Understanding the Relationship Between Pain & Racism

No human leaves this life unscathed: stubbed toes, broken arms, sports injuries, car accidents, illness, childbirth, cancer—many of the most profound human experiences are rounded out with pain. But humans are resilient, and over time, more and more effective ways to treat pain have been developed. So today, for many people, modern medicine stands between them and the full impact of living completely unmedicated. From anesthesia during surgery; to Tylenol for a headache, and all of the little moments between; there are clinical proactive steps to manage any type or level of pain.

While many are afforded the comfort modern medicine has to offer, racism once again steals opportunities for the good health, and the relief from severe suffering of our Black communities. Today, in the United States, the under-prescription of pain medications for Black patients is a real, documented phenomenon. A phenomenon that can only be explained by systematic racism and outdated myths held by medical professionals, including false beliefs about higher pain tolerance, addiction, and basic human anatomy.

Though the over prescription of pain medication, and therefore addiction, has become a serious issue in many communities across the nation, it is almost exclusively Black communities that are associated with this crisis and are therefore denied adequate care. Black individuals remain 22% less likely to get relief from chronic pain than white patients, and when it comes to acute pain, are 40% less likely to be prescribed pain medication. This leaves Black patients needlessly suffering, without the otherwise accessible medication to relieve it. Physicians who discriminate against their patients—even if they do so unintentionally—can be held responsible for medical malpractice.

What is the Medical Definition of Pain?

The American Academy of Pain Medicine classifies pain in two categories, acute and chronic. When a patient is experiencing acute pain, the source is related with an injury. The pain is considered “short-lived and self-limiting” because, ideally, the need for pain management is temporary and will alleviate on it’s own as the injury heals. 

However, if the underlying cause of acute pain is not treated, it may become persistent and intractable. This happens if the underlying disease or injury is incurable, or if the activation of pain is unavoidable and caused by movement or weight bearing. This happens most often with patients experiencing injuries of the spine or in diseases such as arthritis. In general, pain that is considered chronic is defined as: pain that lasts longer than three months, regardless of the cause.  

Both acute and chronic pain can be managed by a general practitioner or specialist with a range, or combination, of treatments such as nonsteroidal anti-inflammatories (NSAIDs) and other nonopioid medications, physical therapy, psychological interventions, alternative medicine, or opioids.

Why are Some Not Treated for Their Pain?

Evidence indicating that physicians and nurses do not treat pain adequately began to appear in medical literature nearly 30 years ago. It exists alongside current news chronicling the opioid crisis sweeping the nation. In the following decades, the accumulated data showed that many types of pain—acute pain, cancer pain, and chronic nonmalignant pain—were largely being undertreated, despite news that has indicated otherwise. The reasons offered for undertreatment, usually characterized as “barriers” to effective pain relief, are remarkably consistent across the literature. 

These “barriers” included insufficient knowledge among clinicians about the basic assessment and management of pain; the failure of health care institutions and professionals to make pain relief a priority; a lack of accountability for providing effective pain relief; physician concerns about regulatory scrutiny of prescription practices; and the persistence of myths and misinformation about the risks of addiction, tolerance, and adverse side effects associated with opioid analgesics in the Black community.

The idea that Black communities are more prone to addiction have been conjured up by the “War on Drugs”. This “war” has relied heavily on a reciprocal relationship between the criminalization of blackness and the decriminalization of whiteness that persists very strongly in American culture today. 

In addition to misinformation about the risks of addiction that disproportionately affect Black communities, there are also disturbing, persistent, and incorrect biological beliefs that are not-forgotten 19th-century relics.

Many false beliefs persist today. In fact, half of trainees surveyed held one or more such false beliefs, according to a study published in the Proceedings of the National Academies of Science, in 2016. A stunning 40% of first- and second-year medical students endorsed the belief that, “black people’s skin is thicker than white people’s and that there are biological differences between the two, mainly that black bodies are stronger” both of which are medically unfounded. Participants who more strongly endorsed false beliefs about biological differences reported lower pain ratings for their black patents, ie, the stronger the racial bias, the worse the ability to accurately treat pain.

The Relationship Between Racism & Pain Treatment

Drilling down through the healthcare system from birthing suite to hospice care, reveals that at every point along the journey, Black patients are less likely than white patients to receive any pain medication at all. And when pain medication is administered, lower doses are prescribed, regardless of pain score. 

As studies begin to slowly emerge, the data offers a picture of a healthcare system that is not functioning to serve every member of the community. 

Black patients are:

• Having pain needs met less frequently in hospice care. 
• More likely to wait longer to receive pain medications in the emergency room. 
• Having lower back pain misdiagnosed by clinicians despite reporting greater pain and higher levels of disability.

Additionally, Black veterans with osteoarthritis received fewer days’ supply of the nonsteroidal anti-inflammatory drug than white veterans during routine office visits. 

Sickle Cell Anemia and Pain Treatment?

The outreaching effects of racism on the healthcare system means that when dealing with diseases that predominantly affect the Black community, the treatments, research, and medications are inefficient at the core.

Sickle Cell Anemia (SCA) is an example of this, as it is a disease affecting nearly 73 in 1000 Black Americans, but only 3 in 1000 white Americans. SCA occurs when the human body is producing hemoglobin, the protein molecule that carries oxygen in red blood cells. The amino acid glutamate, an amino acid responsible for the role it plays in nutrition, metabolism and signaling, is replaced by valine, causing a change in the elasticity of red blood cells. 

In fact, this substitution causes some of the red blood cells to collapse, assuming the characteristic sickle shape. Red blood cells are typically elastic and will conform to the shape of tiny capillary blood vessels, SCA causes red blood cells to become rigid and block the blood vessels, depriving tissue of oxygen and ultimately resulting in severe pain.

Other Complications of SCA are:

• Stroke: a complication of SCD, affecting 10% of children with sickle cell anemia.
• Acute chest syndrome: similar to a pulmonary embolism, it can precipitate with cough, shortness of breath, fever.
• Tissue Death: sickling can lead to blockage of oxygen to tissue in any part of the body and is extremely painful, similar to the effects of gangrene. 

Many people suffering from SCA live in a constant state of chronic pain. Adults report pain on more than 50% of days surveyed and children on about 10%. Chronic pain often leads to other problems, like depression and anxiety.

Chronic Pain Exacerbated by Lack of Access to Care

SCA patients are frequently seen in emergency rooms or require admission for treatment of pain, infection, or other complications. Readmissions to hospitals are receiving enormous attention from Medicare and other payers, such as health insurance companies, with hospitals being penalized for readmissions for specific diagnoses. 

These include congestive heart failure, pneumonia, COPD, and diabetes. Illnesses with readmission rates greater than 25% include HIV; hepatitis: lupus: and sickle cell, which has the highest rate of readmission at 31.9%. This means SCA patients, among others, are often undertreated or turned away from treatment in order to avoid penalization. 

Can a Physician be Held Liable for Failing to Treat Pain?

There is an established standard of care when it comes to pain management and physicians who fail to treat pain according to those standards are committing medical malpractice, and gross negligence. And, even if professional medical or hospital boards don’t hold physician licensees to that standard, juries will. 

Fortunately, the implementation of the new pain standards by the Joint Commission for the Accreditation of Healthcare Organizations, which recognize the right of patients to the appropriate assessment and management of their pain, will continue to uncover disparities in the healthcare community. 

Is Access to Pain Medication a Human Right?

The ethical responsibility of clinicians to manage pain is well understood and stands as a basic element of ethical medical codes. Many organizations around the world recognize this right. The American Medical Association, for example, states that “Physicians have an obligation to relieve pain and suffering,” and the World Health Assembly resolved that, “It is an ethical duty of health care professionals to alleviate pain and suffering.”

Understanding the idea that pain relief is, in fact, available in many forms, but is being withheld from patients is unacceptable. The Black community is suffering, needlessly. Pain management and palliative care are basic human rights. And in defense of these basic human rights, physicians who fail to treat pain are negligent and can be held responsible for medical malpractice.

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