美国初级保健保障诊所中慢性非癌症疼痛管理中药物使用歧视与种族歧视的交集：对医疗保健系统和诊所层面变革的启示。

The intersection of drug use discrimination and racial discrimination in the management of chronic non-cancer pain in United States primary care safety-net clinics: Implications for healthcare system and clinic-level changes.

机构信息

Department of Community Health Systems, School of Nursing, University of California-San Francisco, 2 Koret Way, N505, San Francisco, CA94143-0608, United States.

Department of Humanities and Social Sciences, School of Medicine, University of California-San Francisco490 Illinois Street, 7th Floor, San Francisco, CA94143-0850, United States.

出版信息

Drug Alcohol Depend. 2023 Sep 1;250:110893. doi: 10.1016/j.drugalcdep.2023.110893. Epub 2023 Jul 7.

DOI:10.1016/j.drugalcdep.2023.110893

PMID:37459819

Abstract

BACKGROUND

Clinicians' bias related to patients' race and substance use history play a role in pain management. However, patients' or clinicians' understandings about discriminatory practices and the structural factors that contribute to and exacerbate these practices are underexamined. We report on perceptions of discrimination from the perspectives of patients with chronic non-cancer pain (CNCP) and a history of substance use and their clinicians within the structural landscape of reductions in opioid prescribing in the United States.

METHODS

We interviewed 46 clinicians and 94 patients, using semi-structured interview guides, from eight safety-net primary care clinics across the San Francisco Bay Area from 2013 to 2020. We used a modified grounded theory approach to code and analyze transcripts.

RESULTS

Clinicians discussed using opioid prescribing guidelines with the goals of increased opioid safety and reduced bias in patient monitoring. While patients acknowledged the validity of clinicians' concerns about opioid safety, they indicated that clinicians made assumptions about opioid misuse towards Black patients and patients suspected of substance use. Clinicians discussed evidence of discrimination in opioid prescribing at the clinic-wide level; racialized stereotypes about patients likely to misuse opioids; and their own struggles to overcome discriminatory practices regarding CNCP management.

CONCLUSION

While clinicians and patients acknowledged opioid safety concerns, the practical application of opioid prescribing guidelines impacted how patients perceived and engaged with CNCP care particularly for patients who are Black and/or report a history of substance use. We recommend healthcare system and clinic-level interventions that may remediate discriminatory practices and associated disparities.

摘要

背景

临床医生对患者种族和药物使用史的偏见会影响疼痛管理。然而，患者或临床医生对歧视性做法的理解，以及导致和加剧这些做法的结构性因素，尚未得到充分研究。我们从有慢性非癌性疼痛（CNCP）和药物使用史的患者以及他们在美国阿片类药物处方减少的结构性背景下的临床医生的角度报告了对歧视的看法。

方法

我们于 2013 年至 2020 年期间，在旧金山湾区的 8 家社区医疗诊所，使用半结构化访谈指南对 46 名临床医生和 94 名患者进行了访谈。我们采用改进的扎根理论方法对转录本进行编码和分析。

结果

临床医生讨论了使用阿片类药物处方指南，目标是提高阿片类药物安全性并减少对患者监测的偏见。虽然患者承认临床医生对阿片类药物安全性的担忧是合理的，但他们表示，临床医生对黑人患者和疑似药物使用者的阿片类药物滥用做出了假设。临床医生讨论了诊所层面上阿片类药物处方歧视的证据；关于可能滥用阿片类药物的患者的种族化刻板印象；以及他们自己在克服 CNCP 管理方面的歧视性做法方面所面临的困难。