All Pain Is Not Equal

Studies show low income people and minorities suffer from more chronic pain and less effective pain treatment. Credit: esbenh/ 123RF Stock Photo.

Studies show low income people and minorities suffer from more chronic pain and less effective pain treatment. Credit: esbenh/123RF Stock Photo.

Thirty-one-year-old Less Henderson recently returned from a week-long hospital stay after her lung collapsed due to endometriosis, a reproductive disease in which the lining of the uterus grows in other parts of the body, causing pain. Though endometriosis usually only affects the pelvic area, in rare cases like Henderson’s it can spread further, causing serious and potentially fatal complications.

While Henderson’s collapsed lung was addressed quickly and she is now on the mend, she has not always been as fortunate in the health care she’s received. Henderson—who is both black and working class—struggled for years to get a diagnosis for her horrible abdominal pain. Instead, she says doctors were quick to dismiss her, often accusing her of exaggerating or fabricating her pain.

“I wasn’t getting the proper care I needed,” says Henderson. “When you’re in pain and just looking for a solution, it can be very discouraging.”

While Henderson’s experiences could be chalked up to many things—a lack of adequate pain education amongst providers who treated her in the past, for instance, or an overburdened health care system—a growing body of evidence suggests that how people experience pain, as well as their ability to access adequate pain treatment, often depends on factors such as race and income.

In fact, the data are overwhelming.

For instance, analyses of data from 1998 to 2004 of nearly 15,000 adults aged 60 years or older who participated in the landmark University of Michigan Health and Retirement Study (a survey, conducted every two years, of about 20,000 Americans older than 50 years) found that black patients were much less likely than white patients to receive hip or knee replacement surgery to relieve associated pain—this despite demonstrated need. Another study published in 2007 that also relied on data from the Health and Retirement Study found that of those who reported pain, 27% of blacks and 27% of Hispanics experienced it as “severe,” compared to only 17% of non-Hispanic whites.

Several studies have also found that while blacks and Hispanics tend to have lower rates of addiction and overdose of prescription opioids compared to whites, blacks are much less likely to have these drugs prescribed for them, even when given a diagnosis that would support such treatment. For instance, a study of nearly 100,000 veterans found that blacks under the age of 65 who were suffering from moderate to severe chronic non-cancer pain were less likely to receive opioid prescriptions than their white counterparts.

Economic insecurity predicts pain
On the income side of the issue, research has repeatedly found that those who experience economic insecurity are more prone to experiencing pain.

A paper published earlier this year reported a series of studies evaluating the link between levels of economic insecurity and physical pain. One of these studies analyzed economic data from nearly 34,000 geographically diverse households in the U.S., looking at consumption of over-the-counter painkillers like ibuprofen. Results indicated that households with higher levels of unemployment tended to spend significantly more on painkillers, with households with two unemployed adults spending 20% more on painkillers than a household with only one unemployed adult.

Other studies reported in the paper found that employment status, as well as the economic prospects of the state in which study participants lived, predicted the amount of physical pain they were experiencing at the time of the survey; that a causal relationship existed between economic insecurity and physical pain; and that it was specifically a feeling of a lack of control over one’s circumstances that explained why economic insecurity predicted physical pain.

A final study from the paper was conducted in a laboratory setting, where 114 participants were asked to hold their hands in ice water for as long as they could to establish their baseline pain tolerance. Afterwards, they read statements about the economy meant to impart either a high or low level of economic insecurity, before being asked to again submerge their hands in ice water. Those who were made to feel less secure about the economy experienced a significant lowering of their pain tolerance.

“[I]t is important to note that the influence of economic insecurity on pain emerged regardless of how insecurity was operationalized,” says lead study author Eileen Chou, of the University of Virginia in Charlottesville, US. This means that people in the studies experienced increased pain when employment status was considered, when economic insecurity was felt at an individual or state level, and even when subjects simply recalled or anticipated economic insecurity, rather than it being a current reality.

Chou believes it should follow that individuals who have other emotional and financial resources to draw from during times of income scarcity will not be as physically impacted by pain as those who lack such resources.

“People who have the resources available to confront economic insecurity, such as a cushier savings account or strong family support, may be less susceptible to experiencing physical pain,” says Chou.

For individuals who are generally of low socioeconomic status (SES)—those who are undereducated and either unemployed, underemployed or working full-time in low-paying occupations and who have annual incomes at or below the federal poverty level—as opposed to just experiencing a rare instance of financial insecurity, the pain they experience tends to be chronic and intense. In particular, the 2007 study mentioned above that relied on data from the Health and Retirement Study also found that for both whites and minorities, being on Medicaid, and having lower education levels—both of which indicate low SES—were each significant predictors of severe pain. This experience of severe pain can of course be made even worse when patients fail to receive proper and timely treatment for their ailments.

“When I was treated [while on Medicaid], they wouldn’t give me any kind of check-up,” says Henderson. “They would just write me a prescription and show me the door.”

Race and class: an intimate relationship
While it can be difficult to determine whether patients like Henderson receive substandard treatment either because of race or class, some researchers believe the two are so intimately intertwined that one factor cannot be considered without the other.

“Race is a social construct, so it is nothing by itself but a proxy for a lot of different social realities,” says Salimah Meghani, who studies disparities in pain and palliative care at the University of Pennsylvania School of Nursing in Philadephia, US. “When you are only looking for race to explain an outcome, you may likely be missing something very important,” says Meghani, who published a commentary last year on the importance of taking socioeconomic status into account when looking at racial disparities in pain outcomes.

In that commentary, she pointed to results published in 2004 from a U.S. population-based telephone pain survey, which consisted of 1,335 participants, including almost equal numbers of whites, blacks and Hispanics. People who earn less than $25,000 annually have been found to experience disabling pain at more than double the rate of those who earn more than $75,000. Yet, only 3% of the African Americans surveyed reported an income level above $75,000, and one in two reported earning less than $25,000. She concluded that even though race alone was found not to predict disabling pain in the study described above, race was still an important factor since an overwhelming majority of African Americans were below an income level that was protective against pain.

Adam Hirsh, from Indiana University-Purdue University Indianapolis, U.S., who has studied the differences in pain experience and treatment between blacks and whites, agrees that race and SES are hard to tease apart when looking at disparities. “Race may operate through SES,” he says.

However, Hirsh’s recent research has yielded evidence of specific differences between blacks and whites independent of income, in regard to the perception of chronic pain and the coping mechanisms used to deal with it. In particular, one of his studies, which reviewed 19 previous studies, found that African American patients used pain coping strategies more often than did whites, particularly more passive, less effective strategies like prayer and pain catastrophizing; the latter is the tendency to obsessively ruminate about the pain and feel helpless about it.

Yet, these strategies may actually serve a more pragmatic purpose for black pain patients than research initially suggests.

“If black people have historically received poorer care due to cultural biases, catastrophizing may be a natural adaptive way to get medical attention and treatment,” says Hirsh.

Likewise, Hirsh notes that if black patients don’t receive proper treatment and their pain continues, they may feel helpless and use prayer as a way to manage their pain.

Meanwhile, on the treatment end, there also exists compelling data to show that race can either significantly compound disparities in medical treatment or even sometimes act independently of income.

In work led by health disparities researcher Carmen Green, of the University of Michigan in Ann Arbor, U.S., Tami Hart-Johnson, a social psychologist and statistician at the same institution, has examined the relationship between race and SES in chronic pain outcomes and treatment. One study assessed the relative roles of race and neighborhood socio-economic status in the chronic pain experience of 3,730 younger adults under age 50, with about 10% of the participants being black.

That study was based on prior research indicating that the socioeconomic status of one’s neighborhood often plays a stronger role in determining disparities in chronic pain treatment than one’s individual SES. In other words, if a person with low income happens to live in a wealthy neighborhood, the neighborhood’s relative affluence will have a compensating effect when it comes to how well people deal with chronic pain. In particular, poor people who live in higher income neighborhoods can have access to the superior medical centers and pharmacies that are offered in wealthy areas, whereas poor people who live in lower income neighborhoods often do not have convenient access to such resources. Neighborhoods of lower SES also tend to have higher crime rates and fewer resources such as community centers and green spaces, and are usually more stressful areas in which to live; residing in high stress environments often is linked to higher pain levels. However, the study indicated that neighborhood SES plays a less protective role for poor African Americans than it does for poor whites.

“Part of the reason neighborhood SES may not be as protective for people of color stems from the fact we still live with a large degree of segregation in the US,” says Hart-Johnson. “This means that a [person of color] living in a wealthy neighborhood is also likely to be living in a neighborhood where they are the minority [in number].” Hart-Johnson says that being the minority race in one’s community can make that person more vulnerable to bias or mistreatment within the community and at local medical centers or pharmacies.

For the most part, studies indicate that biases from healthcare providers toward people of color dealing with chronic pain are usually implicit, rather than deliberate. Furthermore, such biases are held not only by whites, but by people of color as well. For instance, in one study, Vani Mathur, who studies pain disparities at Texas A&M University in College Station, Texas, U.S., found that black participants perceived the pain exhibited by white patients as more serious than that of black patients.

“Overall, both African Americans and [whites] revealed an implicit bias by perceiving more pain in white, relative to black, patients,” says Mathur. “This is consistent with known racial disparities in pain and we argue may be reflective of the implicit racial biases about pain that exist in our culture.”

A brighter future
The implicit and pervasive nature of racial and class biases can make it especially challenging to address pain disparities. Yet, there is hope.

“There are quite a few activities that the NIH [U.S. National Institutes of Health] is either supporting or leading the effort in to address disparities,” says Linda Porter, who directs the Office of Pain Policy at the National Institute of Neurological Disorders and Stroke, part of the NIH.

In particular, Porter notes that a key area of the newly released National Pain Strategy (NPS), which outlines the U.S. federal government’s first coordinated plan for reducing the burden of chronic pain, is pain disparities. The goal is to increase understanding of bias in pain care and develop ways to overcome it, increase access to pain care for vulnerable populations, and improve communication among patients and healthcare providers.

For example, Hirsh currently has a grant from the NIH to fund a study using computer-simulated patients—or avatars—where features such as race/ethnicity, class and gender can be manipulated. He is testing whether these virtual patients can be used to enhance empathy and perspective-taking in those taking care of pain patients. His hope is that if the trial proves effective, this tool can be used in medical schools around the country or in continuing education courses to help medical professionals become more aware of racial and class biases they may be harboring and improve their care of patients.

The timeliness of this technology is noteworthy, as a recent study has shown that whites, including white medical students, can harbor significant biases concerning biological differences between blacks and whites, thereby impacting the accuracy of pain treatment recommendations. One part of the new study surveyed 121 laypeople (92 of whom were U.S.-born whites) and documented racial biases among whites that correlated with their downplaying pain experienced by blacks as compared to pain experienced by whites. The second part of the study found that half of over 200 white medical students and residents sampled held racial biases that contributed to less accurate treatment recommendations for black patients.

Another line of research on pain disparities aims to provide low-income individuals with better access to educational materials that help them understand their health care options.

“The definite goal for my research is to get patient and therapist materials widely and freely disseminated, with access to appropriate training for behavioral health interventionists to be able to use them,” says Beverly Thorn, a clinical pain researcher at the University of Alabama in Tuscaloosa, U.S.

Thorn recently collaborated with the Patient-Centered Outcomes Research Institute, an independent nonprofit, nongovernmental organization authorized by the U.S. Congress in 2010, to create educational materials for undereducated and low SES chronic pain patients that are easy to read. Thorn also believes that enabling easier access to cognitive behavior therapy will be crucial for low-income patients struggling with chronic pain.

“If we can show through research that [vulnerable] populations benefit from behavioral interventions, while saving money and time, then we have some grounds to advocate for even more policy change to address disparities in pain care,” says Thorn.

Laura Kiesel is a freelance writer based in the Boston area. Her articles have appeared in The Guardian, Salon, Science, Al-Jazeera America, BioScience and Earth Island Journal.