Understanding the contribution of racially and ethnically discordant interactions to pain disparities: proximal mechanisms and potential solutions

The disproportionate impacts of the COVID-19 pandemic on racially and ethnically minoritized individuals have led to a renewed sense of urgency in addressing persistent and widespread disparities in health care. Within pain medicine, robust evidence indicates that Black patients report higher levels of acute and chronic pain than White patients. Similarly, the results from more than 40 experimental studies have consistently demonstrated moderate-to-large effects of participant race on experimental pain sensitivity across multiple modalities. Despite clinical and experimental evidence for racial and ethnic differences in pain, Black and Hispanic or Latino/a/x (the terms Hispanic and Latina/o/x are not interchangeable. We use the term “Hispanic” to reflect the term used by the authors of the specific studies we reviewed. In cases where participants of specific studies have self-identified as “Hispanic or Latino”, we have used the term “Hispanic or Latino/a/x” to be gender inclusive. When referring to non-White populations conceptually, not in relation to a specific research study, we use the term “Hispanic or Latino/a/x” in recognition that there are diverse preferences and perspectives on the terms Hispanic and Latino/ a/x within these communities) patients frequently receive less adequate pain care. For example, a recent meta-analysis of analgesia prescription rates in emergency departments found that Black and Hispanic or Latino/a/x patients were 34% and 13% less likely, respectively, to receive opioid analgesics for acute pain compared with White patients. The factors contributing to racial and ethnic disparities in pain—and disparities in health more broadly—ultimately stem from the historical and ongoing unequal treatment of racially and ethnically minoritized individuals. Systemic racism creates and perpetuates socioeconomic disadvantage among minoritized individuals, reduces health care access and trust in providers, and increases exposure to physical, psychological, and social factors that predict worse health outcomes including pain. System-level changes, including parity in the racial and ethnic diversity of health care providers, legal reforms to protect minoritized individuals against systemic racism, and social reforms to increase equity of access to health care, are essential to mitigate racial and ethnic disparities in pain and painmanagement. At the same time, it is also important to seek out more immediate solutions that may be useful for minoritized patients experiencing the effects of systemic racism. In fact, a growing body of evidence points to a proximal contributor to pain disparities that may be addressed in the moment of the clinical encounter: intergroup anxiety—experienced by both providers and patients—associated with racial and ethnic discordance. In this review, we outline evidence for the contribution of racial and ethnic discordance to differences in experimental pain and disparities in clinical outcomes. We propose a framework for understanding the impact of racially and ethnically discordant interactions on the pain experienced by minoritized individuals, focusing on the role of intergroup anxiety experienced by minoritized individuals (Fig. 1). We identify factors that may moderate intergroup anxiety and discuss potential ways clinicians can reduce the intergroup anxiety experienced by minoritized individuals in racially and ethnically discordant interactions (Table 1).