A multi-level examination of the influences of racism on cancer pain equity

PROJECT SUMMARY The goal of this proposal is to develop a comprehensive understanding of the scope and key drivers of racial and ethnic disparities in opioid management across the cancer care trajectory, and to use this understanding to design a multi-level cancer pain equity intervention for future testing. Pain is a common and disabling symptom

of cancer, affecting half of patients on treatment, one third of survivors, and over two thirds of those with advanced disease. Despite their risks, opioids remain a cornerstone of managing cancer pain. Cancer patients of color receive less potent analgesics than White patients, and consequently experience more severe and

debilitating pain. Yet, there have been few population-based studies of opioid inequities among cancer populations and much remains unknown about its magnitude and scope, the patients and communities most affected, and the relative influence of physician, practice, health system, and neighborhood factors.

In preliminary work examining over 300,000 Medicare beneficiaries with poor prognosis cancers, we found that Black and Hispanic patients received fewer and less potent opioids than White patients, and Black patients were more likely to undergo urine drug screening near the end-of-life. Disparities disproportionately affected

Black men and those living in urban areas, underscoring the need to better understand the neighborhood factors and subpopulations most impacted. Here we propose a comprehensive analysis of inequities in opioid management among Black, Hispanic, Asian, and non-Hispanic White Medicare and Medicaid-insured patients

across the post-operative, active treatment, survivorship, and end-of-life phases of cancer care. By linking administrative data to comprehensive information about physicians, practices, health systems, and neighborhoods, we will examine racial variation across versus within these levels, elucidating key mechanisms

by which racism undermines equitable pain management. The project will be informed by an explicitly anti- racism framework, led by a team with expertise in multilevel analyses of healthcare quality and equity, and guided by longitudinal engagement of patient stakeholders belonging to communities of color.

After identifying the populations and settings at greatest risk, and the chief drivers of opioid inequities, we will use a rigorous 4-phase research process to design a multi-level cancer pain equity intervention targeting the most potent and mutable drivers, and the clinical settings with greatest need. This process will be grounded in

a multilevel model based upon the Racism as a Fundamental Cause of Inequalities in Health and guided by qualitative feedback from cancer patients and caregivers of color, and from clinicians, staff and organizational leaders from diverse cancer care systems. This proposal will yield a comprehensive understanding of the

scope and root causes of racial inequities in cancer pain management, and a trial-ready intervention that addresses strategic sources of inequities at multiple levels. Our findings will also have clear implications for policy makers, insurers, and health systems leaders committed to providing equitable care for cancer patients.