Learning Objectives: After participating in this continuing professional development activity, the provider should be better able to:

1. Distinguish the ways in which bias and systemic racism can affect pain management.

2. Explain the consequences of discriminatory practices on minoritized populations who are receiving pain management.

3. Evaluate specific actions that can be taken to establish health equity in the delivery of pain management services.

Health care professionals view pain assessment and treatment as a moral human right and have advocated for this right to be a critical element of ethical and humane health care practice. However, there remain enormous disparities in pain management across various populations of the United States. This article focuses on recent research that highlights evidence on the vast inequities in pain management and reviews approaches that all clinicians can use for improving health equity in pain management.

Disparities in Pain Management

In 1985, the US Department of Health and Human Services (HHS) released a seminal report under the leadership of former HHS Secretary Margaret Heckler entitled Report of the Secretary's Task Force on Black and Minority Health,1 referred to as the Heckler Report. Although this was not the first report to document inequities in health among America's minority populations, it was the first report initiated by the federal government that commissioned a panel of health experts to assess factors affecting disease risk and make recommendations to improve the health of minority populations across the nation.

The Heckler report provided a starting to point to address health disparities, or differences in health outcomes among groups that are systematic, unjust, and avoidable, at a national level. The HHS Office of Minority Health was established soon after the release of the Heckler Report to carry out the recommendations, and many organizations joined the mission to eliminate health disparities and work toward health equity, creating a fair opportunity for all people to reach their full health potential and have access to healthy lifestyle choices.

Specific to disparities in pain management, the Institute of Medicine's 2011 publication, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, provided a thorough overview of known disparities in the prevalence of pain, treatment, and outcomes among various population groups.2 The publication documented the intersections between pain, educational attainment, employment, and poverty, describing how the cumulative effects of pain can widen health disparities for minority populations. A decade later, there continue to be reports of inadequate assessment and management of pain for people with English as a second language, racial and ethnic minorities, veterans, and populations with low income or educational attainment, and other socially minoritized populations. Yet, the obligation to relieve suffering is ubiquitous throughout the ethical principles espoused by all health care professionals. In particular, the American Nurses Association reapproved its position statement in 2018 for the ethical responsibility to manage pain, with the mandate to take action against disparities associated with access to pain management.3

Bias and Systemic Racism in Pain Management

With a professional commitment to end disparities in pain management, why then do health disparities continue to be observed? Bias and systemic racism are 2 factors involved as root problems in the persistence of health disparities in pain management. Bias denotes partiality in favor of one group (or individual) compared with another, in a way that would be considered unfair. Assumptions about another person may influence a clinician's assessment of pain, willingness to accept subjective pain reports, motivation to administer appropriate treatment, or perception of the patient's tolerance of pain and coping.

As an example, a retrospective analysis of 25,732 encounters by emergency medical services provided to adults with a traumatic injury demonstrated that Hispanic patients were 21% less likely and Asian patients were 31% less likely to receive a pain assessment procedure compared with White patients.4 In addition, Black patients were less likely by 32%, Hispanic patients by 21%, and Asian patients by 24% to receive any pain medications when compared with White patients. Another cross-sectional study of 11,576 adults with long-bone fracture who presented to the emergency department reported that total morphine milligram equivalent units prescribed were 4.3%, 6.0%, and 8.1% less for Hispanic, Blacks, and Asians as compared with non-Hispanic Whites.5

Bias can be implicit or explicit, but both result in decisions made based on prejudice or unjust attitudes toward a person who is perceived to belong to a minoritized group. When explicit bias exists, individuals are aware of their beliefs and values that influence their behaviors, whereas implicit bias is unintentional, often due to lack of awareness, and therefore uncontrollable. Clinicians who recognize their own prejudices can gain control by reconciling their conscious beliefs and values in their decision-making process.

Racial and ethnic bias in pain management has been shown to be a phenomenon tied to beliefs about biological differences in pain perception, often propagated in formal educational programs, which then influence bias in treatment recommendations.6

Bias can result in variation in the way pain is managed across specific populations who have the same type of injury or disease.

For instance, de-identified data from 115 patients presenting to the emergency department with a long-bone fracture were examined for the clinical and demographic variables associated with medication administration.7 White patients overall were more likely to receive opioid medication for pain treatment compared with non-White patients (70% vs 50%, P < 0.0001), whereas adult and elderly patients were prescribed opioid medications more than pediatric patients.

Among 266,210 patients with kidney stones treated in the emergency department, White patients received the highest median morphine milligram equivalents, whereas Black and Hispanic patients received less, and Black patients were less likely to receive ketorolac.8

Although White patients are more likely to misuse opioid medications, studies have shown that Black patients receive opioid analgesics less often than do White patients.9 However, when Black patients perceive discrimination during their medical encounter, their risk of opioid misuse increases.9 Thus, beyond the direct detrimental effects of stereotyping and bias-driven decisions in pain management, discriminatory actions can be an other-imposed self-fulfilling prophecy that promotes adverse patient reactions and behaviors.

Bias is an inclination that can lead to discrimination. Discrimination is unjust treatment of different categories of people, usually on the grounds of race, age, or sex. However, another study demonstrated that bias can exist toward additional characteristics that can influence pain assessment, including the use of prehospital analgesics, type of injury, and behavioral characteristics.

Researchers found that among 539 adult patients admitted to the emergency department with musculoskeletal pain, nurses underestimated pain by a mean difference of 2.4 on an 11-point scale (95% confidence interval, 2.2-2.6).10

Nurses' documented assessment of pain and patients' self-reported pain were in agreement 27% of the time, and the authors found that pain was underassessed for 63% of patients. Patients at risk of underassessment of pain included women, smokers, people with a lower educational level or with injury to the lower extremities, use of prehospital analgesics, and those who were anxious or expressed a lower urgency level.

From the patient's point of view, discriminatory treatment by health care providers not only has an impact on the patient's perception of pain management, but can also negatively influence pain processing and outcomes. A survey administered to 622 veterans with pain demonstrated that negative interpersonal experiences and unresolved pain were strongly associated with perceived racial or ethnic discrimination.11 In combined models stratified by racial or ethnic groups, perceived discrimination was significantly associated with poor interactions with health care providers for Latinos, negative demeanor of health care providers for African Americans, and unresolved pain for Whites.

In a study of 71 individuals with sickle cell disease, discrimination in health care settings was associated with greater clinical pain severity and enhanced sensitivity to experimental pain testing measures, perceived stress, depression, and poor sleep.12 In addition, discrimination was a significant predictor of mechanical temporal summation, a marker of central pain facilitation.

In research that involved 3056 women from the Study of Women's Health Across the Nation, the authors reported that chronic, everyday discrimination was significantly associated with more bodily pain among all ethnic groups included (Japanese, African American, Chinese, White, and Hispanic).13 Discriminatory practices can lead to worse pain outcomes for historically excluded individuals, including the impact of pain on activities of daily living, employment and income, mental and physical health, quality of life, and risk of suicide.2

Systemic racism, also known as structural or institutional racism, is a term that means preferential treatment given to specific racial groups that are implemented through laws and regulations. Business practices that limit accessibility to pharmacies and analgesic medications, including opioids, affect neighborhoods with a higher density of minority residents.14

This limited accessibility is also the case for nonpharmacologic pain management services, such as physical therapy, cognitive behavioral therapy, and chiropractic manipulation, which may also require copayments or may not be covered by insurance.15 In addition, procedures to relieve pain, such as spine augmentation for individuals with osteoporotic fractures, have been shown to be offered significantly less often to ethnic minorities and patients on Medicaid.

Among a total of 110,028 patients in the National Inpatient Sample registry with a primary diagnosis of vertebral fracture between 2011 and 2015, patients who identified as Black, Hispanic, or Asian/Pacific Islander were significantly less likely to receive any spine augmentation, such as kyphoplasty or vertebroplasty, compared with White patients.16 Spine augmentation was performed more often on patients with Medicare compared with those with Medicaid, private insurance, or self-pay.

Similar findings of offering treatment options more often to select populations have been reported on the use of knee and hip arthroplasty. Lower rates of knee and hip arthroplasty have been shown among Black and Hispanic patients compared with non-Hispanic Whites, although Black and Hispanic populations have a higher prevalence of osteoarthritis.17

Regional differences in reimbursement of these procedures through Medicaid expansion in some states have been shown to reduce these disparities. However, the structural barriers in access to specialty health care providers and services remain a significant problem.

Recently, Medicare enrollment and claims data were used to examine hospital referral region-level variation and disparities in hip and knee joint replacement by race and socioeconomic status, including 924,844 total hip replacements and 2,075,968 total knee replacements.18 The study demonstrated that disparities in knee replacements remain unchanged from 2009 to 2017 whereas total hip replacement use for Black and White Medicare-only beneficiaries increased. However, disparities are increasing for Black and White dual-eligible beneficiaries, especially in regions with high concentrations of socioeconomically disadvantaged populations.

Action Toward Eradicating Disparities in Pain Management

Ideally, action toward eradicating disparities in pain assessment and treatment begins with an institutional or practice-level commitment that involves the entire health care team, from schedulers to providers, and from practitioners to administrators. Building an equity-oriented culture of inclusivity takes time, effort, and persistence but is crucial for ensuring that a respectful environment is experienced by each patient. If the institution is not ready for such a commitment, individual practitioners can serve as role models and advocates for meaningful change. However, this change will require persistent and mindful dialogue to garner buy-in and resources allocated for staff and provider education; policies and procedures to support a healthy work environment free of racism and discrimination; and a network of referral services to assist patients in addressing structural barriers to care.

To address the bias that exists in health care delivery today, it needs to be addressed not only by the system, but also by each provider. Policies and trainings for the acknowledgment of existing bias in health care delivery, specifically pain assessment and treatment, are needed to prevent the systemic perpetuation of discriminatory practices.19

A study conducted by Hirsh et al19 showed that a personalized educational training with computer-simulated patients exhibiting various ethnic and racial qualities and socioeconomic status eliminated 85% of care bias in acute and chronic pain treatment. Although this intervention may not be the ideal training for every provider, it serves as an example of the effectiveness of personalized simulation to improve knowledge of existing bias and techniques to eliminate stereotype-based judgment for pain treatments.

Although there has been a movement to include education about implicit bias and social determinants of health in the curriculum of health care professionals, training to recognize and address stereotyping behavior and language in the clinical setting should be emphasized for seasoned practitioners and those in educational programs alike.

Removing assumptions from interactions with patients takes time, practice, and teamwork. Allowing for frank and honest discussions regarding how each member of the health care team is approaching their own assumptions and recognizing and eliminating biased language and decision-making can help to establish an inclusive practice. Stigmatization of patients presenting with pain, especially of a chronic nature, can be harmful to patients and the culture of the clinical environment.20 Perceived discrimination or stigmatization can arise inadvertently from body language, negative demeanor, and poor interactions with clerical staff or health care providers-another reason for normalizing the giving and receiving of feedback to other members of the health care team. Patient satisfaction surveys also can be insightful regarding the inclusivity of the clinical environment and help evaluate progress of the team's goals.

During work to address health inequities affecting indigenous populations in Canada, Browne et al21 developed an equity-oriented health service model that entails inequity-responsive care, culturally safe care, trauma- and violence-informed care, and contextually tailored care. This model has been used to transform primary care practices through organizational-level interventions, and has demonstrated improved outcomes in population health.22 Inequity-responsive care is conceptualized as the creation of safe and trusting environments in which historical and current trauma, discrimination, racism, and power relations are explicitly addressed. This is operationalized through cultural safety, which entails health care provider training to promote an environment that validates these issues and their impact on health.

Trauma- and violence-informed care recognizes the impact of trauma ranging from early childhood adversities to structural discrimination, such as enforced poverty and disproportionate criminalization, and the effects of violence, both past and ongoing, on health. Planning for the care of populations with these experienced histories entails a wide range of services that should be coordinated to address things such as food and housing, mental health, violence, transportation, and financial planning. Specific to pain management, avenues for quick referral to free or low-cost access to nonpharmacologic therapies is important for facilitating active treatment and reducing disability. Working with community partners and public health agencies may reveal untapped programs, resources, or contacts who can assist in a logical referral program.

Cultural safety entails training health care providers to explicitly address power relations, institutionalized and interpersonal biases, and other forms of discrimination, and the ongoing impact of historical injustices on health and health care.21 This may involve having the prescriber explain historical power relations involved in the provider-patient relationship, how it is important to be cognizant of this, and how it is addressed in the clinical setting.

The concept of cultural safety may also be made explicit in the mission, vision, and principles of the institution and agency and aspects upon which every employee is evaluated. Providing a way for patients and families to report when they perceive discrimination and quick follow-up from administration with the involved staff is important to demonstrate the institution's genuine efforts to carry them out.

A critical aspect of pain management, however, is that some patients may perceive discrimination when they are not offered opioid medications or when their pain remains unresolved.11 Prescribers must be supported in their decision to avoid opioid medications based on clear contraindications or evidence presented. In turn, the potential for variable levels of pain to remain during and after treatment should be fully disclosed and explained by providers. Using a network of community resources aimed at providing nonpharmacologic therapies to patients experiencing pain will help providers address patients who have unresolved pain.

The concept of harm reduction encompasses the use of compassionate, respective, and inclusive language and interactions with patients who are using substances and the development of policies and services to reduce harms in the use of substances (such as providing naloxone administration devices).21 However, this also includes addressing the criminalization of substances and people who use substances, and how these structural factors affect pain management. As described, the equity-oriented health service model expands the biopsychosocial model of pain, and calls for action in addressing the various barriers to pain management, including structural and systemic factors that are at the root of health inequities.

Antidiscriminatory Practices in Pain Assessment and Management

Addressing each patient by name and asking their chosen pronouns can prevent misgendering. Alternatively, using gender-neutral pronouns (they/them/their) is acceptable until the patient's chosen pronouns are known. Misgendering can be a traumatic trigger for people who have experienced gender discrimination and may complicate the establishment of a therapeutic relationship.22 Some languages, such as Spanish, do not have gender-neutral terms, so it is important to ask the patient's preferred pronouns upon introduction and use them throughout the conversation. In addition, language barriers contribute to difficulties in pain assessment among patients who speak a different language than the provider. Interpretation services should be readily available to facilitate the dialogue between the patient and the provider. Although various pain assessment tools have been translated and validated, communication breakdown can still occur due to differences in contextual interpretation and meaning.23

To adequately address the assessment of pain, communication between the health care provider and the patient is of utmost importance. The provider needs to understand the timing of onset, quality, frequency, duration, associated symptoms, and alleviating and inciting factors of pain for the patient.

The issues of pain assessment and accurate description of pain experience are complicated when health literacy challenges exist. Lower quality of care can result when providers do not communicate in a way that can be understood by the patient or when patient understanding is not assessed by the provider.24 Patients with lower perceived health literacy have decreased confidence in communicating with providers, and this leads to more inaccuracies in reporting pain and unpleasant symptoms.25,26

Pain treatment options may also be impacted by health literacy if a patient does not have an adequate understanding of the treatment plan, rationale for how it works, intended applications, potential complications, or how to identify whom to contact if any problems or questions arise.26,27 Lower levels of health literacy can also negatively impact the patient's ability to develop self-management skills that could supplement and/or replace pharmacologic treatments.28

Culture may influence the interpretation and expression of pain. For example, an ache can be understood as a mild pain, whereas in other cultures it is rated more severely using a numbered scale.26,29 This can be a challenge when differences in culture exist between the patient and the provider, and when there is no attempt by the provider to understand the deeper cultural meaning of the patient's pain.

Health care providers enter an encounter with cultural bias because of assumptions made based on education and experiences.30 This form of discrimination can impede the accurate assessment of pain for individuals. Extra time is needed with a special attention to separating preconceived notions of pain experience in groups of individuals.6,31 Getting to know the patient and taking an extra step to depict the pain experienced accurately is crucial to the development of an individualized plan of pain management.

To understand the contextual issues surrounding the patient's experience of pain, all patients should be asked about their overall health, current living situation, and access to primary care services and treatment.19 Other factors that may affect pain outcomes should be assessed, including social relationships, safety at home and in the neighborhood, history of depression and/or anxiety, and dietary, sleep, and exercise patterns.

Bias in pain assessment leads to inadequate pain management treatment.29,30 The belief that different races experience pain differently impacts the ability of a provider to accurately assess a patient's pain and further alters the course of pain management and treatment. A study conducted by Hoffman et al6 compared perceptions of ethnic and racial differences in pain experience and correlations with pain treatment options. The assumptions included the idea that some ethnic groups do not experience pain in the same way or to the same degree as others, or that some patients would not adhere to medical treatment because of their ethnicity. These false beliefs then led to undertreatment of chronic pain and, in some instances, no treatment for pain at all.31 Equipping providers with tools to help them explain the physiology of pain may be helpful in addressing such biases.32 Although pain neurophysiology education (PNE) is a cognitive behavioral intervention delivered to patients, it provides a common understanding across all people regarding the fundamental principles of how and why pain exists and ways in which individuals can modulate their pain experience (ie, reconceptualization). It provides a method of understanding and explaining pain across different patient populations, but does require provider training. A recent systematic review of PNE that involved 18 randomized controlled trials and 1585 patients with musculoskeletal pain demonstrated that the PNE intervention provided small to moderate effects on pain, disability, and psychological distress at postintervention and long-term, 12 months after the intervention.33

Before the physical examination, patients should be asked about their comfort level and whether they want someone to be in the room during the examination. In addition, the provider should ask for assent before touching the patient and explain what will occur and any instructions the patient will be asked to follow during the examination. Diagnostic tests or procedures should be thoroughly explained, along with planned follow-up and options for treatment. It is important to assess for any barriers that may prevent the patient from attending appointments for diagnostic testing and follow-up, including work schedule, child care, transportation, insurance coverage, and lack of understanding the necessity of the appointment. Having a clinical case manager or patient navigator who is familiar with the patient population and their needs can be helpful as a contact for answering questions, coordinating follow-up communication and appointments, and ensuring that the patient and family are able to access the services provided.

Conclusion

Recognizing the impact of bias and discrimination in pain management across the United States, clinicians have the opportunity to change this dynamic by integrating just and equitable methods for practice, validating factors beyond the biopsychosocial dimensions that influence pain outcomes, and taking action to eradicate these inequities. Awareness and correction of one's own implicit biases in daily interactions is a foundational first step, while building systems to support the needs and address the inequities of care take time and resources to bring about sustainable change. Using the antidiscriminatory pain management practices, every clinician can contribute to building a more equitable-oriented system for improving pain outcomes across various populations.

References