Addressing racial inequities in chronic pain

man holding his head

New research offers interventions

In her latest research, Kristine M. Molina, associate professor of psychological science, raises awareness about the link between chronic pain and racism.

“Systemic racism can generate or worsen chronic pain, not only through biased medical care, but also via the brain’s pain-danger-alarm processes,” Molina says. “Racism has been an overlooked but preventable source of chronic pain that unjustly burdens the lives of Black Americans and their ability to contribute to society.”

She calls the framework “critical because it moves beyond traditional medical conceptualizations of the pain experience resulting from tissue pathology to considering factors at multiple levels that can contribute to the presence, duration, and intensity of pain.”

In a paper Molina co-authored in the Journal of General Internal Medicine this month with Howard Schubiner, Benita Jackson, John A. Sturgeon, Shawnita Sealy-Jefferson, Mark A. Lumley, Jallicia Jolly and Zina Trost, the researchers offer interventions.

“The epidemic of chronic pain, affecting approximately 20 percent of Americans and estimated to cost $600 billion per year, exacts a tremendous personal, economic, and societal toll,” the researchers note in “Racism as a source of pain.”

Though various social groups experience heightened rates of trauma, discrimination and pain, the researchers focused on Black Americans, given their unique history of anti-Black racism in the United States. 

“Since cultural, structural/institutional, interpersonal and individual levels of racism can be sources of pain that unjustly burden Black Americans and may contribute to racial inequities in chronic pain, we have to intervene to address racism at multiple levels,” Molina explains. “We must move beyond solely considering traditional biomedical or psychosocial therapies and intervening only in clinical and medical contexts. We also need changes in society to address the painful effects of racism. This can include multilevel interventions that directly address structural conditions with substantial and concrete institutional and community investments that improve access to crucial resources. We can also mobilize individuals across communities to raise awareness about injustices and to build coalitions across diverse groups and stakeholders to advocate for policy reform across sectors and at multiple levels, all while building on the expertise of community-based leaders and groups and supporting grassroots advocacy.”

Among the interventions, Molina and her colleagues call on healthcare providers, clinicians, trainees and policymakers to:

  • Consider the role of their own biases as they approach each patient to find ways to acknowledge the role of historical and contemporary racial injustices faced by their patients in a therapeutic and respectful manner. 
  • Recognize that emotions such as anger, fear and grief stem not only from living with chronic pain, but also from a personal, community-level and cultural histories of racism-related mistreatment, threat and loss. 
  • Perform careful clinical evaluations for structural disorders that are causing pain. 
  • Thoughtfully and gently inquire about linkages between stressful life events — including experiences of racism and discrimination within and outside of the healthcare system — and the onset or exacerbation of pain. 
  • Develop a multi-faceted approach that acts on the major causes of pain not only limited to the level of the individual but also encompassing the healthcare system and societal levels. 
  • Understand the impact of systemic racism on the individual pain experience and the unequal burden of pain in Black communities in the United States. 
  • Modify the practices of healthcare systems such as creating solutions to increase access and improve clinical encounters to address inequities of underestimation of pain and reduced provision of pain assessments and treatments.
  • Provide better education in the history of societal anti-Black racism, exclusion from and disparate treatment faced by Black and other racialized groups, and a shared commitment to “know and do better” for healthcare trainees and providers. 
  • Teach clinicians to recognize the inequitable care that their patients have received in the past and continue to receive, and to identify alternatives to their role in perpetuating these disparate and damaging patterns. 
  • Create interventions that effectively address racial inequities in chronic pain by moving beyond both the clinical and medical contexts to consider the sociocultural and structural conditions that catalyze disadvantage and poor health outcomes. 
  • Dismantle social systems that perpetuate racial injustice and the identification of and implementation of solutions to these social problems. 
  • Conduct more research to identify mechanisms linking multiple levels of racism to pain and pain-related outcomes, and putative modifiable protective factors.
  • Understand and commit to dismantling systems that create and perpetuate racial inequities and to improve access to crucial resources, such as healthcare, childcare, and financial and educational resources. 
  • Conduct multi-level interventions directly addressing upstream factors by connecting knowledge about pain, levels of racism, and systemic inequalities and understandings of social systems and structural conditions with concrete institutional and community resources and investments.
  • Support grassroots advocacy, such as the National Pain Advocacy Center, building on the expertise of community-based leaders and groups, and connecting to cross-sectoral coalitions of clinicians and healthcare providers as well as social workers, case managers, or community health workers. 
  • Mobilize individuals across communities to raise awareness about injustices while simultaneously building effective coalitions to catalyze social movements to advocate for policy reform across sectors and at multiple levels — local, state, and federal. 

“Systemic racism has negative consequences for the health and well-being of our entire society,” the researchers note. “Indeed, as chronic pain is associated with substantial disability, the consequences of systemic racism on Black Americans’ ability to contribute to society are large and remediable. Viewing physical pain as one of the consequences of racism and societal injustice more broadly illuminates these effects and points toward effective solutions for those afflicted with chronic pain as well as offering the potential for a more just and inclusive society.”
— Mimi Ko Cruz