Here’s Another Racial-Ethnic Disparity in Back Pain Care

Among Medicare beneficiaries with chronic low back pain and opioid use disorder (OUD), white patients were dramatically more likely to have received nonpharmacologic treatments such as physical therapy or chiropractic care than most other racial-ethnic groups, researchers found.

In particular, patients classified as Black or Hispanic received these nondrug alternatives at about half the rate for white patients, with adjusted odds ratios of 0.46 (95% CI 0.39-0.55) and 0.54 (95% CI 0.43-0.67), respectively, according to Patience Moyo, PhD, of Brown University in Providence, Rhode Island, and colleagues.

But it was also notable that use of nonpharmacologic pain therapies was low overall, at just 10.2% of patients in the population-based study, the group reported in JAMA Network Open.

“Although there is uncertainty about the individual and practitioner contexts that may explain our findings, historic racial and ethnic disparities in pain treatment appear to persist and are also specifically evident for chiropractic care in persons with OUD,” Moyo and colleagues wrote. The latter remark stemmed from the researchers’ finding that only 1.7% of Black patients in the study had seen chiropractors, versus 5.4% of whites; other minority groups also had chiropractic care at significantly lower rates than whites.

Moyo and colleagues weren’t especially surprised. “[P]ersons with chronic pain and OUD often have other undertreated comorbid substance use disorders, making them a population particularly susceptible to systemic and structural inequities,” the researchers observed. While published guidelines emphasize a major role for nonpharmacologic therapies for chronic pain, many previous studies have found that these are underutilized overall. A “racial and ethnic gap in pain care has been well documented for pharmacologic therapies,” the group noted; they suspected the same might be true for physical therapy and chiropractic.

To get real-world data, they drew on a 20% sample of original Medicare enrollees from 2016-2018 whose records indicated a new diagnosis of chronic low back pain and comorbid OUD. They then examined claims for physical therapy or chiropractic services both before the pain episode and within a 3-month period after diagnosis. In total, just under 70,000 individuals qualified for inclusion.

The sample’s racial-ethnic distribution was as follows:

• American Indian or Alaska Native: 1.1%
• Asian or Pacific Islander: 0.6%
• Black or African American: 14.2%
• Hispanic: 5.9%
• Non-Hispanic white: 77.0%
• Other/unknown: 1.2%

Unadjusted data showed that, within 3 months of diagnosis, 10.8% of white patients had received physical or chiropractic therapy, versus 7.3% of Black patients, 9.0% of those classed as Hispanic, 7.7% of the Native American group, and 13.7% of those with Asian/Pacific Island ancestry. Physical therapy was given more often than chiropractic care by wide margins in all groups except for white and Native American individuals.

After adjustment for potential confounders such as sex and age, use of physical/chiropractic care prior to the new episode, geography, and social determinants of health (as identifiable from Medicare data), the disparities widened for Hispanic and Black patients. Receipt of nondrug therapy within 3 months did not differ significantly between whites and Asian/Pacific Islanders, but the latter group’s small numbers and resulting broad confidence intervals made that hard to interpret.

Moyo and colleagues also looked at median time to first receipt of nondrug therapy, and that, too, showed significant differences between groups. For white patients, it was 5.0 months, as compared with 13.0 months for Black patients, 8.5 months for Hispanic persons, 9.0 months for Native Americans, and 6.0 months for Asian/Pacific Islanders. For all groups, the interquartile range’s upper bound was about 3 years, another indicator of how infrequently such services are utilized.

Of course, these data did not permit solid conclusions as to the reasons for the disparities. Moyo and colleagues speculated that their findings reflect “barriers in accessing and using PT and chiropractic care for chronic pain that are compounded by the intersectional nature of racism and OUD-related stigma.”

They continued, “Harmful biases about racial and ethnic minority groups with OUD are reinforced in health care settings, resulting in these groups receiving fewer referrals to pain specialists and consequently fewer opportunities to receive nonpharmacologic treatments compared with non-Hispanic white individuals.”

That, they argued, makes it all the more important for clinicians to pay attention to the CDC’s 2022 guidelines on opioid prescription that endorse evidence-based medical therapy for OUD, as well as to consider nonpharmacologic pain treatments.

Limitations to the study included the reliance on Medicare records, lack of evaluable data on other nonpharmacological treatments such as cognitive behavioral therapy, and probable inconsistency in OUD diagnoses. Also, it is possible that some patients paid out of pocket for nonpharmacological therapies that would then not be reflected in the Medicare data.

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