Patients of color receive different pain care than white patients, and universities are turning to implicit bias training for clinicians and revamping medical school curricula to help fix the problem.
Disparities between racial groups in pain management largely exist due to the widespread, incorrect belief among providers that race is biological rather than a social construct, according to experts. This ingrained, sometimes unconscious assumption that people of color experience pain differently means marginalized communities often go without adequate medication or treatment for their pain.
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For example, Black and Hispanic emergency department patients are less likely to receive opioids for pain than white patients who have the same elevated blood pressure or heart rate, according to a study released earlier this month by Epic Research. Similar studies have found that providers are also less likely to prescribe opioids to patients of color in other departments, including pediatrics, said Dr. Joseph Wright, chief health equity officer with the American Academy of Pediatrics.
“We know how to treat pain,” Wright said. “The problem is that biases relative to the administration of pain [medication] or assessment of pain in different groups of people produce different outcomes.”
Here are strategies institutions and states are trying to reduce bias and improve pain treatment among marginalized groups.
Implicit bias training
Providers’ unconscious biases are a main contributor to disparities in pain management, said Dr. Stephen Thomas, professor and director of the Center for Health Equity at the University of Maryland School of Public Health. Making healthcare professionals aware of the negative outcomes of their biases and resetting their thinking patterns could make a difference in how patients of color are treated, Thomas said.
Seven states — California, Michigan, Maryland, Minnesota, New Jersey, Delaware and Washington — have enacted laws requiring some level of implicit bias training for providers or medical students. California’s law mandates implicit bias training courses for nursing students.
Healthcare professionals in Maryland must complete an implicit bias training program accredited by the Accreditation Council for Continuing Medical Education or recognized by a health occupation board in order to renew their medical license.
One 2019 study by Indiana University found physician residents and fellows had lower odds of demonstrating a treatment bias against Black patients with chronic pain after receiving an implicit bias intervention. The intervention gave the providers personalized feedback on their biases, as well as a broader perspective on how pain impacts Black individuals’ lives using videos and a virtual patient simulator, according to Adam Hirsch, psychology professor at the Indiana University’s School of Science.
The next step is to monitor physicians’ adherence to pain management protocols and ensure they are administering medication and other forms of treatment equitably across the board, said Dr. Megan Mahoney, professor and chair of the department of family and community medicine at the University of California, San Francisco. Health systems should regularly collect data and check in with providers to see whether disparities stem from the assessment or prescription stage, or another step in patients’ care, she said.
Anti-oppressive medical curriculum
University of California, San Francisco’s School of Medicine overhauled its undergraduate medical education program in 2021. The school launched the Anti-Oppression Curriculum initiative to combat race-based medicine — the concept that certain racial groups are at higher risk for various conditions and patients should be diagnosed or treated differently based on their race. As part of the initiative, UCSF removed any elements of its curriculum deemed oppressive based on race, gender identity and sexual orientation.
Mahoney was shocked and dismayed at how much her education relied on race-based medicine. Professors in some areas were still teaching medical students just a few years ago that Black people feel less pain and have different kidney function than white people because of their skin and muscle mass, she said.
Efforts to teach students early on about how to provide adequate care for patients of different backgrounds are instrumental in ensuring that they don’t go on to treat people of color differently when managing pain or any other condition, said Mahoney.
Educators and medical students should still talk about race, but as a factor linked to inequity and social determinants of health, not a biological identifier, she said.
Patient advocacy and non-opioid pain management
Black patients with chronic pain can face challenges receiving the same non-pharmacological treatment options as white patients, according to Hirsch.
Hirsch has helped implement several projects at various health systems helping Black patients become more involved in pain management care by communicating their treatment goals to providers.
At Eskenazi Health, based in Indianapolis, one pilot study offers Black patients with chronic pain virtual coaching services to help them determine how different treatment options like exercise, chiropractic care and cognitive behavioral therapy could help. The one-on-one coaches also walk patients through how to advocate for their care needs and communicate their feelings and experiences effectively within the time constraints of a 15-minute appointment.
“The ultimate goal is to have Black patients and their providers engage in shared decision making around pain care,” Hirsch said. “That is one of the things that Black patients do not receive as much as white patients do.”
Hirsch said he hopes efforts aiding Black patients will help providers, healthcare leaders and public health organizations to enact change on a structural level.
