The Institute of Medicine (IOM) defines health disparities as differences in treatment provided to members of different racial (or ethnic) groups that are not justified by the underlying health conditions or treatment preferences of patients.¹ Pain management varies and is commonly tailored to the patient’s individual pain condition and needs. However, when pain management differences are not justified by the underlying pain condition or treatment preference of a patient, this contributes to health disparities.² Disparities in pain management have been well documented and not limited to racial or ethnic minorities and may include other characteristics such as gender, sexual identity, age, disability, religion, socioeconomic status, geographic location, and other social determinants. This chapter identifies some of the most common health disparities in pain management.

Nearly 100 million American adults suffer from chronic pain, and disparities in pain management may occur because of a variety of patient-, provider- and system-level factors.³ Differences in pain management commonly occur in the setting of an uncertain diagnosis and limited treatment options. In addition, a patient’s background, identity, or affiliation and other characteristics may limit a clinician’s ability to develop a comprehensive patient-centered pain evaluation and treatment plan. For example, a clinician may not able to communicate effectively with a patient with low health literacy or limited English proficiency, not have the training or allied staff support to adequately develop a treatment plan, and these challenges can result in suboptimal pain management.⁴ Reducing pain management disparities for all patients will ensure those most vulnerable receive optimal pain management evaluation and treatment.

Racial-ethnic disparities are often solely attributed to lack of access to health care. However, even racial-ethnic minority patients with access to health care still receive lower quality of care. Patient race-ethnicity influences physician interpretation of patients’ complaints and clinical-decision making, such as treatment or procedure referrals.^5,6 Racial-ethnic minorities consistently receive less adequate treatment for acute and chronic pain when compared with non-Hispanic whites, even when controlling for age, gender, and pain intensity.⁷ These pain management disparities may occur when there is pain intensity underreporting and/or clinicians have a limited awareness of their own cultural beliefs and stereotypes regarding pain, racial-ethnic minorities, and the use of opiate analgesia. For example, a study of primary care physicians (PCPs) in 12 academic medical centers across the United States found that the PCP’s underestimated pain scores of African American patients by greater than 2 points on an 11-point numeric pain rating scale 47% of the time compared to 33.5% of the time for non-African Americans. In addition, systemic literature reviews consistently show African Americans are more likely to experience undertreatment of pain when compared to non-Hispanic whites.^8,9,10 Racial-ethnic differences in pain reporting and treatment are increasingly documented in other groups such as Hispanic- and Asian Americans.¹¹ Recent studies are exploring racial bias as possible cause of pain management disparities and early results suggest clinicians may hold false beliefs about biological differences between racial-ethnic groups.¹²

Sex refers to biologically based differences, whereas gender refers to a socially based identity.¹³ These terms are not interchangeable. Most basic science pain research has included male subjects only and few have explored sex differences.¹⁴ Clinically the prevalence of pain reporting is higher among women compared to men.^3,15,16 The most concerning pain management disparity in women is the gap between them reporting pain and not receiving an appropriate evaluation and treatment.^3,17 While psychosocial research supports the cultural stereotype that women are more willing to report pain than men,¹⁸ biological differences such as fluctuations in estrogen during menses and pregnancy have been linked to migraine and temporomandibular pain conditions.^19,20 In addition, the impact of these biological differences on opioid response have been contradictory and unclear.^13,21 Further research is needed to further characterize sex and gender differences in pain and pain management. Training should also include education on how clinicians can provide culturally and clinically appropriate care for lesbian, gay, bisexual, and transgender (LGBT) people.²²