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Pain as a cultural construct considers conscious and unconscious biases, as well as methods for assessing and managing pain in all patient populations, including those with mental health challenges.
PAIN & PSYCHIATRY
Most health care professionals are aware that medical care in this country varies a great deal based on the patients’ race and ethnicity. We only have to look at the current coronavirus disease 2019 (COVID-19) crisis, in which Black individuals have been disproportionately affected both in number of infections and deaths as a result of a myriad of psychosocial, genetic, and environmental factors.
On top of unequal access, some individuals hold discriminatory beliefs about pain experienced by individuals of different racial and ethnic groups. In 1892, S. Weir Mitchell, MD, the father of American neurology, wrote about the experience of pain in White people of Northern European ancestry in comparison with Black and Native American people. He stated, “In our process of being civilized, we have won, I suspect, intensified capacity to suffer. The savage does not feel pain as we do.”1
This view of pain was often used to rationalize the mistreatment of enslaved and Native American people: when violence was inflicted on them, they did not suffer as White people did. Pre-Civil War, 19th century New Orleans physician Samuel A. Cartwright, MD, said he identified “dysaesthesia Aethiopis,” an inherited disorder specific to Black individuals that made them insensitive to pain.2
These views were perpetuated solely based on racism, without any science to support them. However, we now know that genetics can play a significant role in disease. Different races and ethnicities can be more at risk for certain diseases, such as sickle cell disease among Black people and Tay-Sachs disease among people of Ashkenazi Jewish ancestry. Thus, there is still the question of whether pain is experienced differently by individuals from different backgrounds.
A complicating factor in this discussion is how the experience of pain is affected by culture. It is readily apparent that it is more acceptable in some cultures and societies, often based on race or ethnicity, to complain about pain. How much of this is due to actual differences in the pain experience versus cultural acceptability of reporting pain—nature versus nurture—remains unclear.
A recent literature review examined the effects of race and ethnicity on the care individuals received for chronic pain.3 The review identified trends in the effects of race and ethnicity on the experience of pain and how it is treated. Among the multitude of previous studies, one can find many different results, ranging from race and ethnicity playing significant roles to playing virtually no role.
Some studies have reported that Black individuals and people who belong to certain ethnic minority groups have higher pain thresholds, while other studies have reported that they are more sensitive to pain.4-6 Minority patients, especially those from groups in which there are relatively small numbers of represented physicians, may have their level of pain underestimated by their caregivers.
Several studies have examined affects of race or ethnicity on the prescribing of opioids for pain. The most common finding was that Black patients were less likely to be prescribed opioids than White patients; however, it is worth noting that Hispanic patients were less likely to receive opioids than non-Hispanic White or non-Hispanic Black patients.7,8 Furthermore, some studies found that Black patients who were prescribed opioids were monitored more closely for misuse than White patients.9
In light of the prescription epidemic in this country, resulting in rising rates of misuse and overdoses, it could be argued that more restrictive prescribing and closer monitoring might be a positive thing. If so, Black patients might accidentally benefit from these prescribing patterns. However, there is no indication that physicians are more carefully looking out for their Black patients than for their White patients. Even if the result is positive, there is no apparent intent. Furthermore, research has shown that Black patients and non-White Hispanic patients may have a more difficult time than White patients filling opioid prescriptions, as pharmacies in their neighborhoods may carry smaller supplies of these medications.10
Unfortunately, there has been a tendency to have limited participation of non-English speakers and immigrants in studies of Hispanic patients, and this may have resulted in an unrepresentative sample. Considering that pain is a subjective complaint that must be self-reported, limited language skills could impair patients’ ability to convey the presence and severity of pain, all important factors in determining proper treatment protocols.
The extent to which race, socioeconomic status, and access to medical care contribute to the apparent discrepancies in the management of pain remains unclear. The issue of poor access to health care may extend beyond just the pain itself and may also affect the identification and treatment of underlying disorders that may be causing or exacerbating the pain. This includes mental health issues, most notably depressive and anxiety disorders, which can play important roles in the development and maintenance of chronic pain.
It is not too surprising that so many factors may explain variances in pain among different racial and ethnic groups. We know that there are many elements involved in the development of pain, especially chronic pain, including genetic, cultural, psychological, and environmental influences. The importance of each factor can vary from individual to individual.
The authors of the current study noted that there are no easy answers to pain management discrepancies, especially between Black and White individuals in the United States. More research is needed to identify the reasons for these discrepancies and the best methods for addressing them. Physicians should be aware of biases, including unconscious ones, and the methods for assessing and managing pain, especially among patients who may belong to different racial and ethnic groups than they do. Viewing all patients as complex individuals whose pain may involve many factors is crucial.
Dr King is in private practice in Philadelphia, Pennsylvania.
1. Morris DB. The meanings of pain. In: The Culture of Pain. University of California Press; 1993:39.
2. Cartwright SA. Report on the diseases and physical peculiarities of the negro race. In: Caplan AL, McCartney JJ, Sisti DA, eds. Health, Disease, and Illness: Concepts in Medicine. Georgetown University Press; 2004:28-39.
3. Morales ME, Yong RJ. Racial and ethnic disparities in the treatment of chronic pain. Pain Med. 2021;22(1):75-90.
4. Green CR, Hart-Johnson T. The impact of chronic pain on the health of black and white men. J Natl Med Assoc. 2010;102(4):321-331.
5. Hausmann LRM, Gao S, Lee ES, Kwoh KC. Racial disparities in the monitoring of patients on chronic opioid therapy. Pain. 2013;154(1):46-52.
6. Nguyen M, Ugarte C, Fuller I, Haas G, Portenoy RK. Access to care for chronic pain: racial and ethnic differences. J Pain. 2005;6(5):301-314.
7. Bauer SR, Hitchner L, Harrison H, Gerstenberger J, Steiger S. Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting. Subst Abus. 2016;37(1):110-117.
8. Hollingshead NA, Vrany EA, Stewart JC, Hirsh AT. Differences in Mexican Americans’ prevalence of chronic pain and co-occurring analgesic medication and substance use relative to non-Hispanic white and black Americans: Results from NHANES 1999-2004. Pain Med. 2016;17(6):1001-1009.
9. Becker WC, Starrels JL, Heo M, Li X, Weiner MG, Turner BJ. Racial differences in primary care opioid risk reduction strategies. Ann Fam Med. 2011;9(3):219-225.
10. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “We don’t carry that”--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med. 2000;342(14):1023-1026. ❒