Psychological and brain mechanisms underlying disparities in opioid and non-opioid pain treatment decisions

项目摘要 在人口统计群体中，阿片类和非阿片类止痛药的处方不平等导致了两个主要原因 美国的健康差距。阿片类止痛药超量用药治疗急、慢性 非恶性疼痛，特别是非西班牙裔白人，助长了阿片类药物滥用的流行。开得太少 阿片类和非阿片类镇痛剂在少数族裔和妇女中的使用情况，即使有医学上的指示(例如， 急性疼痛和癌症疼痛)，降低了这些群体中疼痛管理的有效性。为了缓解 止痛药处方的差异以及阿片类药物滥用和疼痛管理不善的相关风险，我们必须 了解这些差异背后的机制。当前的项目将测试两个潜在的贡献者 对于这些疼痛治疗差异：1)临床医生关于疼痛敏感性和疼痛敏感性的不准确的人口统计学刻板印象 滥用阿片类药物的倾向(即刻板印象假说)，以及2)临床医生疼痛相关的激活减少 神经系统(如前扣带回和前脑岛)对人口外群疼痛的反应 患者(即代替性疼痛假说)。止痛药处方机制的研究进展 差异通过使用生态学效度较低的实验范式来限制，例如 要求参与者仅根据基于文本的医学插图或对 假装痛苦的个体。此外，尽管关于代替性疼痛偏向的可靠的fMRI文献与 疼痛评估中的偏差，代替性疼痛偏差尚未被测试为可能导致疼痛偏差的因素 治疗决定。在本提案中，这些方法上的局限性将得到解决， 刻板印象和代替性疼痛假说将通过3个具体目标进行检验。目标1涉及设计和 制作更具生态有效性的基于视频的模拟疼痛评估和治疗范例 描绘了经历真正痛苦的人。目标2包括对临床医生的影响的功能磁共振研究 (医学生)模拟疼痛中的代替性疼痛反应和疼痛刻板印象 评估和止痛药处方，使用目标1中创建的视频范式。最后，确定 来自目标2、目标3的研究结果的临床适用性包括面对面疼痛评估和治疗 在与标准化患者参与者进行模拟临床交互期间提出建议。如果这样做的目的是 这些研究将对疼痛相关的相对贡献产生新的理解 刻板印象和替代疼痛到止痛药处方的差异。这些结果可能表明疼痛是否 刻板印象教育，增加疼痛共鸣的努力，或两者兼而有之，应纳入临床医生 旨在减少止痛药处方差异的干预措施。通过这个K01职业发展奖， 应聘者将获得过去培训中未包括的三个领域的技能：临床疼痛评估和 治疗、多元统计分析和行为医学，以便更有效地了解 疼痛和疼痛管理中健康差异的心理社会和神经生物学机制。

Project Summary Unequal prescribing of opioid and non-opioid analgesics among demographic groups contributes to two major health disparities in the United States. Overprescribing of opioid analgesics to treat both acute and chronic nonmalignant pain, especially in non-Hispanic whites, has fueled the opioid abuse epidemic. Underprescribing of opioid and non-opioid analgesics in minorities and women, even when their use is medically indicated (e.g., acute and cancer pain), reduces the effectiveness of pain management in these groups. In order to mitigate analgesic prescribing disparities and the associated risks of opioid abuse and poor pain management, we must understand the mechanisms underlying these disparities. The current project will test two potential contributors to these pain treatment disparities: 1) clinicians' inaccurate demographic stereotypes about pain sensitivity and tendency to abuse opioids (i.e., the stereotype hypothesis), and 2) reduced activation of clinicians' pain-related neural systems (e.g., anterior cingulate and anterior insula) in response to the pain of demographic outgroup patients (i.e., the vicarious pain hypothesis). Prior studies of mechanisms underlying analgesic prescribing disparities have been limited by the use of experimental paradigms that were low in ecological validity e.g. asking participants to make prescribing decisions based solely on text-based medical vignettes or depictions of individuals feigning pain. Additionally, although the robust fMRI literature on vicarious pain biases is related to biases in pain assessment, vicarious pain biases have not been tested as a potential contributor to biases pain treatment decisions. In the present proposal, these methodological limitations will be addressed and the stereotype and vicarious pain hypotheses will be tested through 3 specific aims. Aim 1 involves the design and production of a more ecologically valid video-based simulated pain assessment and treatment paradigm depicting individuals experiencing genuine pain. Aim 2 includes an fMRI study of the effects of clinicians' (medical students') vicarious pain responses and pain stereotypes on demographic biases in simulated pain assessment and analgesic prescribing, using the video paradigm created in Aim 1. Finally, to determine the clinical applicability of the findings from Aim 2, Aim 3 includes face-to-face pain assessments and treatment recommendations during simulated clinical interactions with standardized patient actors. If the aims of this proposal are achieved, these studies will yield new understanding of the relative contributions of pain-related stereotypes and vicarious pain to analgesic prescribing disparities. These results could indicate whether pain stereotype education, efforts to increase pain empathy, or both should be incorporated into clinician interventions aimed at reducing analgesic prescribing disparities. Through this K01 career development award, the candidate will gain facility in three areas not included in her past training: clinical pain assessment and treatment, multivariate statistical analysis, and behavioral medicine in order to more effectively understand psychosocial and neurobiological mechanisms underlying health disparities in pain and pain management.