can we do to address the problem?

United States of America

United States of America 2010 Census Data – Sex Female - 50.8% Male - 49.2%

United States of America 2016 FSMB Census of Licensed Physicians Female - 33.5% Male - 64.7% 2016 AAMC Medical School Survey (Faculty Members) Female - 39% Male - 61%

United States of America 2010 Census Data - Race White - 72.4% Hispanic/Latino American - 16.3% Black - 12.6% Asian - 4.8% Native American - 1.1% Two or More Races - 2.9% Other - 6.2%

United States of America 2016 AAMC Medical School Graduation Data White - 58.8% Asian - 19.8% Black - 5.7% Hispanic or Latino - 4.6%

Arkansas

Arkansas 2010 Census Data Women - 51.2% Men - 48.8% White - 77% Black - 15.4% Latino or Hispanic - 6.4% Asian - 1.2% Native American - 1%

Does This Matter?

JAMA Pediatrics Journal Club Slides: Racial Disparities in Pain Management for Appendicitis Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial disparities in pain management of children with appendicitis in emergency departments. JAMA Pediatr. Published online September 14, 2015. doi:10.1001/jamapediatrics.2015.1915.

Results Predicted Probabilities for Analgesic and Opioid Administration by Race Stratified by Pain Score and Adjusted for Ethnicity

Results Predicted Probabilities for Analgesic and Opioid Administration by Race Stratified by Pain Score and Adjusted for Ethnicity

7000 patients in 12 centers No difference in pain scores Mount Sinai Hospital (NY, NY); Medical University of South Carolina (Columbus, SC); UCLA (Los Angeles, CA); Colorado SOM (Aurora, CO)

UAMS. Multi-logistic regression comparing patient characteristics of trauma patients. G. Lawson Smith, Rebecca Reif, Kevin Sexton, Johnathan Goree Odds Ratio for Black patients 0.64 (0.56,0.73)

Discussion of Possible Reasons

Discussion Patient Provider Systemic Cultural Health literacy Distrust of medical profession/ lack of disclosure Provider Implicit Bias Poor communication Systemic Cultural

Discussion Patient Provider Systemic Cultural Health literacy Distrust of medical profession/ lack of disclosure Provider Implicit Bias Poor communication Systemic Cultural

Implicit Bias Unconscious stereotypes. “Even the most well-intentioned individuals, such as Emergency Medicine Physicians (who choose to work in highly disadvantaged areas and) provide the ‘safety net’ of our healthcare system can lean towards unconscious stereotypes when fatigued or required to make quick decisions with little information”

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Most Likely  Least Likely

How do we combat racial, gender, and class bias in healthcare 1) Understand our own biases. 2) Challenge ourselves 3) Strive towards a culture of diversity and inclusion

Challenge ourselves Source: Armenta,K and Bain,B 2008 Ask ourselves where our thoughts and behaviors come from. Find the source and cease self-blame Attend workshops Be open to change Develop awareness of your own thoughts Take a risk: Be the only person in a group of people different than you.

Push for Diversity and Inclusion Push for Diversity and Inclusion in organizations that you are apart of. Diversity = what you have. Snapshot. Can be accomplished through leadership Inclusion = what you do. Movie. Must be accomplished through culture change throughout organization.

Summary Unconscious and Conscious Bias can and do affect healthcare outcomes, especially in patients with chronic pain. A blanket decrease in opioid administration without an understanding of the entire picture can lead to unintended consequences. We must be careful, especially as we rapidly decrease opioid use, that we don’t negatively impact the care of women and minority groups.

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