Increasing Equity in Pain Management, Substance Use Disorder Treatment, and Linkages to CARE

PATIENT PERSONA: Tasha

Tasha is a 62-year-old Black woman with chronic back pain who presents to your care team. She previously received care at a health center that had a strict “no opioid prescribing” policy. Patients were provided referral information for local pain management specialists, all of whom were cash-in-advance clinics. Although she felt that her primary care provider and therapist were very responsive, she routinely expressed concern that she couldn’t manage her pain “because I don’t have health insurance.” She believed that her lack of health insurance and inability to afford the pain clinic fees meant she did not deserve to have her pain treated. Tasha began purchasing oxycodone from family members and friends who were prescribed opioids by their medical providers, and she increased her utilization of marijuana for pain relief. She shared this with her primary care team and always answered truthfully when asked about frequency, amount, and duration of use. Approximately three years ago, Tasha was awarded a disability settlement and enrolled in Medicare. This enrollment allowed her to enter a pain management program that accepted Medicare. To enter the program, she needed to abstain from using marijuana and opioids for 30 days in order to “pass” the urine drug screen. Her pain returned to its baseline, and her functioning was significantly impaired. She enrolled in the pain management program and received treatment for one year until she was dismissed for having a “dirty” urine drug screen--the clinic stated they found cocaine metabolites, which Tasha denied. Because she had been previously “dismissed” from a pain management program, other programs in the community declined to enroll her in their programs. She went six months without prescribed pain management and returned to using marijuana and family members’ prescriptions to manage her pain. When she was offered a referral to another pain management program, she stated she was labeled an “addict” and a “high-risk patient” because of her previous “dismissal.” Now Tasha questions whether returning to this pain management program is worth it if it means she must feel demeaned to receive treatment.

Reflections and questions

■ What harm reduction principles might be applied to Tasha’s care? ■ Who at the health center should become involved in Tasha’s care? How might you need to expand the care team? ■ What kinds of training might care team members and other staff at your health center need to a) best meet Tasha’s health care goals?; b) provide the most culturally responsive care for Tasha?

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