Introduction
Although it is widely recognized that the United States has a severe and broad systemic
racism problem, recent events have dramatically elevated the issue. Widespread protests
in the US and around the world have brought much-deserved attention to the plights
of Blacks, Indigenous and People of Color (BIPOC) regarding injustices that they experience
on a daily basis. For the sake not only of BIPOC, but communities and societies as
a whole, racial injustice can no longer be ignored or minimalized.1
Racism in medicine dates to antiquity. Byrd and Clayton noted that the ancient Greeks
viewed all slaves as inherently inferior and less intelligent, and that Aristotle
displayed particular prejudice toward Black and Asian people.2 This laid the foundation
for White superiority and non-White inferiority espoused by Galen, the 2nd-century
Roman physician.3 Views of non-White individuals as “subhuman” persisted in Europe,
and were brought to the Americas by Caucasian Western Europeans.2 White superiority
and racism were used as a justification for enslaving Africans and Indigenous peoples
for the financial gain of White colonizers. Non-White inferiority served as the bedrock
of slavery, an ideology that was necessarily maintained by the White elite to continue
their exploitation of Black persons. Enslaved Africans were provided with medical
care only when financially advantageous to their owners.4 It was assumed by White
American physicians that Black patients inherently experienced poor health, and this
assumption persisted into at least the late 20th century, perpetuated in part by racial
stereotypes, stigma and bias in medical school curricula.2 Even after the Civil War,
racism in medicine persisted, with the profession writing off Black individuals as
a “syphilis-soaked” and unfit race.5 Well into the 1900s, Black individuals were overutilized
in medical demonstrations and risky experimentation,6 with the Tuskegee experiments
leaving 500 poverty-stricken Black men with untreated syphilis.7 This long history
of unequal treatment has rightfully led to a distrust of the medical community by
Black patients.8
The 1965 Civil Rights Act and the creation of Medicare and Medicaid resulted in improved
access to health care for Black patients, and limited efforts to improve access to
medical education for underrepresented groups were made.9 Regardless, systemic racism
in American medicine has persisted, resulting in problems with access, inferior treatment
and poorer outcomes for BIPOC patients in every area of health care.10 Since arriving
in the United States, Black individuals have had the worst health outcomes of any
racial group—not in small part due to stigma, systematic oppression, and lack of access
to care.2
Today, implicit bias continues to negatively influence multiple avenues of the care
continuum including access and quality of care. Bias also affects patient and provider
communication, treatment-related decisions and ultimately contributes to poorer health
outcomes and health disparity.11 In addition, studies show systemic racism, including
discrimination, inflicts continued trauma, which increases hypervigilance and stress
particularly in Black, Latinx, and Indigenous patients. Collectively these factors
lead to a greater negative cumulative impact on both physical and mental health. Such
impacts are manifest as changes in cardiovascular, metabolic, inflammatory, and psychological
responses.12,13
In 2008, the American Medical Association (AMA) issued a formal apology for racism
in medicine.14 While this was a symbolic gesture, acknowledgement of wrongful past
actions particularly toward Black individuals was a step in a positive direction toward
building trust and improving health equity. In 2020, the AMA updated their AMA Manual
of Style when classifying race and ethnicity in medical literature. This manual now
recommends providing more information on race and ethnicity in research studies and
calls for capitalizing Black and White race identifiers to align with the capitalization
of other racial and ethnic categories. These changes signal an acknowledgment that
race and ethnicity continue to play a role in disparities in medicine.15
Racism in Pain Medicine: A Review of the Literature
As is the case in medicine, broadly, racial and ethnic disparities plague BIPOC patients
suffering from pain. Disparities in pain assessment and treatment stem from both the
personal nature of pain experiences and provider-related racial bias regarding pain
in BIPOC patients, which can lead to undertreatment of pain.16 Further, failure by
clinicians to account for the significance of cultural context in patient behavior
cues and pain coping skills hampers assessment and treatment decisions.17 Much of
the early research demonstrating these disparities pertained to their ability to predict
oligoanalgesia in emergency medicine. For example, Todd and colleagues determined
that Latinx patients with isolated long-bone fractures presenting to the Emergency
Department (ED) were only half as likely as non-Latinx White patients to receive opioid
analgesia.18 This finding was particularly poignant given the results of a follow-up
study published the following year from the same ED, which found no difference in
physician ability to assess pain between Latinx and non-Latinx White patients.19 Further,
data indicate that Latinx and non-Latinx White patients have the same expectations
for analgesia in EDs.20 Another study determined that Black patients with long-bone
fractures in the ED were significantly less likely to receive opioids than White patients,
and significantly more likely to receive no analgesics whatsoever.21 Perhaps even
more distressing are results from a study demonstrating that Black patients were significantly
more likely to be denied insurance authorization for ED visits than were White patients.22
On a more general basis, myriad studies have demonstrated that BIPOC patients have
historically been less likely to receive opioid analgesia than are White patients
across ages and painful conditions.23–33 Unfortunately, recent studies continue to
demonstrate that BIPOC patients presenting with painful conditions continue to face
disadvantages regarding assessment and treatment in EDs,34–38 with patient perceptions
of this disparity serving as a barrier to even seeking emergency care.39 Similarly,
a 2018 study of traumatically injured individuals requiring emergency medical services
(EMS) transport to hospitals found that significantly fewer Black patients received
opioids prehospital compared to other ethnic groups.40 Similar findings were obtained
from a more recent study.34 Studies have found that implicit bias among providers
affects their clinical judgement, decisions and behavior. Racial and ethnic stereotypes
also influence assessments and treatment, especially with high pain intensity self-report
among BIPOC patients.41–43 Use of the Implicit Association Test (IAT) in health systems
has indicated that implicit bias among clinicians leads to discrimination and unequal
care.44 Higher implicit bias among physicians is associated with specific behaviors
such as failure to make eye contact with patients, using a condescending tone and
pitch, discordant word choices, and more top-down directive communication with BIPOC
patients. This negatively influences trust, causes anxiety, and leads to poorer outcomes.45,46
Although the literature on disparities that BIPOC patients with acute painful conditions
face in EDs is discouraging, numerous studies support the presence of disparate treatment
in all areas of pain medicine, from assessment to treatment. Regarding diagnosis,
for example, a VA study determined that Black patients in primary care were significantly
less likely to be screened for pain than were White patients.47,48 Further, several
studies have indicated that BIPOC patients were less likely to receive advanced diagnostic
imaging compared to White patients.49–53 Given these findings, it is not surprising
that BIPOC patients’ pain is less likely than that of White patients to be treated
through rehabilitative approaches such as physical therapy54–59 or addressed surgically.49,60–69
Regarding racial and ethnic disparities in adult acute postoperative pain, McDonald
found that White patients received higher dosages of opioids following appendectomies
than did BIPOC patients.70 Ng and colleagues found in two 1996 studies that Black
and Latinx patients received significantly less opioid analgesia than White patients
following open reduction and internal fixation of a limb fracture.48,71 McNeill and
colleagues determined that non-White hospital inpatients who had undergone surgeries
were less satisfied with their analgesia than were White patients.72 Jimenez and colleagues
found that Latinx children undergoing tonsillectomy and adenoidectomy received 30%
less opioids than did White children.73 A more recent study of pediatric postoperative
pain using case vignettes determined that as pediatricians' pro-White bias increased,
they became less likely to express willingness to prescribe to Black patients with
an unvarying willingness to prescribe to White patients.74 Similarly, two studies
determined that BIPOC women were less likely to receive opioid analgesics postpartum
compared to White women.75,76 Again, this is not surprising given the findings that
White women were more like to receive neuraxial anesthetics for caesarian sections
than were Black and Latinx women.77,78
BIPOC outpatients with chronic noncancer pain in a wide variety of settings have been
found less likely to receive opioid analgesia than White patients, with these findings
unfortunately having persisted for several decades to the present.79–92 Yet, with
so many investigations indicating the difficulty experienced by BIPOC patients regarding
access to opioid analgesia, studies suggest that they are generally subjected to even
more aggressive risk mitigation procedures by providers. For example, Black patients
receiving opioid analgesia were found to be more likely to be subjected to urine drug
testing and restricted early refills than White patients,93 with similar findings
obtained in a 2013 Veterans’ Administration study.94 Not surprisingly, Black chronic
pain patients were determined to be more likely to have their long-term opioid therapy
discontinued following the detection of illicit drug use than were White patients.95
Additionally, in this day of involuntary opioid tapers among non-aberrant and stable
chronic pain patients, multiple studies have demonstrated that Black patients are
more likely to have their dosages reduced than are White patients.96,97 These findings
are particularly discouraging in light of recent data indicating that prescription
pain medication misuse is less common among Black patients than in any other racial
and ethnic group studied,98,99 as well as those from a 2018 study that found that
prescription opioid abuse was significantly lower among Black and Latinx patients
admitted for opioid misuse treatment as compared to admitted White patients.100 Further,
recent data determined that deaths from prescription opioids are more common among
White individuals misusing than BIPOC misusers.101 Finally, a 2020 study determined
that while BIPOC chronic pain patients were less likely than White patients to receive
a prescription for opioids, they were more likely to receive a prescription for naloxone,
signaling providers’ heightened mistrust of BIPOC patients’ personal medication management.102
This is consistent with the “racialization” of legitimate opioid use vs prescription
and illicit opioid misuse that has been described in the literature.103,104 Collectively,
these studies paint a clear picture of BIPOC patients being perceived as less “worthy”
of opioid analgesia, at higher risk of aberrancy, and requiring more rigorous risk
mitigation – irrespective of the data demonstrating that this represents an egregious
false narrative.
Another empirically established cause of BIPOC patients receiving inadequate analgesia
compared to White patients is a disparity in pharmacy access. Pharmacies in predominately
underrepresented neighborhoods serving BIPOC patients were found in two early studies
to be less likely to receive sufficient opioid analgesic supplies compared to those
in predominately White neighborhoods.105,106 Further disparity can be identified through
a 2017 study determining that generally, areas with more BIPOC residents per capita
had significantly fewer pharmacies,107 thereby increasing the challenges that BIPOC
patients endure in their efforts to obtain all prescribed medications – including
those for pain. This is consistent with the results of earlier studies identifying
access issues in heavily underrepresented neighborhoods, which the authors identified
as “pharmacy deserts” and “medication deserts”.108,109 Additionally, a 2014 study
determined that race was a determinant of access to pharmacy services such as discount
generic drug programs.110 Thus, BIPOC patients are forced to deal not only with challenges
relating to obtaining prescriptions for adequate analgesia but with difficulties in
actually being able to fill prescriptions should they obtain them.
Access to pain care based on financial deprivation and/or insurance coverage is another
disparity with which BIPOC patients are faced. This is not surprising given that racial/ethnically
underrepresented patients have more limited access to health care due to their insurance
coverage (or lack thereof), generally.111–115 Studies have determined that BIPOC patients
have less access to quality pain care than White patients due to their insurance or
inability to afford copays and other out-of-pocket expenses, which tends to result
in poorer outcomes.116–121 In addition to economic barriers, literacy and language
barriers also present challenges in accessing pain treatment for BIPOC individuals
and can lead to miscommunication further eroding trust and influencing treatment decisions.122,123
Numerous studies have demonstrated a strong positive relationship between perceived
racial and ethnic discrimination and pain intensity.124–136 This is of particular
importance, given the literature indicating that the experience of discrimination
predicts inferior physical and mental health outcomes.137–139 Not surprisingly, data
also indicate a positive relationship between perceived injustice and pain severity
as well as poorer pain outcomes among BIPOC compared to White patients.140–144 Perceptions
of racial injustice have been well established as undermining BIPOC patients’ trust
in the medical establishment in which they are treated,145–149 with this lack of trust
potentially compromising pain management efforts and their outcomes. Data suggest
that due to perceptions of discrimination, many BIPOC individuals go so far as to
delay, avoid seeking, or prematurely discontinue health care.150–153 Again, BIPOC
patients’ access to adequate medical treatment becomes compromised, potentially resulting
in increased morbidity and even mortality.
Moving Toward Equal Care Standards
Society has identified myriad social injustices at the systemic level stemming from
inherent bias, discrimination and long-held stereotypes that lead to unequal healthcare,
yet the medical community and policymakers have failed to enact substantial measures
to right past wrongs. While there are a multitude of discussions regarding unequal
access and treatment of BIPOC patients in health research, within health systems and
broadly in our communities, change has been slow and perfunctory. Up to this point,
we have summarized myriad studies demonstrating the pervasiveness of racially motivated
disparities in pain care in the US. However, simply raising awareness of implicit
and explicit bias is insufficient; the time for definitive action toward substantial
improvements in the racial determinants of pain care is now.
To deconstruct the current system and rebuild it, increasing trust and addressing
gaps in access and treatment will require large-scale will and action. This can be
done by taking steps to incorporate BIPOC voices in policy decisions, increasing the
number of BIPOC professionals in leadership and health equity roles, and providing
more opportunities for BIPOC individuals to enter health and medical professions,
in particular Black, Indigenous and Latinx individuals focused on pain management
practices. In parallel, utilizing an individualized approach to pain assessment and
treatment will help clinicians recognize the significance of cultural context in pain
coping, pain experiences, and how economic factors such as treatment affordability
and access can drive treatment decisions for underrepresented groups.
Training issues are paramount, as effective cultural sensitivity training in the health
sciences seems to be uncommon. Numerous calls have been made for the inclusion of
anti-racism training within medical school curricula,154–156 as teaching students
about issues such as implicit bias, health disparities, and cultural competence has
apparently been insufficient. Additionally, aggressive proactive measures should be
taken to increase the number of BIPOC health care professionals engaged in pain management.
Recent census data estimate that approximately 76% of Americans identify as “non-Hispanic
White”, with the remaining 24% identifying as BIPOC.157 That roughly 56% of the US
physician population identifies as White with the other 44% identifying as BIPOC appears
at first glance to be encouraging.158 However, closer scrutiny of these data indicates
that only 5% identify as Black and 6% as Latinx, with the aforementioned census data
indicating that Black individuals comprise 13.4% of the population and Latinx individuals
comprising 18.5%.157 Thus, in medicine broadly, the two most prevalent BIPOC groups
are severely underrepresented, and patients within these groups are less likely to
have a racially concordant provider than are White patients, which has the potential
to result in less favorable pain outcomes.159 Data regarding the representation of
Black and Latinx physicians in pain medicine are more elusive, but there is no evidence
suggesting greater representation than in medicine, generally.
Given the data indicating that physician-patient race/ethnicity concordance increases
patient trust and adherence,160–166 a national effort to produce more BIPOC physicians
in primary care and all specialties is essential as our nation’s population continues
to become more diverse. With concerns regarding adherence associated with opioid analgesics
continuing to be prominent, such efforts become even more imperative in pain medicine.
Accordingly, consideration should be given to incentivize both undergraduate medical
students and residency/fellowship training programs to increase the ranks of BIPOC
trainees. Such incentivization would not be without precedent. For example, a 2009
systematic review determined that incentivization programs have resulted in greater
numbers of health care providers choosing to work in underserved areas.167 Types of
incentives include direct financial incentives, service-requiring scholarships, educational
loans with service requirements, loan repayment programs, and service-option educational
loans. Incentivizing physicians where to practice, however, has proven easier than
incentivizing them regarding what to practice. With the passage of the Affordable
Care Act (ACA), the shortage of primary care providers became an even more salient
issue, and calls for similar direct and indirect incentivization were made.168,169
Although Primary Care Residency Expansion (PCRE) grants from the Health Resources
and Services Administration were temporarily available per the ACA, a 2015 study determined
that these time-limited grants were unlikely to increase the flow of medical students
into primary care residencies in a sustainable manner.170 Congress has attempted to
incentivize the expansion of primary care graduate medical education, yet the offered
incentives have offered only minimally financial benefit to those choosing primary
care – resulting in the perpetuation of the shortage.171 Additionally, it is in hospitals’
best financial interests to train subspecialists for whom their reimbursements will
be higher as opposed to primary care residents.172 Accordingly, recent calls for a
more direct financial benefit are being made,173 with Ahmed and Carmody recently opining
that providing financial compensation or expanding loan forgiveness programs for physicians
entering practice in the most needed specialties or areas would create a powerful
incentive to encourage doctors to work in the areas of greatest societal need. (p.
5) 172 Given the relative shortage of BIPOC pain physicians, we posit that such direct
financial incentivization for BIPOC physicians to enter pain medicine training programs
will be imperative as a step toward reducing systemic racism in pain medicine and
improving the care that BIPOC patients receive. Similarly, BIPOC nurses, physician
assistants, physical therapists, all others who treat chronic pain, and students in
these fields should also be directly incentivized to level the playing field. However,
more needs to be done in terms of education, beginning in the earliest phases of health
care education. Courses covering systemic racism and strategies for overcoming racial/ethnic
bias should be provided to both undergraduate and graduate health care students. Although
health care curricula deal with the strains of a growing amount of information that
needs to be taught in a limited amount of classroom time, the importance of teaching
students about the damage unnecessarily caused by systemic racism ought not be understated.
Further, continuing education requirements for physicians and allied health providers
should include mandatory training in racial/ethnic sensitivity issues. State boards
of health care professions have the right to require their licensees to take coursework
covering specific topics and do so regularly. For example, 20 state boards currently
require a prescribed number of continuing medical education (CME) each renewal cycle
on pain management, with many others having requirements for CME specifically on opioid
prescribing.174 Should there not also be a continuing education requirement for issues
of racial/ethnic bias?
Another strategy for enhancing communication between providers and BIPOC patients
is enhanced utilization of culturally competent interpreters when needed. Such practices
have strong evidence-bases for improving pain outcomes. For example, a 2012 study
of limited English proficiency (LEP) patients found that those provided with access
to interpreters reported better quality pain treatment and appeared to result in patients’
reports of better communication regarding pain with their providers.175 Additionally,
the importance of interpreters having a degree of medical competence as well as bilingual
fluency if they are to be effective cannot be understated.176 Even if an interpreter
must be used, pain care providers can engage in thoughtful dialogue regarding race
and culture with patients and how they play a role in pain management. Doing so can
foster trust and engender collaborative treatment decisions, which has been found
to be particularly challenging for White providers treating BIPOC patients.177,178
Physicians and other pain care professionals should also be aware of the availability
of several useful tools that can aid organizations in bridging language and communication
gaps. For example, the National Institute on Minority Health and Health Disparities
(NIMHD) has developed a language access portal (LAP) which provides information in
several languages specific to conditions identified with health disparities.179 Other
useful tools for improving cross-cultural communication with BIPOC patients include
the Culturally and Linguistically Appropriate Services (CLAS) standards180 and the
National Institutes of Health’s HealthReach program for health information in multiple
languages.181
Summary and Conclusions
Based on our review, it is clear that the history of systemic racism in pain medicine
has been an ugly and unfortunate one, resulting in needless suffering by so many patients
simply because of their race/ethnicity. The current Coronavirus pandemic – together
with the ongoing protests regarding the need for social justice – has highlighted
the persistent detrimental effects of systemic racism, including the impact of long-standing
stress and trauma. Yet, we should not lose sight of these unfortunate times representing
an opportunity to create sustained and meaningful change toward delivering equitable
pain care. Implicit bias remains a contributor to healthcare disparities, broadly.
Given that patients suffering from chronic pain are already stigmatized and marginalized,
BIPOC chronic pain patients are particularly vulnerable. Provider self-awareness of
bias, understanding the cultural context of pain, showing empathy, using a softer
tone, listening, and allowing patients to voice their concerns are all important strategies
to reduce stress and improve pain management outcomes. On a broader level, evening
the playing field will also require the incorporation of BIPOC patients into policy
decisions, increasing the availability of BIPOC pain care professionals in the American
health care system, and a paradigmatic revision in the models under which pain care
professionals are trained. Each of these transformations will be imperative if pain
care is to ever adhere to the bioethical principle of justice. Our expectation is
not that this analysis will result in an immediate and dramatic revision of the system
in which BIPOC patients with pain are treated. However, we are hopeful that by bringing
these issues to the attention of policymakers and pain care professionals, the unique
plights of BIPOC patients with pain will begin to be more widely recognized and addressed.