Health Disparities in Access to Nonpharmacologic Therapies in an Urban Community

Abstract

Objective:

The overuse of prescription opioids for chronic pain is recognized as a public health crisis. Yet, poor access to nonpharmacologic treatments is the norm in low-income, racially and ethnically diverse patients with chronic pain. The main objective of this study was to understand how chronic pain impacts low-income individuals with chronic pain and their communities from multiple perspectives.

Design:

This was a qualitative study using a Science Café methodology.

Setting:

The Science Café event was held at an urban community center in Boston, MA.

Subjects:

Inclusion criteria included the following: having the ability to attend the event, being at least 18 years of age or older, and participating in English.

Methods:

Data were collected through self-reported questionnaires and audio or video recordings of two focus groups. Quantitative and qualitative data were analyzed with SAS 9.3 and NVivo 10.

Results:

Thirty participants attended the Science Café event. The average age was 45 years, 77% reported as female, 42% identified as black, and 19% as Hispanic. Participants identified themselves as either patients (46%) or providers (54%) to the chronic pain community. Our forum revealed three major themes: (1) nonpharmacologic options for chronic pain management are warranted, (2) larger sociodemographic and contextual factors influence management of chronic pain, and (3) both patients and providers value the patient-provider relationship and acknowledge the need for better communication for patients with chronic pain.

Conclusions:

Future research should consider identifying and addressing disparities in access to nonpharmacologic treatments for chronic pain in relation to underlying social determinants of health, particularly for racially and ethnically diverse patients.

Introduction

In 2015, ∼56% of adults in the United States reported having daily chronic pain in the last 3 months.¹ This prevalent health condition is complicated by multiple socioeconomic factors, such as race/ethnicity, income levels, and neighborhood.² Health care disparities in chronic pain experience and treatment tend to correlate with low-income and racial/ethnic categories.^3

–6 Patients in the lowest wealth quartile are 58% more likely to report they have chronic pain compared to those in the wealthiest quartile; both non-Hispanic blacks and Hispanics also tend to deem their pain levels more severe relative to non-Hispanic whites (8.8% and 8.3% vs. 4.9%).⁷ While there are various pharmacologic pain treatments available, the majority of patients report only mild-to-moderate relief.³ This article reports the findings of a Science Café event attended by patients with chronic pain and various stakeholders (e.g., health care providers [HCPs], family, friends, and other community members) discussing chronic pain's effects on the community and access to nonpharmacologic treatments.

Today, prescription opioid abuse is recognized as a public health threat in the United States,⁸ and is associated with a rise in fatal opioid overdoses.^9,10 In addition, the high prevalence of chronic pain and opioid abuse is especially apparent in low-income communities and urban areas. At the same time, HCPs and their patients are challenged to choose the most affordable, accessible, effective, and safest treatments for the complex illness of chronic pain. Patient-provider communication may suffer not only because of time constraints but also because of new prescribing requirements and laws, patient preference for treatment options, and the stigma of chronic pain and opioid use.^{5,11

–17}

Integrative medicine (IM), which focuses on nonpharmacologic techniques, offers a different avenue to manage chronic pain by considering the full range of influences that affect a person's health.¹⁸ Specifically, IM chronic pain treatment involves multimodal interventions—including conventional and complementary approaches—to personalize care and improve overall health status.¹⁸ Prior IM studies have shown reduction in pain, increased function, and enhanced quality of life.^19

–24 Despite these promising results, utilization of such modalities differs across patients with chronic pain by selected characteristics: race/ethnicity, education level, poverty status, and health insurance status.^25,26

Few qualitative trials have focused on perspectives of patients with chronic pain and the effects of pain on their individual and family members' lives. None to date has examined the perspectives of multiple stakeholders.^27,28 Most qualitative researchers have either reported only one perspective or recruited both patients and providers to offer feedback in separate groups.^17,29,30 By holding a Science Café, we brought together stakeholders from different backgrounds in the Boston community to discuss how chronic pain, opioid use, and experiences with nonpharmacologic therapies impact both individual and community levels. Our qualitative study is the first to (1) involve predominantly racially and ethnically diverse patients (e.g., African American and Hispanic) affected by chronic pain and (2) include various stakeholders within the same focus group in an urban setting.

Methods

Design

Science Cafés are live events that encourage conversation, debate, and dialogue between the scientists and the public.³¹ In this case, our Science Café aimed to provide a public forum for discussing the Boston community's experience with chronic pain, as well as to gain information about treatment preferences (e.g., nonpharmacologic and medication) for chronic pain, and their effects on individuals and families from the perspectives of various stakeholders. The Science Café was a one-time, 2-h long event held on a weekday evening at an urban community center.

This study was approved by the Boston Medical Center (BMC) Institutional Review Board.

Recruitment and enrollment

Recruitment flyers were placed in primary care outpatient clinics, community health centers, and community organizations throughout the Boston area. By e-mail or telephone, research assistants (RAs) contacted the leaders of local community organizations to either invite them to participate and/or ask them to inform their members about the event. Stakeholders were also encouraged to contact other members in their family or neighborhood to attend the event. After their contact information was provided by stakeholders, RAs contacted potential participants by telephone or e-mail to further explain the study, screen for eligibility, and obtain informed consent. Other people who were interested also reached out to the RAs directly by telephone or e-mail, were screened for eligibility, and gave informed consent. Inclusion criteria included the ability to travel to the community center on the designated date, older than 18 years of age, and ability to provide informed consent and participate in the Science Café discussion in English. Participants provided verbal consent to the study over the telephone. Upon arrival to the event, participants received a paper copy of the consent form, were asked to consent for audio and/or video recordings of the focus groups, and completed a brief survey.

Implementation of Science Café

Upon arrival at the event, attendees were asked to fill out a brief survey, invited to share a simple meal, and asked to write on large posters boards with the prompt, “What does chronic pain mean to you?” Next, the principal investigator (PI) presented an overview of chronic pain in the Boston area. Participants were then invited to join one of two focus groups based on their consent: focus group 1 with audio and video recording, and focus group 2 with audio recording only. Groups were moderated by experienced qualitative researchers (a medical anthropologist or an occupational therapist) using a semistructured guide (Appendix 1).

Data collection

The following information was collected through self-reported questionnaires: demographics (including age, sex, race, and ethnicity), relationships to person with chronic pain (e.g., self, family member, HCP, volunteer, community member), reasons for attending the Science Café, how participants heard about the event, and their chronic pain levels. Data were collected from both patients and providers. Providers were broadly defined as anyone who had a connection to the chronic pain community through employment or volunteer work.

Data analysis

Descriptive statistics were used to analyze survey information. Means and standard deviations as well as frequencies and percentages were calculated for demographic characteristics. Comments from participants for specific questions were categorized and summarized into numbers. Fisher's exact test was used to test the association between different variables, which accounted for the small numbers (<5) in table cells. All quantitative analyses were conducted using SAS 9.3 software.³²

One RA transcribed both groups' transcripts from audio recordings. Two RAs trained in qualitative methodology independently coded both transcripts using NVivo 10 qualitative data analysis software.³³ The initial coding pass used a priori codes derived from the moderator guide. Using modified grounded theory, coders also inductively generated new codes. After transcripts were coded, the two RAs and PI reconciled the codes and resolved any difference by consensus and transcript review. The PI was not involved in the initial coding, and primarily served to resolve differences found between the two initial coders. Three RAs viewed the video recording of focus group 1 to assess nonverbal agreement (i.e., nodding) and dissent (i.e., head shaking) to participant responses during the discussion. From audio and video reviews, affirmation categories were created: low affirmation was defined as two participants or less agreeing to a response or statement, medium affirmation was defined as three to four participants, and high affirmation was defined as five participants or greater.

Coders identified high density codes and combined similar codes into categories, which were shared with the research team. Larger themes were created and defined, including (1) experiences with pharmacologic and nonpharmacologic treatment, (2) intersection of chronic pain with other health determinants, and (3) relationships between patients and providers.

Results

Quantitative results

Out of 40 people contacted for the event, 30 participants attended the Science Café event. Out of 26 participants who filled the surveys, the mean age was 45 years of age (range: 26–74 years) and 77% reported as female. Forty-two percent identified as black; 16% as white; 23% as other races; and 19% as Hispanic (Table 1).

Table 1.

Demographics of Participants in the Science Café

	Total (N = 26)	Patients with chronic pain (n = 12)	Providers with chronic pain (n = 9)	Providers without chronic pain (n = 5)
Age^a (years)	45.3 (14.4)	46.4 (11.4)	55.0 (14.2)	29.2 (3.5)
Sex, n (%)
Female	20 (77)	9 (75)	8 (89)	3 (60)
Male	6 (23)	3 (25)	1 (11)	2 (40)
Race, n (%)
Black/African American	11 (42)	6 (50)	5 (56)	0 (0)
Caucasian/White	4 (15)	0 (0)	0 (0)	4 (80)
Other	6 (23)	4 (33)	1 (11)	1 (20)
Did not answer	5 (19)	2 (17)	3 (33)	0 (0)
Ethnicity, n (%)
Hispanic	5 (19)	3 (25)	1 (11)	1 (20)
Non-Hispanic	19 (73)	8 (67)	7 (78)	4 (80)
Did not answer	2 (8)	1 (8)	1 (11)	0 (0)
Chronic pain, n (%)
Do you currently have or ever had chronic pain?	21 (81)	12 (100)	9 (100)	0 (0)
Do you have family member(s) with chronic pain?	17 (65)	9 (75)	7 (78)	1 (20)
Do you work for an organization that interacts with people with chronic pain or have any connection to the chronic pain community?^b	14 (54)	0 (0)	9 (100)	5 (100)
Provide patient care	7 (50)		3 (33)	4 (80)
Work at nonprofit organization	5 (36)		4 (44)	1 (20)
Other^c	2 (14)		2 (22)	0 (0)

Reported as mean (std); remaining values in the table are reported as n (%).

One answer can be applied to multiple categories.

Other includes the following: “research purposes” and “unknown.”

Participants either had personal experiences or familiarity about others' experiences with chronic pain. Eighty-one percent reported having a history of chronic pain, and 65% reported having family member(s) with chronic pain. Fifty-four percent reported themselves as providers to the chronic pain community. Of those providers, 64% reported a current or past experience with chronic pain. In regard to the relationships between different variables, having chronic pain was significantly related to having family member(s) with chronic pain (p = 0.03). In addition, being a provider was significantly associated with having chronic pain (p = 0.04).

Reasons for attending the event are presented in Table 2; specific participant comments can be found in Appendix Table A1. Thirty-eighty percent of participants reported that they wanted to learn more about chronic pain, while 15% were seeking help or alternative care for chronic pain. Appendix Table A2 provides information on how participants heard about the Science Café event.

Table 2.

Reasons for Attendance and How Participants Heard About the Science Café

	Total ^a (N = 26)	Patients with chronic pain (n = 12)	Providers with chronic pain (n = 9)	Providers without chronic pain (n = 5)
Why did you come to the Science Café?^b, n (%)
Interested/get information	10 (38)	7 (58)	2 (22)	1 (20)
Dealing with pain/get help or alternatives	4 (15)	3 (25)	1 (11)	0 (0)
Seek social connections	4 (15)	1 (8)	1 (11)	2 (40)
Invited by others/saw the advertisement	3 (12)	1 (8)	2 (22)	0 (0)
Providers/volunteers want to be involved	4 (15)	0 (0)	2 (22)	2 (40)
How did you hear about the Science Café?, n (%)
Heard from study at BMC	11 (42)	4 (33)	4 (44)	3 (60)
Friends/others	7 (27)	4 (33)	2 (22)	1 (20)
E-mail	3 (12)	1 (8)	1 (11)	1 (20)
Other programs	2 (8)	1 (8)	1 (11)	0 (0)
Physical advertisement (e.g., flyer, poster)	1 (4)	1 (8)	0 (0)	0 (0)

Two participants (8%) did not answer both questions, which were counted as missing.

One answer can be applied to multiple categories.

BMC, Boston Medical Center.

Qualitative results

Based on our analysis, we focused on three overarching themes: (1) nonpharmacologic and pharmacologic treatments for chronic pain, (2) contextual factors (health, financial, and social) affect access to chronic pain treatment, and (3) patient and provider perspectives on chronic pain in the health care system. Quotes listed in Tables 3 –5 were generally met with medium-to-high affirmation, noted by verbal agreement (i.e., “yea(h)”) and/or body cues (i.e., nodding).

Theme 1: Nonpharmacologic compared to pharmacologic management for chronic pain

Participants consistently discussed both pharmacologic and nonpharmacologic methods to manage or treat chronic pain (Table 3). Specific nonpharmacologic methods included the following: herbals, yoga, water (aerobics) therapy, exercise, relaxation, body scans, physical therapy, meditation, acupuncture, and home remedies.

Table 3.

Nonpharmacologic and Pharmacologic Methods to Chronic Pain Management

Nonpharmacologic methods	Pharmacologic methods
Nonpharmacologic therapies help manage chronic pain.	Pain medication is not a viable long-term solution to the treatment of chronic pain
Combinations of (nonpharmacologic) methods are used to manage pain^a Participant 1: “So that's why sometime[s] I jump from some exercises for physical therapy… yoga, meditation, relaxation, body scans, that help[s]… I go back to the bag of trick[s], and every time I feel something different, I try something new.” Provider A: “I work[ed] for the (Fitness Center) for about a year now… I am also here working as our Chronic Diseases coordinator so I run different exercise and lifestyle programs for adults living with chronic illnesses… I see the benefit that a lot of our participants get from our exercise programs and lifestyle change… when they are living with chronic pain.” Participant 3: “I want to do a holistic approach to taking pills.”	Pain medication has limited benefits^a Participant 4: “I've been given muscle relaxers, regular pain pills, narcotics—they work to an extent, but then when you get to narcotics, the highest narcotic, there's nothing further that you can go…” Participant 8: “…and then there are those people who think that you get rid of it through this [medication], that, and the other and then there's no one solution for um, when you're dealing with severe chronic pain. There's no one solution so it does, it feels like this prison.”
	Still in pain after using pain medication^a Participant 1: “I tried everything and it's like nothing's working…” Participant 6: “I've tried practically everything [in medication] and it seems not to work. I need other ways about going about it.”
	Medications have unwanted side effects^a,b Participant 5: “The reason I don't like to take medication is because I don't like to have side effects… I don't want to mix up too much different medications that can have a reaction.” Participant 7: “Once we just had a little better care, and not take pills for chronic illness or chronic pain, because that's doing nothing but just make another zombie… When I started taking the pills for my chronic illness, it made me so sad, so depressed, so like, not wanting to do anything. It was killing me more than when the chronic [pain].”
Participants generally report satisfaction with nonpharmacologic techniques.	Participants generally report concerns about medication addiction.
Successes with nonpharmacologic methods^a Participant 2: “I participated in integrative medicine a year ago. And it was probably the calmest time of my life, and I wasn't in pain. I wasn't in pain the whole time. And then I was taking fish oil gummies at the same time, and I was just like, I kept telling my mother, ‘I'm not in pain. I'm not in pain.’ She's like, ‘That's good, that's good!’… So it was an education piece, meditating, we learned self-care skills, everything you were supposed to learn you learned. How to eat better. I mean that's been my forte all the time, how to have a change in my background. But, if I continue and I go back to that, I know my pain is gonna be more in check.”	Addiction from medication is undesirable and concerning^b Participant 14: “It's like hard to get off it. Your body's messed up, you've got withdrawal and you got all kinds of issue.” Participant 15: “Because it's sort of the fact that Band-Aids make me worse than before I started because if you take the um, oxycodone and um, morphine, and what happened when I found out is that the only thing that happens is that you're killing your own body's ability to make [endorphins], which means that whenever you're in a situation where you cannot get to a doctor, you can't get any painkillers, what are you gonna do then?”
Nonpharmacologic methods help both physically and mentally to manage pain^b Participant 16: “…yoga is one of the most wonderful things that ever happened. Not only does it help physically, emotionally, yoga takes away all of the pain.” Participant 17: “So you develop trust and they, with the yoga, they have been able to handle my pain because they train you how to deliver your mind, how to move thoughts out to clean them out. Besides what you have learned, and you have the, any kind of religious of ways to do things, that I also put together.”	There is a concern about the stigma of addiction associated with medication^a Participant 8: “Um, because people have so many different ideas about what it's like to live in chronic pain. I've been in chronic pain most of my life and you know, it just amazes me how people say that you don't need the medication, it causes you to be addicted. Of course it does, but there are times when you have to have it.”

All quotes were from patients with chronic pain except where indicated.

Quotes listed were met with medium affirmation (three to four persons in agreement).

Quotes listed were met with high affirmation (five or more persons in agreement).

Generally, participants positively endorsed nonpharmacologic therapies for chronic pain management. Specifically, they observed and shared the benefits of using these types of methods: “I participated in integrative medicine… and it was probably the calmest time of my life, and… I wasn't in pain. I wasn't in pain the whole time.” Two participants mentioned that yoga helped to manage their chronic pain both physically and mentally.

On the other hand, some participants characterized pharmacologic methods negatively due to their limitations and their associations with addiction. Limitations, including medication ineffectiveness and unwanted side effects, appeared to outweigh the benefits of pain medications, with one participant even commenting that they “tried everything and it's like nothing's working.” When explaining perceptions of addiction, participants reported concerns in becoming addicted to the medication itself as well as the stigma of addiction that may be associated with taking medication. There was no explicit mention or discussion of nonopioid pharmacologic therapies.

Theme 2: Financial and social factors that are implicated in barriers to care

Participants also highlighted factors beyond direct therapy that impacted their chronic conditions (Table 4). Participants noted barriers to accessing and receiving adequate care, including nonpharmacologic therapies for chronic pain. As one person phrased, “It's just so many different things… those are all really great ideas. They're really great approaches to helping people cope with chronic pain, but if you can't really access them, they don't help.” Several participants mentioned difficulty in obtaining such resources, making them less able to properly manage their care. Similarly, one provider offered their experience as part of a care coordination program to emphasize the issue of accessibility: “…if we talk to someone about how to get to a food pantry where there's food access if you know, you can't actually access that service if you're in chronic pain and just the barriers of trying to get basic needs met while experiencing chronic pain.”

Table 4.

Health, Financial, and Social Factors That Affect Chronic Pain or Are Affected by Chronic Pain

Factors	Quotes
Both nonmedical needs and health resource challenges can interfere with chronic pain management.	Nonpharmacologic therapies (e.g., healthy food and integrative medicine) are available but not as accessible^a Participant 11: “Like, you can try to do things health wise, like programs you might have mentioned, but if you overdo it then you throw yourself back… it's just so many different things, like the acupuncture or the massage therapy, those are all really great ideas, they're really great approaches to helping people cope with chronic pain, but if you can't really access them, they don't help.” Provider F: “I work at the (Community Health Center) and [Provider E] and I are both part of this care coordination program. So we help people with patients at the health center in a non-medical need; so housing, food insecurity, and in terms of chronic pain, thinking about like what does it mean if we give someone, if we talk to someone about how to get to a food pantry where there's food access if you know, you can't actually access that service if you're in chronic pain and just the barriers of trying to get basic needs met while experiencing chronic pain…”
	Obtaining adequate health resources and insurance to maintain one's health is difficult^b Participant 15: “I'm not supposed to be pushing myself in this, this chair… unfortunately, MassHealth's attitude is that you only get one wheelchair a year, and since mine got stolen… I have been fighting that in court to get a new chair… now I'm petrified because if I lose my arms I have no idea how I'm gonna take care of myself… If you inspected the chair, if you did your job, you wouldn't have given me this chair.” Participant 11: “Or you might go through something if you do get meds; the meds don't work for you, or they work for you for a minute, but then you can't obtain the meds because insurance wise it's no longer accessed… you can't have access to anything anymore.”
	Work or financial insecurity can accompany chronic pain^a,b Participant 9: “I'm a carpenter… I go to (Hospital) for a lot of my health issues. Uh, the work that I do is very physical and a lot of us, we're not gonna make it to retirement, you know.” Participant 11: “Um, you can get yourself involved in things like eating healthy, the same cycle is kinda there if you're broke because you're in chronic pain, you can't work what you used to work. Like the healthier foods are more expensive, so they're not easily obtainable.”
	Community resources (e.g., housing) are important considerations for chronic pain management^b Provider E: “It's so interesting because if you know, what we see sometimes when someone needs help finding some specific resource like housing that affects, you know, their situation and other areas of their life.”
Chronic pain impacts friend and family relationships.	Chronic pain patients have limiting experiences with their family and friends due to the nature of their condition^a Participant 7: “Yea, ‘cause my mom, she deals with it, it makes me sad, and I'm already dealing with a chronic illness that I'm going through too. And um, a little pain here and there too. They call it chronic… I want to say it's chronic that I'm going through a little something too, giving me headaches and stuff… so, her dealing with her chronic pain on a day to day basis and it affects me because I'm dealing with my stuff, I'm dealing with me transitioning, I'm dealing with me having these issues, having to deal with my mom everyday gets kinda hard… So, it just sucks. And nobody wants to see like your family member suffer like that all the time. So it affects, it affects you. If you have kids, it affects your kids. If you have like your family, it will affect them.” Participant 12: “Sometimes that—you have to get up and go to work with all of this. You got to function with your children and your grandchildren. You have to… for life in that type of pain and then you have to deal with medical people that meet at any given point based on, you based on other people and their actions, right? Or inactions. And it's just emotionally draining, um, to you and to your family, to everybody.”
Chronic pain impacts friend and family relationships.	Supportive social relationships can help patients manage chronic pain^b Participant 3: “Well what did work for me is having a strong support system, so like family, friends and my rock… they've been helpful with me getting through the next step and building a strong… foundation.” Participant 13: “I go to an all-women's gym. And it's like the women, they're so like well bonded with each other… so I have all types of support from all different ages.”

All quotes were from patients with chronic pain except where indicated.

Quotes listed were met with medium affirmation (three to four persons in agreement).

Quotes listed were met with high affirmation (five or more persons in agreement).

Nonmedical needs included work/financial security, health insurance, and community resources. Other factors discussed frequently included health supply challenges, incomplete fulfillment of nonmedical needs (housing and healthy food), and relationships with family, friends, and HCPs.

Theme 3: Patient and provider perspectives on chronic pain in the health care system

Comments from both patients and providers reflected commonly identified subthemes on chronic pain within the health care system (Table 5).

Table 5.

Patient and Provider Perspectives on Chronic Pain Management in the Health Care System

Theme	Patient perspective	Provider perspective
Theme 1: Chronic pain is not well understood or easy to treat.	Providers have difficulty understanding when patients experience chronic pain^b Participant 12: “But my thing is sometimes when the doctor—like say you might have chronic pain… I really can't tell if you have chronic pain. But now, if I'm like, you know, you get up and if um, you know, how they give us a physical or something like that, they still can't tell if you really in chronic pain. Now maybe they have to put you in to scan you or something—” Participant 11 (in response to above quote): “—they still can't tell from that either! It's you—It's usually use of history will speak to the fact that you have chronic pain because there's a paper trail, there's documentation. That's when they finally start turning their heads, ‘Ok, it's chronic pain in addition to XYZ.’” Participant 4: “Cause I think that's the thing is that we try to describe what's going on because there's so much and it's not understanding pain that they're used to treating. They don't care of the in betweens so they give you whatever.”	Chronic pain is difficult to treat^b Provider B: “I think chronic pain matters because um, it's a really complicated illness and we don't have good solutions for it… we know how to treat high blood pressure and diabetes… we don't know how to treat chronic pain so we're not treating chronic pain well, and it doesn't have the respect that it should have and the patients don't have the respect that they should have.”
		More information is needed on identifying treatments to help patients with chronic pain^a Provider C: “I'm here to get more information for people coming from the center and who are suffering with chronic pain.” Provider D: “I'm a physical therapist… they got me interested in integrative medicine as a whole and has also let me lead my practice to try out and find other ways of helping patients with their pain.” Provider B: “I think there's a lot of room and I also think it's a fascinating disease because I think there's a lot of potential for really good solutions when something gets done about it.”
Theme 2: Both chronic pain patients and related providers value the relationships they have with each other.	Patients want providers to hear their voices^b Participant 7: “I kinda wished we had someone, that we have doctors that are treating these among patients. I wish that we could talk to them…about what's going or something, ‘cause it is something that is hurting us.” Participant 11: “I think it's, like she said, [I want the doctor] to listen to you, to understand you, to not count you as a number. Like, they have a lot of people. There's a whole bunch of things going on. But like, to really acknowledge what's going on. It's, it's challenging. It's no one particular route to get there.”	Providers' primary responsibility is to listen to their patients^b Provider D: “I just want to say one thing from a provider perspective… I think one of the biggest things is that you're right, our primary responsibility is to listen. The one thing that I do like doing is something I've changed over practicing for 12 years, and is something that I've changed is that, ‘What's the primary goal of the patient?’”
	Patients desire relationships with their providers^b Participant 2: “I think it's the relationship sometimes, too, that helps to bridge the gap because if you're comfortable with your doctor, they gonna talk more, they gonna listen more.” Participant 10: “My doctor who I finally built a relationship over the last year left um, because he was a resident. And I trusted him and um, I was able to—he understood me. When I came to my appointment he told me he'd be gone in a month, I just haven't made an appointment because I have not, I don't want to go through the process again. It's hard, it's tiring, right?”
	Providers make chronic pain patients feel ashamed of having pain^a Participant 11: “We're all human beings. Sometimes, you get lost in the sauce where you're not treated like a human being. An animal, you get sad. You just feel uncomfortable or you just get tired. It gets taxing emotionally and physically and um, you almost wanna throw down the towel.”
Theme 3: Types of stigma that affect the quality of care for chronic pain patients (addiction, narcotic use, homelessness, and race).	Addiction^a Participant 8: “Sometimes you know, I'm dealing with chronic pain and you're just looking for a solution, you're not looking for medication and soon as you come in, ‘I'm not giving you any medication’, you know? And then maybe you're at a 10 when you need medication and you can't get medication because of situations with other people who are dealing with addiction and um, and people abusing um, meds, so you just get caught up…”	Providers acknowledge the stigma that comes with chronic pain^a Provider E: “So it's kinda like chronic pain… sometimes it's just thought of something physical or all in your head, but it affects all areas of life, so. Discussions like this will help bring down those types of stigmas, um, just by sharing different experiences.”
	Opioid use^b Participant 10: “You know, it's frustrating, it really is frustrating, for people to um, to come out with like um, the whole [opioid] contract thing that they use now in the clinics, you know, where 6–7 people come up with this idea that if you don't do this, this and this, then you get cut off from your medication, right? They don't even know who you are, or what you have.” Participant 12: “Yup, I say, ‘I'm in chronic pain’. You know automatically, doctors gonna be looking at me like that, you know what I'm saying? And even though, even though my doctor knows that I have had something wrong for 14 years, it don't matter. ‘Cause the damages are already still in the computer.”
	Homelessness^b Participant 15: “And they won't give them medication… I've seen a guy break his arm and because he's known for being homeless, they would not give him any pain medicine whatsoever. Nothing… You can go to certain hospitals and they know you're homeless, they don't even care what's going on about you.”
	Race^b Participant 7: “I think that chronic pain for us—well, for our community is very bad and we do get treated, you know, a little different from um, being African American. We do get treated a little different from Caucasians. I just wish we had better care for us African Americans, and even for everybody.” Participant 4: “The other thing is that we talked about race and culture in terms of doctors administering treatment or supporting. I also think that it's very important that people… are also listened to… equally. ‘Cause that group of people is also being underserved.”

Quotes listed were met with medium affirmation (three to four persons in agreement).

Quotes listed were met with high affirmation (five or more persons in agreement).

The first subtheme both patients and providers highlighted was the notion that chronic pain is not well understood or easy to treat. Patients felt that current HCPs had difficulty understanding when their patients were experiencing chronic pain and “can't [even] tell if you have chronic pain.” Some participants affirmed and agreed with that statement. Several providers added that more information was necessary to improve chronic pain treatment and management.

The second subtheme both patients and providers shared was the importance of the patient-provider relationship in treating chronic pain. Many patients explained that they only wanted to be listened to and have a voice when interacting with their doctors. Relatedly, one provider shared that their “primary responsibility is to listen” to their patients, which was met with responses of verbal agreement by patients in the same group. Other patients mentioned their desires to have actual, trusting relationships with their providers.

The third subtheme both parties discussed was the different types of stigma that affected the quality of health care for chronic pain patients. Specifically, these stigmas pertained to providers' assumptions of characteristics of chronic pain patients and the subsequent impact those perceptions had on the quality of care. Types of stigma identified by patients included addiction, narcotic use, homelessness, and race. Some patients discussed being denied medication for chronic pain due to the stigmas of addiction and recurrent narcotic use; other patients commented on their personal statuses of homelessness as reasons for receiving inferior care. In addition, specific comments were mentioned in relation to race; for example, one patient who identified as African American explained that in terms of chronic pain care, “we do get treated a little different from being African American… we do get treated a little different from Caucasians.”

Discussion

Patients, providers, and community stakeholders attending a Science Café elucidated three major themes: (1) nonpharmacologic methods to managing chronic pain are warranted, (2) larger contextual factors of health (i.e., individual, financial, and social) should be considered in care, and (3) both patients and providers agree that improved communication about chronic pain treatment and management is necessary.

Participants were interested in using nonpharmacologic methods to manage chronic pain due to concerns about pharmacologic treatments. These views are consistent with several qualitative studies, which have shown that patients found the use of prescription medication (i.e., opioids) as the primary solution to chronic pain management to be unnecessary and unwanted.^34

–38 Patient concerns about addiction to pain medications offer a new contribution: patients are not only concerned with the physical effects of being addicted to pain medication but also concerned about the stigma of addiction that may be associated with taking pain medication. As such, nonpharmacologic therapies may provide another option to relieve these concerns. However, despite strongly expressed interest in such modalities, patients of lower socioeconomic status (SES) may have more difficulties accessing these resources from a logistical and financial standpoint.³⁹ Often, these resources are not located in low-income neighborhoods or readily available after business hours. While several private insurances are starting to cover other therapies (including acupuncture, massage, and chiropractic),⁴⁰ many low SES patients tend to not have adequate coverage or disposable income to spend out of pocket.⁴¹ Research is needed to understand the role of nonpharmacologic options for lower SES patients in reducing the risk of opioid overdose. Nonetheless, participants did not completely deny the role that pain medication played in treatment regimens for chronic pain.

Although nonpharmacologic treatments for chronic pain are warranted, other factors beyond direct treatment should be considered in the context of chronic pain. Using Maslow's Hierarchy of Needs as a theoretical framework,⁴² we identified food insecurity, unstable housing, and lack of individual health necessities (i.e., insurance and assistive devices) as factors impacting adequate care for our patients. Lower SES individuals are more likely to experience food insecurity, live in public housing, and be diagnosed with chronic conditions.^43
–45 This may suggest that lower SES patients are financially constrained in accessing therapy options, as they may prioritize fulfillment of survival needs (i.e., food, shelter). However, more research is needed to study the complex relationship between these multifactorial influences and their impacts on chronic pain management.

The patient-provider relationship is an essential component of the health care experience; studies document disparities in the quality of communication, especially among low SES, racial, and ethnic patients.^46
–48 In our study, we found that patients were less likely to perceive their providers positively because of their race and/or ethnicity; White-Means et al. confirmed similar findings.⁴⁸ There are also several types of stigma that can affect the patient-provider relationship. For example, stigmas of addiction (specifically, addiction associated with prescription opioid medication use) and homelessness have an impact on the chronic pain experience. Several participants expressed fear of being perceived by their doctors as an addict due to their regular prescription medication use; Hurstak et al. confirmed similar findings.¹⁷ To address the need for improved care through open, effective communication between providers and patients with chronic pain, additional training may be required so that providers are more knowledgeable about chronic pain not only as a medical condition⁴⁹ but also as a chronic condition and a socioeconomic experience prone to inadequate care.

The main strength of using the Science Café approach lies with the setting. By using a community-based focus group and shifting the context away from a medical setting,⁵⁰ we created a friendly atmosphere that was inviting to all participants regardless of their backgrounds. As the study took place in a community center, the event was made accessible to patients with chronic pain, their families, and other stakeholders. This allowed both participants and the study team to stimulate discussion and engagement through informal communication processes.

Limitations to our study include a small sample size and specific inclusion criteria. Participants were persons who could attend a Science Café on chronic pain at a specific scheduled date and time. The Science Café was also conducted in English, excluding participants who are not fluent in English. For participants who identified as patients, being in the presence of HCPs may have prevented them from speaking freely (and vice versa). In addition, participants may have responded to moderators' questions favorably, knowing that this was a research study and that they were being reimbursed for their participation.

Conclusions

Findings from our qualitative study strongly suggest that there is room to improve the health care experience for chronic pain patients, particularly those who are racially and ethnically diverse and/or low income. These patients are interested in nonpharmacologic modalities as a substitute or an accompaniment to prescribed pain medications. Given the valuable feedback garnered from numerous stakeholders involved in chronic pain, future studies should also consider inviting multiple perspectives. The emergent state of the opioid crisis prompts further research to identify and mitigate disparities of chronic pain care in relation to the full range of physical, emotional, mental, social, and environmental influences that affect health.

Footnotes

Acknowledgments

We would like to thank Joann Donnelly for providing the community space for the Science Café event, and Brendan Ross for technical edits. This work was supported by the Aetna Foundation (Grant no.: 6003433).

Author Disclosure Statement

No competing financial interests exist.

Appendix 1

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