Researchers Link Social Determinants to Pain Management in End-of-Life Care

Recent research shows that social determinants of health programs can help improve pain and symptom management for end-of-life patients in underserved communities.

A recent study published in the Annals of Surgical Oncology found disparities in pain management among Black, Asian and Hispanic cancer patient populations, based on variation in the availability of social determinants of health services.

These patient populations had less hospice access and utilization of pain medications such as opioids when approaching the end of life, researchers found.


The study highlights how persistent racial and ethnic inequities can impact access and quality outcomes among patients of color with life-limiting illnesses, according to researcher Dr. Timothy Pawlik, surgical oncologist and chair of the department of surgery at The Ohio State University Wexner Medical Center. Pawlik also serves at the university’s Comprehensive Cancer Center-James Cancer Hospital & Solove Research Institute.

“Our research highlights how critically important social determinants of health are,” Pawlik told Hospice News. “This research shows the intersection of race and ethnicity with persistent poverty and vulnerability. Social determinants of health are important drivers in access and when it comes to outcomes for many cancer patients. Black or Latino patients in socially vulnerable areas were less likely to utilize hospice than white patients, and there’s a compounding effect on end-of-life pain management.”

Researchers examined patient data for 48,631 Medicare hospice decedents from 2008 to 2016 across 15 states. The study focused on cancer patients who were 65 and older in areas in which 20% of the population lives at or below poverty level. Data were linked with county-level poverty rates from the American Community Survey and the U.S. Department of Agriculture.


Compared to white patients, Black, Asian, Hispanic and other racial groups had “markedly decreased odds” of utilization of pain medication and were less likely to utilize hospice services, Pawlik stated.

Patients of color were less likely to fill an opioid prescription near the end of life. Black, Asian, Hispanic,

and other racial/ethnic minority patients were less likely to fill at least one opioid prescription near the end of life. Of those who did fill opioid prescriptions at the end of life, minority patients received lower daily doses than white patients.

“The disparities can also be impacted by a lack of access,” Pawlik said. “People who live in socially vulnerable areas that are more economically depressed may find it harder to access medication in ‘pharmacy desserts’ than people in more affluent areas who perhaps have the means and more transportation at their disposal.”

The findings also highlight a need to address the potential impacts of health care provider bias on disparities, according to Pawlik.

“There’s undoubtedly multifactorial basis for the differences and disparities that can be related to clinicians’ unconscious, implicit biases,” Pawlik said. “Physicians may have some bias when it comes to different prescribing patterns and it’s important to be aware of that to hopefully address it and improve health equity.”

Another study published in the journal Annals of Surgery in December 2023 found similar disparities in social determinants of health fueling health outcomes. The study spanned electronic health record data of roughly 25,070 patients who had a complex oncologic operation between 2012 and 2016, comparing those who resided in areas with high income rates against individuals in lower socioeconomic areas.

Black patients in lower income areas had farther travel distances (28.5 miles on average) to reach health care facilities than compared to patients living in the predominantly white, higher income regions, as well as over 70% greater odds of forgoing surgical care.

The centralization of high-risk surgery, social determinants of health “play a critical role in preventing equitable access to care,” researchers, including Pawlik, stated in the study.

The growing data around social determinants of health is illustrating a greater need to tie supportive resources around food, transportation, employment and housing services that impact quality and access, Pawlik said.

An “allostatic load” exists between the weight of stress and anxiety related to lagging socioeconomic support and adverse clinical outcomes among minority patients in particular, he stated.

A key for hospices working to address social determinants of health is to include more detailed patient and family assessments that adequately target unmet socioeconomic needs, Pawlik stated. Additionally, establishing partnerships with diverse community groups will be essential to connecting patients with helpful health care resources.

“It’s super important that we screen for these social determinants of health,” Pawlik told Hospice News. “If we aren’t routinely assessing, we can’t target care appropriately. But it’s not enough just to screen. It’s also important to have community partners that identify resources and have that warm handoff with a 360-degree approach to helping patients who are particularly vulnerable.”

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