Pain management has been an increasing topic of interest, and so too have the disparities in pain care across different cultural and ethnic groups. Despite the concerted efforts to diminish health care disparities, it is apparent that we continue to fall short. Retrospective cohort studies conducted by Todd et al. in 1993 and 2000 found that Hispanic and Black patients were considerably more likely than Caucasian patients to not receive analgesics for similar injuries in the emergency department (Ann Emerg Med 2000;35:11-6). These differences in analgesic administration were mirrored by a 2019 meta-analysis that confirmed practices have minimally changed (Am J Emerg Med 2019;37:1770-7). This phenomenon extends past the management of acute pain and is also seen in obstetric, chronic, and cancer pain care (Pain Med 2021;22:75-90; Ann Intern Med 1997;127:813-6; Obstet Gynecol 2019;134:1147-53).
Understanding the factors that mediate these differences is essential in the pursuit of eliminating disparities in pain management. In that regard, the impact that cultural and ethnic differences can have on the self-perception and expression of pain as well as pain assessment should continue to be evaluated. Defined by a lifetime of an evolving cultural framework, pain is a subjective experience that is cognitively appraised by the individual. Culture influences how pain is characterized, how it is expressed, and what approach we should offer to manage it.
Historically, with regard to pain practices, cultures will fit into two broad categories. They can be more stoic or expressive. Patients from stoic cultures have a learned suppression in expressing their pain, while those from expressive cultures can seem to overexpress their pain qualities and labeled as such by providers. Many traditional Chinese cultures believe the notion that expression of pain outside of childhood is undignified, therefore its overt expression demonstrates having poor social skills (Age Ageing 2013;42:455-61). Similarly, African Americans have been known to underreport pain in clinical settings. Social pressures to appear stoic and implicit cultural frameworks pressure patients to not lead the interaction with a negative impression, especially toward those of a “higher social value” (Clin Orthop Relat Res 2011;469:1859-70). Conversely, traditional Muslim Middle Eastern cultures have spiritual definitions for many ailments. These cultures instill a strong belief in a greater meaning behind their discomfort. Their expression of pain is unhindered by external pressures, allowing for more effective diagnoses of underlying etiologies (Curr Opin Psychiatry 2009;22:200-4; J Pain Symptom Manage 2016;52:771-4).
Like the expression of pain, implicit beliefs about pain guide patient preference in its management. These preferences have significant impact on quality of life and, at times, prognosis. Across studies, Hispanics report acute pain with high expressivity but underreport chronic pain (asamonitor.pub/3iK5l0s; J Pain 2016;17:513-28). Hispanic patients in America recognize chronic pain as prevalent among their communities and accept these types of lingering pains are considered a normal part of aging and will go undertreated. Views on utilization of opioids in pain management is considerably different in Muslim societies than in western cultures. Among most patients from Muslim cultures, there is an underlying fear that opioids will interfere with their sense of self – this fear extends to nonopioid pain management medications. Muslims may fear that, at the very least, pain medications will inhibit them from communicating with loved ones, but a greater fear exists that the use of such medications violate their religious beliefs (West J Med 2002;176:60-1; asamonitor.pub/3uIfopo). What is considered standard-of-care practice for pain management is unpalatable with traditional views in these cultures because of lack of familiarity, mistrust in another culture’s approach to pain management, and fatalism.
Cultural and ethnic differences can also affect how pain is assessed by others. A 2007 study found physicians to be twice as likely to underestimate pain in African American patients compared to other ethnicities, and a 2019 study by Mende-Siedlecki et al. found that pain was less readily recognized on the faces of African Americans compared to Caucasians (asamonitor.pub/3FqkJXq; J Exp Psychol Gen 2019;148:863-89). Racial biases can directly affect treatment recommendations, possibly partially explaining the differences in pain management approaches among ethnic groups, e.g., African American and Hispanic patients receiving less opioid medication (Pain Med 2012;13:150-74). Health care professionals display the same levels of implicit bias as the general population, and a substantial number of medical and nonmedical personnel alike hold misguided views about biological differences between ethnicities that affect pain perception (asamonitor.pub/3FIraGJ; Proc Natl Acad Sci USA 2016;113:4296-301).
Disparities in pain management arise from a complex and multifactorial interplay between individual, health care provider, and health system perceptions on what constitutes optimal patient care. In order to optimize patient comfort and adequately address pain, health care providers should continue to pursue cultural competency and practice cultural humility. Shared decision-making involves not only a discussion of “relevant risks, benefits, and alternatives” but also allows for the patient to discuss their personal beliefs and guide the provider, together deciding which treatment options are “more or less desirable” to the patient (asamonitor.pub/3v33FlP). Paloma Toledo, MD, MPH, and Jerome Adams, MD, MPH, addressed existing evidence to support the necessity of focusing our attention on “diversity, equity, and inclusion …[to] improve patient safety, quality, and outcomes.” Numerous studies have suggested that the delivery of equitable, high-quality care relates to the degree of concordance that exists between the composition of a patient population and their health care providers. Until the proportionality of physicians matches the patient population, efforts to raise awareness and understanding of factors contributing to disparities in pain management add to our cultural competency and provide us with building blocks to empathetic and equitable patient care.