Chronic
pain impacts an estimated 20% of Americans, but it disproportionately
affects certain groups, including older adults, women, veterans, adults
living in poverty, and people in non-metropolitan areas, among others.1 This
is an example of health disparity, a growing concern among chiropractors
and other healthcare professions. Healthy Living Blog talks to
chiropractors about the challenges of members of historically underserved
communities who experience chronic pain.
The
Centers for Disease Control and Prevention (CDC) define health
disparities as “preventable differences in the burden of disease, injury,
violence, or opportunities to achieve optimal health that are experienced
by socially disadvantaged populations.”2 These
populations can be defined by race, gender, sexuality, income, disability
or other factors, and their experiences can directly impact the way they
receive health care.
“These
differences can lead to devastating statistics such as the birth
mortality rate between white and black babies, the differences in life
expectancy between indigenous and black populations compared to white
populations, and the lack of health coverage for specifically black,
Asian, and indigenous populations,” says Maithy
Ta, DC, a member of ACA’s Board of Governors who practices in Kansas
City, Mo., with a wide range of patients.
Health
disparities can present in different ways depending on the patient, their
identity and their experiences. Bias and discrimination contribute to
disparities for people of color and LGBTQ+ people, among others. Lack of access to health care and adequate communication with
providers are disparities that impact many people, including those
in low-income populations. The link between higher levels of mental
health disorder and prevalence of chronic pain among some
populations also may impact the way they receive care.
Chronic
Pain: Complex and External Factors
Chronic
pain can be especially complicated for populations experiencing health
disparities, as pain can often be impacted by other external factors.
“Chronic pain is multi-faceted,” Dr. Ta explains. “As we look at not just
the physical causes, but the mental, emotional, and social aspects that
can all help shape a personal experience, we begin to realize how the
pain experience is much more complicated than the symptom itself. By
having poorer access to care, whether that’s due to geographic location,
insurance coverage, physician shortages, language, or cultural barriers,
chronic pain becomes almost inherent for demographics and populations
that face these health disparities, because they don’t have the resources
to combat the pain or take care of themselves.”
LaKia Brown, DC, CCSP, of Merrillville,
Ind., an ACA member who is active on the association’s Committee on
Equity, Diversity and Inclusion (CEDI), adds, “Those populations will
experience higher rates of illness, injury and death across a wide range
of health conditions.”
Dr.
Brown reiterates that while everyone should receive the same high quality health
care, people in socially disadvantaged populations who experience chronic
pain face additional barriers to care. “The first one would be convincing
doctors that their pain is real,” she says. “The implicit biases of
healthcare providers can contribute to the differences in chronic pain
intervention to certain cohorts of people such as [people of color] and
women.”
Logistical
Obstacles to Care
Another
challenge related to chronic pain intervention is the ability to access
care in the first place. Dr. Brown explains that things such as health
insurance coverage, the affordability of health care, having access to
transportation to and from healthcare facilities, and language barriers
can all contribute to a patient's difficulty accessing care. “[You have]
geographic barriers, lack of transportation, and then a shortage of
doctors who treat chronic pain,” she said.
Dr.
Ta adds that the issue of access goes beyond accessing health care
itself. “[There is] a lack of great resources that meet the patient where
they are,” she says. “Whether it’s the financial responsibilities they
have, or the needs for their children, or the limitations of the education
they received, it’s important to note that sometimes, the choice to live
a healthier lifestyle is not in the cards for certain individuals. Many
communities don’t have the options or materials readily available, so
even in times that the patient may be looking to make a healthy
change, they don’t have the know how or a good starting point to begin.”
Evidence
Supports a New Approach
While
many patients with common musculoskeletal conditions such as back pain
and neck pain might turn to over-the-counter and prescription pain medications
(such as opioids) for pain relief, research today supports the use of nonpharmacologic (non-drug) approaches as beneficial,
safer options to try first. In its 2022 Clinical Practice Guideline for
Prescribing Opioids, the CDC promotes “diverse approaches and varied pain
management solutions” and specifically encourages use of non-opioid/nonpharmacologic therapies as a first line of
treatment against subacute and chronic pain.3
“Chiropractors
are in the unique position that we are the experts on musculoskeletal
complaints, and in addition to that, we are portal of entry, meaning a
patient does not need a referral to see us as providers,” Dr. Ta says.
“As a chiropractor identifies the needs of a patient and the stressors
that have caused them chronic pain, whether it be physical or not, we can
create a truly collaborative and integrative model to help begin
eliminating these barriers to care and develop a strong team-based
approach to how we look at chronic pain and health disparities.”
Nevertheless,
access to non-drug therapies such as chiropractic services sometimes may
be limited due to availability and insurance coverage. “Nonpharmaceutical services such as acupuncture,
chiropractic and massage do help with chronic pain, but often they are
inconsistently covered by health insurance, or the health
insurance does not cover them at all,” Dr. Brown says. “When they’re
not covered at all, that makes those services only available to
those who can afford to pay out of pocket, so now we’re leaving a certain
population out in left field.”
Efforts
to Improve Access
The
American Chiropractic Association is working to pass legislation to increase
Medicare coverage of chiropractic services. In addition to helping seniors
and other beneficiaries gain improved coverage of chiropractic services,
a change in Medicare coverage of chiropractic could have an impact on
private and state health plans, as Medicare’s coverage often serves as a
template for others. The Chiropractic Medicare Coverage Modernization Act
(H.R. 1610/S.799) would improve Medicare beneficiaries’ access to the
chiropractic profession’s broad-based, non-drug approach to pain
management.
In
respect to raising awareness of the challenges encountered by
historically underserved communities, ACA and the CEDI have hosted
several educational courses and roundtables about health disparities for
ACA members. According to Dr. Brown, these sessions help increase
cultural competency among chiropractors and serve as a tool to better
educate doctors on implicit bias.
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