The Health Implications of Disparities in Cancer and Pain Care: Unequal Burdens and Unheard Voices




Several federal agencies have acknowledged and set goals toward eliminating racial and ethnic disparities in health (and health care) and promoting health equity. The literature discussing health and health care inequities based on social determinants (e.g., age, race, gender, class) has mostly failed to address the quality of pain care or the impact that pain has on overall health and well-being. However, the health and health care disparity literature has often focused on diseases frequently associated with pain, such as cardiovascular disease, cancer, diabetes, osteoarthritis, and obesity. Unfortunately, pain has been viewed as a symptom and not a disease, even when it persists and has long-term physical (e.g., disability) and emotional (e.g., depression) health implications. In fact, a report of the Institute of Medicine (IOM), Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care , devoted only a few pages to analgesic care for acute and cancer pain, although pain has important and unique health considerations and socioeconomic implications. The lack of attention to pain in general and to disparate pain care in particular is also missing from other well-publicized public health agendas designed to improve the nation’s colloquial health-related quality of life. Fortunately, the IOM’s recent report Relieving Pain in America: A Blue Print for Transforming Prevention, Care, Education, and Research acknowledges pain’s unique implications, as well as disparate care, while including important policy recommendations.


Race, gender, and age-related health disparities impair public health and are national problems. An emerging literature has begun to highlight differences in pain perception, as well as disparities in pain care, in racial and ethnic minorities for all types of pain and across all settings. Consistent with the social justice literature, in which pain relief is acknowledged to be a fundamental human rights issue, this chapter provides a platform to discuss the impact of pain, pain assessment, and management as a unique and significant public health problem.


Impact of Pain on Overall Health and Well-Being


Pain is defined by the International Association for the Study of Pain (IASP) as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain can further be defined by its cause or duration in terms of acute pain (i.e., pain that is short-lived, usually lasting less than 3 months), cancer-related pain (i.e., pain caused by cancer or its treatment), chronic benign or nonmalignant pain (i.e., pain persisting for longer than 6 months that is not due to cancer), or some combination (e.g., cancer-related chronic pain). Aging and increased survival from cancer, diabetes, and trauma have yielded an increase in pain complaints. Regardless of the etiology, pain diminishes overall physical, social, and emotional health.


The IOM estimates that more than 100 million Americans live with chronic pain. The increasing prevalence of pain has significant socioeconomic and health ramifications for the individual and progressively impairs collective health in the United States. The third largest global health problem, pain causes significant psychological, physical, and social perturbations that result in needless suffering and subsequent disability. Yet pain is a neglected topic in medicine that leads to concomitant depression, anxiety, post-traumatic stress disorder (PTSD), sleep disturbance, fatigue, and decreased overall physical functioning. Living with pain may also cause an individual to withdraw from societal roles, thereby leading to impaired family, community, and career relationships, and diminish health and quality of life. With these facts in mind, the World Health Organization (WHO) joined the IASP and the European Federation of IASP Chapters to host the first Global Day Against Pain in 2004 to document the tremendous disease burden associated with acute, chronic, and cancer-related pain. The literature suggests that racial and ethnic minorities are disproportionately affected by pain.




The Cost of Pain


Currently, pain complaints are the most frequent cause of disability in the United States and lead to more than 700 million lost workdays. The second leading cause of all U.S. physician visits, pain complaints account for more than $500 billion in annual health care expenditures. Americans also spend an additional $40 billion per year on chronic pain. Older adults use more health care resources (e.g., prescription pain medications, procedures) than younger adults do. The prevalence of chronic pain will increase as the U.S. population ages, especially among baby boomers (i.e., those born between 1946 and 1964). Nearly 50% of older Americans live with pain, and racial and ethnic minorities are at increased risk for suboptimal care regardless of age and type of pain. By 2030 there will be an estimated 71.5 million people older than 65 years and 137 million individuals of racial and ethnic minorities in the United States. More specifically, by 2030 the number of hip and knee replacements is expected to grow by 154% (572,000 procedures) and by 673% (3.48 million procedures), respectively. Without improvements in the quality and availability of care, pain will have devastating socioeconomic and health ramifications for an increasingly aging society. Unfortunately, the medical advantages yielding increased longevity for most white Americans have not been uniformly applied to all Americans. For example, racial and ethnic minorities experience many chronic illnesses (e.g., diabetes, cancer) associated with aging and pain and report pain at an earlier age than whites do.


Both positive and negative life experiences have an impact on health and pain. Chronic pain often coexists with other medical conditions associated with aging (e.g., sleep problems, arthritis, Parkinson’s disease, and depression), thereby further impairing health. The pain literature focusing on the intersection between race, gender, and aging has primarily dealt with younger adults and white women; the findings from these studies are not readily generalizable to large and growing population groups such as older racial and ethnic minority women. A key concept common to health disparities and the life course perspective is “multiple exposures over the life-course have combined effects on health” (e.g., poverty’s negative cumulative effect). It follows that impoverished individuals and racial and ethnic minorities may be particularly vulnerable to diminished health when faced with pain. Thus, age, race, gender, and class are important factors in understanding health, pain, and disability. Furthermore, the significant gap in the literature will escalate as more Americans (especially women and racial and ethnic minorities) age.


Chronic pain in older adults often accompanies musculoskeletal conditions (e.g., arthritis) and physical disability, and functional limitations arise as a result of muscle disuse, weakness, and atrophy. Older adults often cope with pain by restricting their activities, which leads to depression, dependence, and social isolation. Sleep disturbance, anxiety, and increased PTSD symptoms are also associated with chronic pain. Women have more pain across the life course than men do, yet chronic pain studies comparing health outcomes and potential racial, ethnic, gender-related, and class disparities across the life span are lacking.




The Cost of Pain


Currently, pain complaints are the most frequent cause of disability in the United States and lead to more than 700 million lost workdays. The second leading cause of all U.S. physician visits, pain complaints account for more than $500 billion in annual health care expenditures. Americans also spend an additional $40 billion per year on chronic pain. Older adults use more health care resources (e.g., prescription pain medications, procedures) than younger adults do. The prevalence of chronic pain will increase as the U.S. population ages, especially among baby boomers (i.e., those born between 1946 and 1964). Nearly 50% of older Americans live with pain, and racial and ethnic minorities are at increased risk for suboptimal care regardless of age and type of pain. By 2030 there will be an estimated 71.5 million people older than 65 years and 137 million individuals of racial and ethnic minorities in the United States. More specifically, by 2030 the number of hip and knee replacements is expected to grow by 154% (572,000 procedures) and by 673% (3.48 million procedures), respectively. Without improvements in the quality and availability of care, pain will have devastating socioeconomic and health ramifications for an increasingly aging society. Unfortunately, the medical advantages yielding increased longevity for most white Americans have not been uniformly applied to all Americans. For example, racial and ethnic minorities experience many chronic illnesses (e.g., diabetes, cancer) associated with aging and pain and report pain at an earlier age than whites do.


Both positive and negative life experiences have an impact on health and pain. Chronic pain often coexists with other medical conditions associated with aging (e.g., sleep problems, arthritis, Parkinson’s disease, and depression), thereby further impairing health. The pain literature focusing on the intersection between race, gender, and aging has primarily dealt with younger adults and white women; the findings from these studies are not readily generalizable to large and growing population groups such as older racial and ethnic minority women. A key concept common to health disparities and the life course perspective is “multiple exposures over the life-course have combined effects on health” (e.g., poverty’s negative cumulative effect). It follows that impoverished individuals and racial and ethnic minorities may be particularly vulnerable to diminished health when faced with pain. Thus, age, race, gender, and class are important factors in understanding health, pain, and disability. Furthermore, the significant gap in the literature will escalate as more Americans (especially women and racial and ethnic minorities) age.


Chronic pain in older adults often accompanies musculoskeletal conditions (e.g., arthritis) and physical disability, and functional limitations arise as a result of muscle disuse, weakness, and atrophy. Older adults often cope with pain by restricting their activities, which leads to depression, dependence, and social isolation. Sleep disturbance, anxiety, and increased PTSD symptoms are also associated with chronic pain. Women have more pain across the life course than men do, yet chronic pain studies comparing health outcomes and potential racial, ethnic, gender-related, and class disparities across the life span are lacking.




Health Disparities and Pain


Despite scientific advances and the ability to alleviate suffering, pain and health disparities remain critical public health issues. However, the science of health disparities with respect to pain is in its infancy. In 1998 the National Institutes of Health (NIH) held a symposium on pain in women, yet potential variations attributable to race, ethnicity, and aging were not addressed. According to 2000 U.S. census data, 12.4% of the U.S. population was 65 years or older (29% of whom consisted of racial and ethnic minorities and 59% were women). By 2030, 20% of the U.S. population will be 65 years or older (50% of the total projected to be members of racial and ethnic minorities and >60% of the total to be women). The 2008 NIH exploratory workshop on pain in the elderly acknowledged the importance of social determinants, but data on race, ethnicity, and gender differences were not provided. New knowledge aimed at clarifying the health domains affected and potential racial and ethnic differences at the individual and group level is essential for health care planning. Consistent with the health disparity literature, older adults, racial and ethnic minorities, women, and impoverished individuals (especially low-income racial and ethnic minority women) may be particularly vulnerable to chronic pain’s negative sequelae, but few prospective and longitudinal studies have examined pain’s impact on vulnerable and underserved populations.


In a retrospective study of 7000 black and white Americans with chronic pain seen at a tertiary care pain center, important differences were found in health based on race and ethnicity. Overall, African Americans reported significantly more comorbid conditions, higher pain scores, increased pain severity, more suffering, and less pain control than did white Americans across the age continuum. Black Americans also reported increased physical disability in activities of daily living as a result of pain (e.g., sexual activity, self-care, occupation, family life) and more problems with falling and staying asleep. The mental health of black Americans living with chronic pain was also more negatively affected than that of whites living with chronic pain. Although both black and white Americans met the criteria for clinical depression, black Americans (regardless of age and gender) were significantly more depressed and reported more symptoms consistent with PTSD and anxiety across the age continuum regardless of gender. It is unclear whether these findings reflect undertreatment, over-reporting of differences in pain sensitivity, or some combination of both. Racial and ethnic minorities are frequently more reluctant than white Americans to seek treatment of mental health disorders, and such disorders are often poorly addressed, misdiagnosed, and inadequately treated when they do seek care. Nonetheless, it is well documented that most individuals with depression go without treatment. Thus, it follows that pain and its negative sequelae are more likely to decrease the overall health and well-being of racial and ethnic minorities than that of white Americans.




The Pain Response


An individual’s response to pain is influenced by complex interactions between biologic, physiologic, emotional, social, and cultural factors. Differences in pain learning, culturally imposed factors, pain care attitudes and beliefs, comorbid conditions, coping styles, and social roles (i.e., career, community, and family responsibilities) may work cooperatively and competitively to influence the pain experience. These differences may predispose some toward multiple actions that maximize rather than minimize threats to bodily integrity and thereby amplify or exacerbate chronic pain. People with similar disease activity report differences in pain intensity and its impact.


Experimental models have shown wide variability in response to a painful stimulus. Race, ethnicity, gender, disease, age, culture, socioeconomic status (SES), past experiences, response bias, and the experimental setting influence pain measurement, coping, health, and the pain response. However, the clinical relevance of experimentally induced pain and how sociodemographic factors influence clinical pain syndromes remain unknown.


Folkman and colleagues described coping as “a person’s cognitive and behavioral efforts to manage the internal and external demands of the person-environment transaction appraised as taxing or exceeding their resources.” Maladaptive coping styles (e.g., catastrophizing, repression) and poor adjustment (e.g., poor information seeking, passivity) influence the response to pain. Passive coping and catastrophizing are detrimental to successfully coping with a pain problem. Social support also has a significant role in coping with many chronic conditions and plays an important role in pain management. Well-validated models support the role of pain-related fear and postulate behavioral responses (e.g., confrontation, avoidance) that ultimately determine outcome. Most models propose that people in pain become enmeshed in a downward spiral of increased fear, avoidance, anxiety, depression, disability, and pain. When there is no pain-related fear and rapid confrontation, an adaptive response yielding recovery and better functioning occurs. Unfortunately, most coping illness models were tested on primarily homogeneous white and younger adult populations and did not consider social roles. Thus, these models are not generalizable to growing populations, which is a critical limitation in an aging and diversifying society.


Differences in coping have been identified. Several studies have revealed that blacks with chronic pain report more suffering from the pain than do whites regardless of age or gender. Blacks tend to use religious coping (e.g., church participation), wishful thinking, and social support systems when dealing with stress more than whites do. They often describe stoicism and believe that pain is inevitable but fear reporting their pain because family and friends may not understand. Associations between John Henryism (i.e., actively coping with stressors by working increasingly harder against potentially insurmountable obstacles) and higher blood pressure, hypertension, and bodily pain were described in a general population of older blacks. In view of the high prevalence of hypertension in racial and ethnic minorities, further investigations are necessary to see whether John Henryism is actually detrimental or helpful to racial and ethnic minorities with chronic pain. Green and associates showed that blacks with chronic pain tend to believe more so than whites that race and ethnicity affect the health care and pain care that they receive. Black patients also tend to believe that good patients avoid talking about pain and that pain medications cannot really control pain.


SES also influences pain. Living in a resource-poor neighborhood was found to affect older blacks more than older whites, thus confirming that neighborhood resources contribute to the negative consequences of chronic pain. A study comparing younger black and white Americans reported that increasing neighborhood resources is associated with decreased negative chronic pain outcomes. In other studies, racial and ethnic minorities, low-income individuals, and older adults were found to face structural barriers to obtaining prescription analgesics in their local pharmacies even when their pain was assessed and treated. Comorbid diseases commonly associated with pain (e.g., cancer) also influence health and well-being more frequently in blacks than in whites. Differences in coping styles, health status, health service access and use, social roles, sociodemographic characteristics, and stressors may also predispose some individuals to an adaptive or ineffective response to pain. Thus, race, ethnicity, SES, neighborhood resources, and comorbid conditions are important considerations when examining the impact of pain on health and health care.




Access to Pain Care


System-related variables (e.g., health services access and use, health insurance), as well as stressors (e.g., social roles, comorbid conditions) and resources (e.g., wealth, poverty), influence health and health care. Health insurance coverage does not ensure quality health or pain care. Regardless of age, black Americans with chronic pain had diminished health when compared with whites with chronic pain. Racial and ethnic minorities with health insurance also reported increased difficulty accessing and paying for quality health and pain care than did similar white Americans. Black Americans also believed that race, ethnicity, culture, and gender influenced access to both health care and pain care more than white Americans did. These disparate attitudes have significant implications in potentially vulnerable, marginalized, and underserved populations already at risk for decreased access to primary care and specialty pain care, as well as suboptimal pain assessment and management.


The absence of health insurance, a primary care physician, or a usual source of medical care diminishes access to quality pain care and contributes to the use of emergency services for preventable problems. Racial and ethnic minorities and low-income individuals are less likely to have a regular primary care physician and have less access to specialty care. The literature has revealed that blacks and low-income people with chronic pain believe more frequently than whites do that they should have been referred to a pain center sooner, report decreased access to health care overall, and believe that race and ethnicity influenced pain care. Since racial and ethnic minority status and income are often interrelated, rising co-payment for health care services and economic downturns tend to have a greater impact on racial and ethnic minorities, who also have increased disease burden for many comorbid conditions associated with pain (e.g., diabetes, cancer), disproportionately more so than whites even when access to quality pain care is available. Nonetheless, these individuals report less access to pain management specialists, receive less pain medication, and are at risk for having their pain poorly assessed and undertreated.




Pain Assessment


The first building block to ensure quality pain care is optimizing pain assessment. Disability, depression, and pain intensity issues often complicate pain assessment and treatment. Overall, the failure to optimize pain assessment and treatment contributes to poor health. Despite the economic, psychological, familial, and social impact of pain, as well as an extensive literature documenting the benefits of optimizing pain management and guidelines designed to improve pain management, this information is not universally taken into account. One major challenge in optimizing pain care is that pain is subjective with no objective measures, and thus implementing quality pain care can be problematic across the continuum of care. Another important limitation is that most guidelines rarely address the role of social determinants despite evidence that age, race, ethnicity, gender, and SES influence communication and pain care.


Patient-physician communication is fraught with difficulties. The literature describes racial and ethnic differences in the ability to discuss pain complaints and negotiate pain treatment plans with physicians. Women and racial and ethnic minorities are at risk for receiving poorer quality pain care than men are. Patient expectations for the patient-physician relationship do not differ by race and ethnicity, but their experiences, perceptions, and satisfaction differ significantly. Physicians were more verbally dominant, engaged in less patient-centered communication, used less rapport building, rated conditions as less severe (even when there were no differences), and provided less information in encounters with racial and ethnic minorities than they did with whites. Racial and ethnic differences in patient-physician interactions help explain the disparities in patient satisfaction, but not in use of health services. When tested in an experimental design, cancer patients receiving coaching discussed their pain concerns more, thereby reducing disparities. Thus, empowered patient-physician communication that encourages patients to ask questions and express concerns, as well as racial concordance, has been shown to reduce disparities.




Patient Variability


Intra-race variability in pain complaints has been observed. Younger blacks reported higher pain intensity and depression than older blacks did. When comparing health status and pain treatment perceptions in older adults, blacks were significantly younger; reported more bodily pain, poorer health, and more problems with social functioning; and had greater role limitations because of emotional problems than white Americans did. After controlling for age, marital status, education, and pain duration in younger women with chronic pain, black women were found to have greater pain intensity, depression, disability, and PTSD symptoms than did white women. Another study identified three clusters of patients with chronic pain within age, race, and gender groups: (1) chronic pain syndrome, (2) good pain control, and (3) disability with a mild pain syndrome. Blacks and younger adults were more likely to have chronic pain syndrome. Blacks with “chronic pain syndrome” or disability with mild pain syndrome reported higher disability than did their counterparts. Older patients and women in the good pain control group reported lower levels of pain and depression, whereas those with “disability with mild pain syndrome” had lower pain and depression. Thus, the response to chronic pain varies according to race, gender, and age.


Race and ethnicity influence pain management–seeking behavior, but the mechanisms remain unclear. What is clear is that the pain complaints of racial and ethnic minorities, older adults, impoverished people, and women are often not treated the same as the pain complaints of white men, who receive better-quality care. Patient behavior, how patients communicate (e.g., language barriers), physician-patient communication, and stereotyping can complicate assessment. Communication differences increase the likelihood of pain complaints being discounted. In addition, most measures used to assess pain lacked cultural and linguistic sensitivity and were not validated in racially and ethnically diverse populations, thus contributing to the persistence of disturbing racial and ethnic disparities in health and pain care.




Clinician Variability in Pain Management Decision Making


Although pain complaints are very common, they are often poorly managed. Patients report that their pain complaints are frequently unheard and undertreated by physicians. In addition, clinicians report that they are not knowledgeable or satisfied with the pain care that they provide. Given these considerations, it is surprising that pain education remains a neglected topic in most medical, nursing, dental, and pharmacy school curricula, a shortcoming that further contributes to poor pain care. A study of practicing Michigan physicians revealed that nearly 30% reported that they had not received any medical school, residency, or continuing medical education specifically directed at managing pain. Thus, physicians and other health care providers are ill equipped to assess and treat pain. Consequently, it is not surprising that most clinicians express low satisfaction, confidence, and goals when treating pain while also prescribing better treatment (e.g., referral to specialist) for men than for women, even when women had similar or more pain than men did. In addition, health care system factors, trust, legal factors, and health care provider decision making influence pain assessment regardless of guidelines designed to ensure adequate pain care.


The worker’s compensation literature also provides evidence of disparate pain care. Blacks were twice as likely to be disabled 6 months following an occupational back injury, and blacks without legal representation received less treatment and lower disability ratings than did whites without legal representation. Overall, Tait and Chibnall found that race and SES disparities are present in the worker’s compensation system, with black men receiving less compensation than white men for similar injuries.


The quality of physician-prescribed pain care also varies with respect to race, ethnicity, and gender for similar pain problems. In a retrospective study of emergency care, a twofold difference in receiving analgesics based on ethnicity was noted in emergency room patients with isolated long-bone fractures, and 55% of Hispanics received no pain medications for similar injuries as whites.


The cancer pain literature shows health care and cancer care disparities, with blacks suffering more severe cancer-related pain, inaccurate pain assessment, and inadequate pain treatment in comparison to whites. The cancer survivor literature reveals similar results, with women having higher rates of pain and blacks suffering greater interference. Multiple factors influence the disparities in cancer care: (1) environmental variables (e.g., segregation, exposure to toxins), (2) patient sociodemographic factors and differences in pain sensitivity (e.g., health behavior, beliefs, attitudes, and coping strategies), (3) health care provider factors (e.g., pain knowledge and education, cultural competence, language barriers, stereotypes, and bias), and (4) health care system variables (e.g., health insurance, access to care). It follows that these factors may play a significant role in disparities in pain care.


Racial and ethnic minority cancer patients were prescribed less potent analgesics and were significantly undertreated with respect to the WHO recommendations for managing cancer pain. Those treated at university centers or centers primarily caring for racial and ethnic minorities were more likely to receive inadequate analgesia than were whites treated elsewhere and in the community. Other studies have shown that physicians underestimate pain severity in Hispanic and black patients. For instance, Bernabei and coworkers showed that black nursing home residents were less likely to have their pain assessed; if their pain was assessed, they still received less pain medication than white residents did. Although 40% of blacks with cancer pain reported daily pain, 25% received no analgesics whatsoever. Green and colleagues recently revealed shortcomings in assessing and treating breakthrough pain (pain flares interrupting well-controlled baseline pain) in advanced cancer, with women and racial and ethnic minorities reporting increased pain and worse health.


Green and associates showed that chronic pain was poorly assessed and treated, with blacks and women being adversely affected. Suboptimal pain care in all clinical settings combined with clinician variability in pain management decision making complicates pain therapy in racial and ethnic minorities and women. A Michigan study revealed that 20% of cancer survivors experienced cancer-related chronic pain, with women and blacks disproportionately affected. Green and Ndao-Brumblay also showed that blacks used less complementary and alternative medicine techniques (including acupuncture) and significantly less manipulation, biofeedback, or relaxation training than did whites for chronic pain. Thus, poor pain assessment, inadequate pain treatment, and decreased ability to obtain pain medications (even when prescribed) complicate appropriate and quality pain management of racial and ethnic minority persons, thereby impairing their overall health and well-being. In general, these studies illustrate that racial and ethnic minorities and low-income people experience more disease burden, receive less pain relief, and are less likely than whites to be adequately assessed for all types of pain and in all settings.


Racial and ethnic minorities face additional barriers to adequate pain management. In two pharmacy studies, those located in minority neighborhoods were less likely to carry opioid analgesics than were those in nonminority neighborhoods. After accounting for zip code median income and stratifying by income, Green and coworkers found structural barriers for racial and ethnic minorities, low-income whites, and older adults, who experienced increased difficulty getting their opioid analgesic prescriptions filled in their local pharmacies across Michigan. Surprisingly, low-income whites had better access to opioid analgesics than did high-income racial and ethnic minorities. Thus, clinician perceptions and goals may lead to the undertreatment of pain (especially in racial and ethnic minorities).




Critical Questions and New Directions


The potential implications of poorly treated pain are devastating for the individual, and the cost to society is staggering. Pain profoundly affects morbidity, mortality, quality of life, and health care expenditures. Therefore, ensuring optimal pain management is critically important from a public health perspective. Both patient and physician variability in attitudes and beliefs contributes to suboptimal pain care (with racial and ethnic minorities, low-income people, older adults, and women receiving lower-quality pain care). Pain’s impact and prevalence will increase as Americans live longer and have a profound effect on morbidity and health care expenditures. Assessment remains the cornerstone of quality pain care. Despite chronic pain’s individual and socioeconomic impact, documented benefits in optimizing pain care, therapeutic advances currently available to treat chronic pain, and guidelines for managing pain, physicians and other health care providers are ill equipped to assess and treat chronic pain. ∗


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There are also important questions regarding estimates of the amount of pain (severity) and its correlates (physical, emotional, and social burden) in different groups, the extent of poorly assessed and treated pain, planning for the amount of health care required, improving pain care delivery, and differences and variability in quality and the way that health services are provided based on social determinants.


There is evidence that all types of pain have unique health implications in racial and ethnic minorities that are often unrecognized or overlooked. No longitudinal and prospective studies have examined the long-term effects of pain on overall health and well-being in an ethnically diverse population. In addition to race and ethnicity, other social determinants may make certain racial and ethnic minorities more vulnerable to pain. Thus, racial and ethnic minority individuals who are elderly, impoverished, or women are extremely vulnerable to the distressing effects of pain. Culturally and linguistically appropriate interventions must be developed to ensure quality pain assessment and management so that racial and ethnic disparities in pain care can be eliminated. The role of clinician and patient-provider variability in pain management decision making, as well as health insurance, health care system, and regulatory factors, must be examined. By improving pain care for the most underserved and vulnerable populations in our society, it will be improved for all. In a climate of increasing patient safety concerns, inadequate pain assessment and treatment must be viewed as a quality-of-care issue. Pain relief is fundamentally a human rights issue, whereas inadequate pain care is fundamentally a medical error. Beyond being a quality issue, inequitable pain care based on sociodemographic characteristics is fundamentally a social justice issue. There is a critical need for increased awareness, advocacy, and health care and pain care policy to rectify these ills. Also needed are physician, health care provider, and health system leadership and interventions that ensure (1) access to quality and equitable patient-centered primary care and multidisciplinary pain care that is culturally and linguistically sensitive; (2) the ability to optimize pain assessment and the comorbid conditions often associated with pain by increasing pain education for both patients and clinicians; (3) comprehensive and multidisciplinary approaches, evidence-based guidelines, and research and policy initiatives; and (4) establishment of mechanisms to ensure access to the resources needed to prevent and manage pain at the neighborhood level.



KEY POINTS




  • •

    More than 100 million Americans live with chronic pain, and racial and ethnic minorities and women are disproportionately affected.


  • •

    Both positive and negative life experiences have an impact on pain and contribute to differences in the pain experience in racial and ethnic minorities, women, older adults, and impoverished persons.


  • •

    By 2030, 20% of the U.S. population will be 65 years or older (50% of the total projected to be members of racial and ethnic minorities and >60% of the total to be women).


  • •

    Racial and ethnic minorities have decreased access to pain care, are at risk for suboptimal pain assessment and management, and have adverse health outcomes.


  • •

    Race and ethnicity, socioeconomic status, gender, and age also influence the quality of pain care, use of health services, clinician decision making, and health outcomes.


  • •

    Both patient intra- and inter-race variability and clinician variability contribute to disparities in health and pain care.






Suggested Readings


  • Anderson K.O., Green C.R., Payne R.: Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain 2009; 10: pp. 1187-1204.
  • Anderson K.O., Richman S.P., Hurley J., et. al.: Cancer pain management among underserved minority outpatients: perceived needs and barriers to optimal control. Cancer 2002; 94: pp. 2295-2304.
  • Bonham V.L.: Race, ethnicity, and pain treatment: striving to understand the causes and solutions to the disparities in pain treatment. J Law Med Ethics 2001; 29: pp. 52-68.
  • Chibnall J.T., Tait R.C.: Disparities in occupational low back injuries: predicting pain-related disability from satisfaction with case management in African Americans and Caucasians. Pain Med 2005; 6: pp. 39-48.
  • Cousins M.J., Brennan F., Carr D.B.: Pain relief: a universal human right. Pain 2004; 112: pp. 1-4.
  • Edwards R.R., Moric M., Husfeldt B., et. al.: Ethnic similarities and differences in the chronic pain experience: a comparison of African American, Hispanic, and white patients. Pain Med 2005; 6: pp. 88-98.
  • Green C.R.: Being present: the role of narrative medicine in reducing the unequal burden of pain. Pain 2011; 152: pp. 965-966.
  • Green C.R., Anderson K.O., Baker T.A., et. al.: The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med 2003; 4: pp. 277-294.
  • Green C.R., Baker T.A., Smith E.M., et. al.: The effect of race in older adults presenting for chronic pain management: a comparative study of black and white Americans. J Pain 2003; 4: pp. 82-90.
  • Green C.R., Hart-Johnson T.: The adequacy of chronic pain management prior to presenting at a tertiary care pain center: the role of patient socio-demographic characteristics. J Pain 2010; 11: pp. 746-754.
  • Green C.R., Hart-Johnson T.: The association between race and neighborhood socioeconomic status in younger black and white adults with chronic pain. J Pain 2012; 13: pp. 176-186.
  • Green C.R., Hart-Johnson T., Loeffler D.R.: Cancer-related chronic pain: examining quality of life in diverse cancer survivors. Cancer 2011; 117: pp. 1994-2003.
  • Green C.R., Montague L., Hart-Johnson T.: Consistent and breakthrough pain in diverse advanced cancer patients: a longitudinal examination. J Pain Symptom Manage 2009; 37: pp. 831-847.
  • Green C.R., Nado-Brumblay S.K., Nagrant A.M., et. al.: Race, age, and gender influences among clusters of African American and white patients with chronic pain. J Pain 2004; 5: pp. 171-182.
  • Green C.R., Nado-Brumblay S.K., West B., et. al.: Differences in prescription opioid analgesic availability: comparing minority and white pharmacies across Michigan. J Pain 2005; 6: pp. 689-699.
  • Green C.R., Wheeler J.R., LaPorte F.: Clinical decision making in pain management: contributions of physicians and patient characteristics to variations in practice. J Pain 2003; 4: pp. 29-39.
  • Kalauokalani D., Franks P., Oliver J.W., et. al.: Can patient coaching reduce racial/ethnic disparities in cancer pain control? Secondary analysis of a randomized controlled trial. Pain Med 2007; 8: pp. 17-24.
  • Smedley B.D., Stith A.Y., Nelson A.R.: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care . 2002. National Academies Press Washington, DC:
  • Todd K., Samaroo N., Hoffman J.: Ethnicity as a risk factor in inadequate emergency department analgesia. JAMA 1993; 269: pp. 1537-1539.

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