A given health-care disparity is most easily identified when there is a clear reference point for what is appropriate and reasonable to expect [7]. Palliative medicine literature establishes that it is appropriate and reasonable to expect that most pain can be brought under control by using basic principles of pain management [8]. The best current practice standard of pain medicine is appropriate to expect. However, current best practice pain assessment may not be sufficient for quality care where pain is combined with maximum vulnerability for other unequal health and healthcare.

Controlled chronic pain can be demonstrated by improved patient function, physiologic, emotional, and social comfort. Pain management, falling short of what is reasonable to expect when best practice standards are applied, leads to suspect pain disparity. The pain disparity assessment modifies the standard pain assessment by considering communication, poverty, health literacy, shared decisional capacity, informed consent, patient concerns about addiction, and unaddressed biopsychosocial needs.

Pain disparity may be lessened through palliative care consultation. Palliative care consultation enhances communication. The family assessment of treatment at end of life (FATE) was used to compare palliative care consultation with other clinicians managing pain. In one study, care was perceived best with palliative care consults for a variety of reasons (Table 15.2). Effects of palliative care consultation were not race or ethnically related. Improved communication, even for those dying, decreases the negative effect of health-care and health disparities on pain and distressing symptom management across race and ethnic subgroups [9].

Experience and education aside, palliative care consultants may compensate for a key institutional shortcoming of most health-care systems, lost focus on clinician-patient communication under duress of time. Consultants frequently have more dedicated individual time per patient encounter than primary care clinicians. A pain assessment requires patient or proxy interviews exploring loss of function, other distressing symptoms, and pain’s relation to them. Emotional, social, psychological, and economic burdens need be explored at the initial evaluation and then re-explored in subsequent encounters. Ultimately, it is the primary care physician who has the long view of a person’s chronic pain management failures and successes [10]. Pain consultants assist in prioritizing associated concerns.

Rigorous initial pain assessment should be visible to patients. This, along with continuity of approach in subsequent assessments, provides a shared shorthand for communicating about pain. Pain assessment, like the physical examination, demonstrates to the patient due diligence, a caring and believing clinician. Relevant to communication, the pain assessment can cultivate a working relationship and language between clinician and patient cultures.

Clinician deficit perspectives, associated with deficits in cross cultural or language of communication, may drive poor pain assessment. Patients uncomfortable in the medical culture may present with apparent stoicism, excited expression, or historically appropriate distrust. Observing and responding to these presentations appropriately improve communication.

The National Institute of Drug Abuse (NIDA), of the National Institutes of Health, recommends assessment of addition potential by screening for cigarettes, alcohol, and illicit drug abuse. The screening involves the ask, advise, assess, assist, and arrange (addiction specialist) approach [22]. Each racial, ethnic, age, and gender group has been explored by NIDA for prevalence of addictive behavior by substance abused. For instance, in the United States, African Americans and Americans of European descent have the same prevalence of 6 % addictive behavior and illicit drug abuse. NIDA believes, as an example, racial profiling results in statistical over representation of African Americans in the prison system related to drug abuse.

For those with pain and present addiction or risks, an honest plan needs to be made for pain management. The plan requires knowing the person’s base opiate use, efficacy of previous therapies, treatment contracts, and commitment by clinicians to arrange substance abuse treatment. Community resources or state medical board opiate monitoring systems should be used to learn the truest history of prescribed opiates. If methadone maintenance for addiction is in place, it should continue at the same dosage and received at the outpatient facility assigned. The usual dose of methadone should not be changed, baring high side effect profile. Additional opiates of choice may be added to the methadone for pain management.

Refusal of appropriate therapy by those without addiction potential may accentuate pain disparity. Pain left unmanaged often results in a persistent pain cycle. In intact communities of color, there seems a burden of responsible people to not want to leave a legacy of weakness by the use of opiates or to avoid tainting the body with drugs.

Many diseases of health-care disparities have pain as a fellow traveler. Acute pain is related to discrete events, better localized and so is less evasive. The specialty of emergency medicine has been aggressive about research on acute care pain disparity [23]. Advances in pain science may shift a disease’s pain category. An example of such a shift is changing the pain classification of rheumatoid arthritis from the chronic pain category to the more accurate recurrent.

Persistent pain is referred to as chronic pain. Persistent pain is more indolent with a source less easily defined than acute pain. Chronic malignant pain includes cancer, HIV/AIDS, amyotrophic lateral sclerosis (ALS), multiple sclerosis, end-stage organ failure, advanced chronic obstructive pulmonary disease, advanced congestive heart failure, and Parkinsonism. Chronic nonmalignant pain encompasses chronic musculoskeletal pain such as spinal pain or low back pain, chronic degenerative arthritis, osteoarthritis, rheumatoid arthritis, myofascial, chronic headache, migraine, and bone pain. Significantly, this group also tends to be frequently ambiguously reported because it has a neuropathic component associated with nerve compression and visceral pain [24].

Persistent pain occurs more frequently in those with health and health-care disparities. When pain is ascribed to an underlying disease, it tends to be more accepted as “real” by a scientifically based medicine system. An example is the validation of pain in HIV/AIDS leading to the realization that pain is the second most reported symptom, just behind fever, in AIDS. For many ethnic peoples of color, the scientific basis for pain is less meaningful than the nonphysical suffering pain causes. The health-care community should be aware that its response to undefined pain ranges from care and compassion to judgmental, sometimes devolving into blaming or inappropriate personalization of responsibility [25].

Clinicians caring for people with persistent pain should carefully review and educate themselves about pain relevant reimbursement coding systems. The complexity of the biopsychosocial issues of pain disparity require more diagnostic and treatment time in individuals with multiple health disparities. Clinical pharmacy specialist, social workers, nurses, and behavioral medicine consultants may need clinician support to access indicated medications and therapies. There is a growing understanding that medications alone are frequently inadequate to decrease persistent pain disparity.

Research supports the effectiveness of self-management programs in pain care. A meta-analysis of 17 self-management education programs for arthritis found that they achieved small but statistically significant reductions in pain ratings and reports of disability [26]. Self-Management occurs with or without clinician involvement through emotional, social, and media influences. Formal clinical assistance likely provides better targeted outcomes. Programs have combined pain self-management with therapy for depression, in cancer pain patients [27]. Convenience of schedule, location, and frequency of programs significantly improves participation rates. An individual’s reinforced belief that they can control their own pain is a strong determiner for successful pain management [28].

Emotion and pain are closely tied. Harnessing positive emotions shows improvement in pain. Pain, [29] anxiety, depression, and fear form a vicious cycle one entity feeding on the other [30]. Anger is prominent for those in pain. Anger is often directed at health-care providers, significant others, and insurance companies. Of great concern is that studies show anger more manifest as self-loathing than directed at others [31]. Therapies which improve emotional competency, like cognitive behavioral or group therapy, are important adjuncts in pain management. Expressed emotion is a window to pain perception. Cultural transparency in emotional expression between clinicians and patients is required before appropriate psychological support can be provided.

Increasingly, pain is considered a disease and not simply a distressing symptom. Disease prevention and management are profoundly influenced by community engagement [32]. Community engagement requires culturally relevant care; those who have the problem may have the solution. Traditional medicine provides a guide to culturally relevant, patient-centered care. Among those at highest risk for health-care disparities are Native, Hispanic, African, and monolingual non-English-speaking Asian Americans.

The majority of the world’s people use traditional medicine as their primary care. Traditional medicine is “the health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral-based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose, and prevent illnesses or maintain well-being” [33]. When traditional medicine is used by medical systems outside of the culture of its origin, it is called complimentary or alternative medicine. When the former is used in conjunction with allopathic medicine, it is called integrative medicine. Traditional medicine is based on nonscientific systems and knowledge which have evolved over thousands of years. The cultural practitioner of traditional medicine operates from a shamanistic base, traversing both the physical and the spiritual world. Traditional medicine seeks to create care that incorporates whole patient principles and is closely allied with patient-centered care [34]. In traditional medicine, the healing dialog often exists in the arena of spirituality.

Culture is how a group of individuals define themselves. A person’s expression, tolerance, and understanding of the meaning of pain are related to culture [35]. Culture tells people how to behave in relationship to pain [36]. Exploration of cultural touchstones provides a means of initiating a cross-cultural exchange between clinicians and patients about pain. A mnemonic for cultural touchstones is family, spirituality, struggles, and icons of culture (FaSSI).

There is rarely a separation between traditional medicine and spirituality. Consciousness raising therapies like meditation, prayer, and yoga are used in all traditional medicine systems. Spiritual assessment tools can clarify personal cultural values and probable acceptance of traditional medicine by a patient [37]. Among these tools is HOPE: what gives hope, organized religion, preferred response to spirituality, effects of spirituality on illness, pain, and suffering. Another similar spiritual assessment is FICA: faith and beliefs, importance of spirituality to life, community of spiritual support, addressing of spirituality by the clinician. More general cultural familiarity can be found through exploring a cultural or individual resonance with screen narratives, books, and arts [38, 39].

There are specific current and historical struggles affecting communities of health disparities. Some of these struggles deteriorate the biopsychosocial-spiritual axis in a way described as a cultural posttraumatic syndrome [40]. This deterioration, when manifest by escalating nonresponse to allopathic pain management, should prompt consideration of traditional or integrative medicine therapy. Cultural icons and associated rituals provide a shorthand for recognizing a person’s identification with a culture. The significance of icons to an individual provides a gentle entree to cross culture exchange between patients and clinicians.

Applying FaSSI allows review of Native American, Hispanic, African, and Asian American traditional medicine. The goal is to provide examples of cross-cultural information about traditional medicine important to pain clinicians during epidemic pain disparity.

In the United States, Native Americans include Alaskan Natives. Applying FaSSI allows review of Native American traditional medicine in relationship to Hispanic, African, and Asian Americans. Though in the US Native Americans include Alaskan Natives, it is the people of the lower 48 states who underscore the historic, cultural, and genetic intersections of those most burdened by health disparities.

Family: Extended family is a crucial factor in the life of Native Americans. Kinships are increased through marriage and adoption rituals. Most American Indian households, until recently, consisted of at least three-generation families. This means that a Native American baby boomer was likely in direct contact with elders born at the turn of the last century. Elder generations frequently are more deeply tied to core cultural practices and values. Family is essential in helping people recover from illness, ameliorating pain and suffering. Family extends to ancestors and clan relationships. It is considered important to have family close at hand when one is hospitalized. Strength is drawn from having support of significant individuals to reaffirm identity. Reflection of the role of family in settling suffering and its cousin, grief, is seen in some ancient Native American practices of burying babies in the home of their bereaved parents. Now, modern parents keep the spirits of their babies from wandering too far by making photographs [41].

Spirituality: A medicine man or woman guides the ailing person to approaches which allow rebalancing between self, nature, and the supernatural. Native religion believes that the Great Spirit is manifested by the natural environment and kinship relationships. Symptoms of illness, like pain, are brought to the attention of a medicine person after trying customary local folk remedies, herbs and procedures. These initial treatments usually derive from the natural environment. If symptoms do not resolve, the person needs both natural and supernatural assistance. The medicine people provide this combined level of care, being both priest and physician. The medicine person uses rituals to communicate with the Great Spirit, through nature or supernatural intermediaries [42]. There are many spiritual healing forms in Native American culture including the medicine wheel, which is a 10,000-year-old tool. Each Native American tribe has a variation. The medicine wheel of the Lakota people is an example.

The Lakota originates from the lands now occupied largely by the Dakota states. The home geography influences the interpretation of the medicine wheel. The medicine wheel is a circle divided into four equal quarters. The spokes of the wheel each represents direction: north, south, east, and west. The center of the wheel represents “self, balance, harmony, and learning.” The quarters of the wheel represent parts of the self’s natural, spiritual, and emotional universe. It also describes races of people. Each quadrant has a color. The colors of the quadrants are white, yellow, black, and red. Red symbolizes the South, red people, heart, and emotion. Yellow symbolizes yellow people, the East, sun, spiritual, and values. Black represents black people, the West (where the sun sets), the earth, the physical, and the action. White stands for the North, white people, snow, wind, brain, mental, and decisions [43].

The medicine wheel clarifies the direction of imbalance and how to change when in pain or suffering. The medicine man (woman) interprets the map of the wheel. The symptomatic person may be told to shift toward, for instance, the black, which is also toward the physical. This may be the case if one is too ethereal, spiritual, or yellow, bringing the person back down to earth. The imbalance of illness is thought to be physical, emotional, and related to others in the human and spiritual environment. This complicated calculus of the medicine wheel combines observation of the ill person, with treatments prescribed by the medicine person.