Pain Management Bias May Impact Sickle Cell Care

Shermel Edwards-Maddox, MSN, RN, CNE, RN-BC

A new literature review highlighted various contributing factors to biases surrounding pain management in African Americans with sickle cell disease (SCD).

The review was conducted by Shermel Edwards-Maddox, MSN, RN, CNE, RN-BC, of the University of Houston College of Nursing, and presented at Creating Healthy Work Environments (CHWE) Virtual 2021.

“Patients affected by sickle cell disease frequently do not receive adequate pain management,” she said, further noting the health disparities facing African American populations.

In her study, Edwards-Maddox utilized CINAHL and Pubmed databases to search for articles published between 2015-2020 and that discussed biases related to pain management and sickle cell disease. From this, she identified 3 major themes, all of which may play a role in pain management-related bias for such patients.

Factors Associated with Biases

A common thread across the literature was the observation of longer wait times in emergency departments experienced by patients with sickle cell disease, when compared with the general population. 

“Wait times were longer for Black, younger patients, women, and those who frequently utilized the emergency departments,” Edwards-Maddox wrote, pointing to a 2016 study that found that sickle cell disease patients have a slightly longer average time-to-provider (+16 minutes) compared with the general emergency department patients.

“Patients with SCD may be judged to be of lower acuity than others with similar pain,” she indicated.

She also noted that the inadequacy of pain control may lead patients to exhibit behaviors resembling pseudoaddiction. As such, patient response to undertreatment can include moaning, grimacing, or grimacing—behaviors that have the potential to be falsely construed as evidence of drug addiction.

Thus, these notions may strengthen stigmas surrounding individuals with sickle cell.

“The healthcare provider’s perception can also be a barrier to adequate pain management in patients with SCD,” noted Edwards-Maddox.

Language, such as “frequent flyers” and “sickler,” can further contribute to such implicit bias.

Furthermore, a survey showed that up to 41% of healthcare providers reported concerns that patients with SCD may be drug-seeking — perceptions which may in turn influence the care provided to the patients.

Towards a Better Care

In light of these observations, Edwards-Maddox stressed the importance of using guidelines for the management of SCD-related pain.

For example, the American Society of Hematology offers guidance specific to acute and chronic pain. The guidelines also emphasize the importance and utility of interdisciplinary care.

Nonetheless, additional research is needed to fully, validly, and accurately measure stigma associated with such patients presenting to the emergency department.

“Clinicians should consider if implicit/direct bias negatively impacts treatment plans while increasing their understanding of SCD,” suggested Edwards-Maddox.

The study, “Pain Management Bias in African Americans With Sickle Cell Disease,” was CHWE 2021.