Barriers to Pain Management

The problem of disparities in pain management based on race and ethnicity is now widely acknowledged. ^{4,6,7,27,31,32} In the emergency department, for example, studies have shown that the administration of analgesics by physicians who encounter patients with pain due to injury is influenced by race and ethnicity, differences that could not be explained on the basis of gender, language, or insurance status, severity of the injury, or physician characteristics such as gender.³¹
Another study found that African-American patients were less likely to receive analgesic medications in the emergency department than Caucasian patients, despite similar reports of pain in the medical records.³² A study of Hispanic patients that did not show the same disparity suggested that hospitals that serve communities with large numbers of minorities may be less likely to undertreat a specific minority group.³³

Disparities in pain management are not limited to the emergency department. A recent review of studies identified ethnic and racial disparities in pain treatment in diverse settings, but also noted that the methodology of these studies has varied in quality and the magnitude of the disparities usually has been relatively small.³⁴ Nonetheless, the consistency in the findings of these reports raises concern that both race and ethnicity have the potential to influence practice and contribute to the undertreatment of pain.

Healthcare providers should be aware that patients describe their pain using terms and qualifiers that vary with ethnicity. A study of patients from 6 ethnic groups, for example, suggested that pain responses within an ethnic group are shaped by surrounding culture.³⁵ The impact of culture and language on pain descriptors is illustrated by a comparison of American and Chinese patients, which revealed that Anglo-Americans typically describe muscle pain as “deep,” but this word was used by only half of the Mandarin Chinese.³⁶ Similarly, most Chinese describe tooth drilling as “sourish,” while this descriptor is rarely used by Americans.

It is not clear whether race and ethnicity affect pain perception.³⁷ Accordingly, differences in pain expression and behavior should not be ascribed to physiological variation without very careful assessment. Patients are best served if clinicians start from the position that a disease process (e.g. trauma or arthritis) that is frequently painful in the majority population is likely to be painful in minorities as well.