Understanding and reducing 

racial and ethnic disparities in 

pain and pain treatment

Diana J. Burgess, PhD

Core Investigator, Center for Chronic Disease Outcomes 

Research, Minneapolis VA Health Care System

Associate Professor; University of Minnesota Medical School
Outline 

 Overview- racial/ethnic disparities in pain and pain 

treatment

 “Unpacking” race/ethnicity – how this can help us 

understand the myriad causes of disparities

 3 studies:

 Racial discrimination and Veterans’ pain

 How patient race affects opioid prescribing decisions

 Patient race and pain management in VHA

 Implications for clinicians and policy-makers

 Future directions
Poll Question #1

 Who is in the audience?

 A. Researchers

 B. Clinicians

 C. Other
Poll Question #2

 How would you rate your overall knowledge on the 

topic of racial/ethnic disparities in pain and pain 

treatment?

 1 (No knowledge)

 2 

 3 

 4 

 5 (Very knowledgeable)
Health and healthcare disparities

 Health disparities: ‘‘differences in the incidence, 

prevalence, mortality, and burden of diseases and 

other adverse health conditions that exist among 

specific population groups...” (*NIH, in Anderson, 2009)

 Healthcare disparities: ‘‘racial and ethnic differences 

in the quality of health care that are not due to 

access-related factors or clinical needs, preferences, 

and appropriateness of intervention.’’ (Unequal 

Treatment, 2002)
Consistent evidence of racial/ethnic 

disparities in pain and pain treatment 

• Greater prevalence of pain and greater 

impairment/severity of symptoms among nonwhites 

• Non-whites receive poorer pain assessment and 

treatment than whites, across a wide variety of settings 

and all types of pain (acute, cancer, post-operative, 

chronic nonmalignant, end of life).

• These racial/ethnic disparities exist outside of and within 

the VA Healthcare System

See reviews: Anderson et al., 2009; Green et al., 2003; Meghani et al., 2012
Disparities in pain treatment are consistent with 

broader evidence of racial/ethnic healthcare 

disparities 

 IOM report, Unequal Treatment, (2002) concluded:

 Across every therapeutic intervention, minorities receive 

fewer procedures and poorer quality medical care than 

whites.0

 Differences persist even after differences in health insurance, 

SES, stage and severity of disease, co-morbidity, and the type 

of medical facility are taken into account.

 Differences persist in contexts such as Medicare and the VA 

healthcare system, where differences in economic status and 

insurance coverage are minimized. 
 Racial differences in joint replacement surgery and analgesic medication use, with less aggressiv

management of osteoarthritis in African Americans and Latinos

African Americans less willing than whites to undergo joint replacement surgery

 Due in part to less familiarity with the procedure & worse expectations of surgical 

outcomes, including recovery, chronic pain, and functioning

Clinicians prescribe opioids less often for African Americans

e 

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*Studies from1966 to October 9, 2006 JGIM, 2008 
“Unpacking” Race and Ethnicity 

• Race: assigns people to one or more of the 

socially-constructed categories (i.e., races) 

established hundreds of years ago to divide 

humans into 5 major subpopulations 

• Ethnicity: encompasses aspects of social life (e.g., 

culture) and personal identity that people within 

some collective share. 

*Ford & Harawa (2010)
2 Dimensions of Ethnicity 

 Attributional: Describes unique sociocultural 

characteristics of a group (culture, diet, beliefs)

 Relational: Captures relationship between an 

ethnically defined group and the society in which it 

is situated (i.e., intergroup hierarchy)

 Useful in understanding how social stratification and 

social exposures (e.g., discrimination) contribute to 

health and healthcare disparities

*Ford & Harawa (2010)
Contributors to Disparities in Pain & Pain 

Management

Attributional (cultural)

 Cultural variation in pain 

perception, expression, 

expectations & response 

(e.g., coping strategies)

 Cultural beliefs about pain 

management (e.g., attitudes 

toward opioids, attitudes 

toward surgical procedures)
Attributional (cultural)

 Cultural variation in pain 

perception, expression, 

expectations & response 

(e.g., coping strategies)

 Cultural beliefs about pain 

management (e.g., attitudes 

toward opioids, attitudes 

toward invasive treatment)

Contributors to Disparities in Pain & Pain 

Management

Relational

 Lack of access to healthcare 

and medication

 Unconscious or conscious 

provider bias (lower likelihood 

of prescribing opioids, poorer 

assessment, poorer 

communication) 

 Greater exposure to life 

stressors (poverty, 

discrimination) 
The Effect of Perceived Racial 

Discrimination on Bodily Pain among 

Older African American Men

Burgess, Grill, Noorbaloochi, Griffin, 

Ricards, van Ryn & Partin

Pain Medicine (2009) 
Background 

 African Americans (AA) experience discrimination at a 

higher level than whites 

 Repeated experiences of discrimination are a source of 

chronic stress and are associated with poorer physical 

& mental health and negative health-related behaviors 

(e.g., smoking, delaying healthcare, poorer adherence to 

treatment)

Burgess et al, Pain Medicine, 2009
Primary Research Question

 Is discrimination associated with greater physical pain 

among African Americans?
Methods 

Sample: Subsample of male African American patients 

(N = 393) from a national survey of colorectal cancer 

screening among VA patients (age 50-75)*

• 60.5% response rate

Dependent Variable: Bodily pain subscale of the SF-36 

1. How much did pain interfere with your normal 

work (including both work outside the home and 

housework)?

2. How much bodily pain have you had during the 

past 4 weeks?

*SCREEN study, Partin PI, VA HSR&D #IIR 04-042 Burgess et al, Pain Medicine, 2009
Methods (cont’d) 

Independent Variable: Experiences of Discrimination (over a 

lifetime)

 

“How often have you experienced discrimination, been 

prevented from doing something, or been hassled or made 

to feel inferior in any of the following situations because of 

your race, ethnicity or color?” 

at school; getting hired or getting a job; at work; getting housing; 

getting medical care; getting service in a store or restaurant; 

getting credit, bank loans or a mortgage; on the street or in a 

public setting; from the police or in the courts

(Krieger, 2005)

Burgess et al, Pain Medicine, 2009
Types of Discrimination Discrimination Experienced (%)

Never Once 2-3x >

4x 

Assoc 

w/Pain

At school 42 8 22 28 0.15**

Getting hired or getting a job 26 10 30 34 0.13*

At work 29 13 30 28 0.19**

Getting housing 45 16 21 18 0.19**

Getting medical care 65 11 16 8 0.19**

Getting services in 

store/restaurant 

23 14 32 31

0.22**

Getting credit/bank 

loans/mortgage 

37 11 26 25

0.13**

On the street or in a public setting 26 14 32 29 0.15**

From the police or in the courts 29 16 28 27

0.26**

Discrimination and Pain (unadjusted)
Association between overall discrimination 

and pain 

Variable name β p 

Perceived discrimination .25 < .0001

Age 65 or over -1.01 .005

Currently employed -1.15 .002

Education: High school or lessa .31 .54 

Education: High school or lessa .46 .35 

Income: <$20,000b -.52 .28 

Income: <$40,000b -.11 .82 

Mental health diagnosis -.22 .57 

Substance abuse diagnosis -.95 .04

Dual (mental health and substance abuse) diagnosis .30 .43 

a Reference category = college graduate or more. bReference category = over $40,000.
Discussion 

 Results suggest that racial discrimination is a potential 

contributor to the greater burden of pain 

experienced by African Americans. 

 Results consistent with numerous studies 

demonstrating an association between racial 

discrimination and poor health.

 Limitation – cross-sectional design so cannot make 

causal statements

Burgess et al, Pain Medicine, 2009
Implications for policy and practice 







Highlights importance of a biopsychosocial approach to 

pain that addresses psychological and environmental 

factors

Multiple pathways by which discrimination affects health 

(Williams, 2009)

Discrimination may affect chronic pain through any of these 

pathways and these pathways may be potential targets for 

intervention

 Chronic stress 

 Poorer mental health

 Sleep disturbance 

 Anger 

 Avoidance of healthcare/poorer adherence to treatment

 Poorer provider/patient communication
Whiteboard

 Any other implications for research, policy and 

practice? Other thoughts?
Patient race and physicians’ 

decisions to prescribe opioids for 

chronic low back pain

Burgess, Matoka, Phelan, Roth, Dovidio, Kerns, 

Saha & van Ryn

Social Science & Medicine (2008)

Funded by a Locally Initiated Project grant from 

CCDOR
Primary research question: 

Does provider stereotyping contribute to 

racial disparities in decisions to prescribe 

opioids for chronic noncancer pain? 

Burgess et al, Social Science & Medicine, 2008
25

Background 

• Stereotypes: concepts that contain our knowledge, beliefs, expectations, and feelings about a social group

• Salient patient characteristics (e.g., race) may activate 

stereotypes, which may influence providers’ – interpretation of behaviors and symptoms

– expectations about patient behaviors

– behaviors toward patients ...which can influence patients 

behaviors 

*This can occur automatically (or “implicitly”), without conscious intent
Everyone engages in stereotyping—not just 

providers

26
Stereotypes & pain treatment

 Evidence that non-whites are less likely than whites 

to be prescribed opioid analgesics

 Decision to prescribe opioids for pain - has several 

features that may increase the likelihood that 

providers’ racial stereotypes will affect their 

clinical decision-making: 

 complex decision: provider needs to weigh risks/benefits 

of opioids

 providers lack knowledge in this area
 We speculated that certain types of “red flag” 

patient behaviors (verbal & nonverbal) will activate 

or legitimate negative stereotypes of blacks (e.g., 

“criminal”, “drug user”) that lead to physician 

concerns about prescribing opioids.

 Hypothesis: Physicians will be more 

reluctant to prescribe opioids to black 

versus white patients, among patients who 

manifest “red flag” behaviors.

Burgess et al, Social Science & Medicine, 2008
Methods: Overview

Design: 

 Vignette study conducted with physicians (mail survey)

 Between-subjects factorial design 

 Patient characteristics were systematically varied 

 Race (black/white) X Verbal behavior (challenging/nonchallenging), X Nonverbal behavior 

(angry/dejected/calm)

Primary dependent measure: 

 Decision to switch patient to a higher dose or stronger 

type of opioid

Burgess et al, Social Science & Medicine, 2008
Development of “Photonovella” Stimulus 

Materials

 Photonovella: 4 photos + “script” depicting a 

chronic pain patient (accompanied by a “clinic note”)

 Created scripts (based on ethnographic research) to evoke 

patient behaviors that would or would not raise “red flags” 

among physicians about the advisability of prescribing opioids. 

 Red flag/ “challenging” verbal behaviors: belligerence, 

demanding behavior, asking for an opioid by name, using the 

opioids of a relative. 

Burgess et al, Social Science & Medicine, 2008
Excerpt from “challenging” vignette:

Patient:This pain in my back is killing 

me. You’ve got to do something. This 

is the worst pain I’ve ever had.

Doctor:When do you have the pain?

Patient: All the time, I’m telling you, 

it’s terrible. I just can’t stand it 

anymore. You’ve got to do something 

for the pain....

I tried some of my wife’s Percocet 

she had from her surgery though, and 

that stuff really worked. I want some 

of that.

Burgess et al, Social Science & Medicine, 2008
Data Collection

Mail survey: National sample of 1000 general 

internal medicine physicians

 Described as study of pain treatment (no mention of 

race).

 40% response rate

Burgess et al, Social Science & Medicine, 2008
Sample Characteristics 

Male 70.1%

Race/ethnicity

 White 41.0%

 Asian American/Pacific Islander 23.3%

 Hispanic/Latino 6.3%

 African American or American born black 4.7%

 Native American .5%

 Other 5.8%

 Did not answer 18.8%

Age M = 44.32 (12.17)

% of your patients who are non-white M = 37.12% 

(26.01%)

% of your patients who have chronic, noncancer 

pain

M = 19.67% 

(18.65%)
Analysis 

 Logistic regression was used to determine the 

effects of patient characteristics on physicians’ 

prescribing decisions. 

 Final model included: 

 Main effects of patient characteristics: race, verbal 

behaviors, nonverbal behaviors

 Two-way interactions: race X verbal behaviors and race 

X nonverbal characteristics

 Main effects of physician age

Burgess et al, Social Science & Medicine, 2008
Results: Decision to switch to higher 

dose/stronger type of opioid

Significant interaction between patient verbal behavior and patient 

race (p=.02), which was counter to our hypothesis.

64.30%

54.50% 51.10%

68.80%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

White Black*

Non-challenging

Challenging

% of physicians

who would prescribe

patient a higher 

dose or stronger

type of opioid.

*P < .05
What might account for these results?

 “Challenging” script - was designed to raise “red flags” 

but also was unambiguous in stating the patient’s desire 

 This might have reduced uncertainty common in 

physicians when treating patients of another race

 Consistent with vignette study in which assertive 

behavior led to full staging of breast tumors among 

black but not white women (Krupat, 1999)

 Vignette studies might not capture actual 

decision-making processes that occur in clinical 

settings
Implications for policy and practice

 Points to the larger issue of the unconscious use of 

factors such as race/ethnicity (“implicit bias”)

 

 

 Current research underway in VA to minimize provider 

implicit bias (Dr. Hausmann, PI with Office of Health 

Equity) 
Implications for policy and practice



 

 

Since data were collected in 2005, stronger legislative and regulatory 

efforts to address the issue of opioid diversion and misuse:

 How might racial biases operate, within this context?

 How might “positive” biases lead to inappropriate prescribing 

among groups stereotyped as unlikely to misuse/abuse opioids

 Tension between addressing disparities in opioid prescriptions and 

acknowledgment of public health crisis caused by increased opioid 

prescribing, particularly in light of incomplete evidence about its 

benefits
Whiteboard

 Any other implications for research, policy and 

practice? Other thoughts?
Presence and correlates of racial 

disparities in the VHA 

VA HSR&D IIR #07-071

Principal Investigator: Diana Burgess

Co-Investigators: Matt Bair, Melissa Farmer, 

Diana Higgins, Robert Kerns, David Nelson, 

Melissa Partin, Michelle van Ryn 

Data/Stats support: Amy Gravely, Joan Barnes, 

Sean Nugent
Primary Research Question:

• Do racial disparities in pain management (screening, 

prescription of pain medication for chronic pain, and 

perceived effectiveness of chronic pain treatment) 

exist in the VA healthcare system? 
Methods

 







Secondary data analysis

Sampling frame: ambulatory care module of the 

2007 Survey of Healthcare Experiences of Patients 

(SHEP)

In all analyses, we accounted for clustering by site 

and whether the patient was new or established
Data Sources

Key Measures Source 

Pain screening: presence of a pain 

score in patient’s record at SHEP index 

visit

Corporate data warehouse (CDW)

Pain treatment (pain medication,

including whether an opioid was 

prescribed) 

Pharmacy Benefits Management 

(PBM) database

Pain outcomes: 

•perceived effectiveness of chronic 

pain treatment

•functional interference due to pain

SHEP Ambulatory Care Module 

(2007) 
1: Are there racial disparities in pain 

screening? 

 Pain Screening Cohort: 27,683 Black and 233,765 White 

SHEP responders & non-responders whose index visit was in 

primary care 

Burgess et al, Clinical Journal of Pain, 2013
Results:

 Blacks less likely than Whites to be screened 

for pain OR: 0.79 p < .0001, 78% vs 82%*

 Adjusting for demographics, medical and 

psychological comorbidities; any active prescription of 

pain medication, outpatient utilization, and facility 

characteristics reduced the OR to 0.86, (p < .05). 

 Reduction due to higher rates of outpatient visits in 2 

yrs prior to index visit among Black patients

*Estimated for Black and White established primary care patients at a 

typical VA facility

Burgess et al, Clinical Journal of Pain, 2013
2: Are there racial disparities in pain 

treatment? 

 Pain Treatment Cohort: Subset of the “screening cohort” 

with diagnoses of low back, neck, or joint pain (9,831 Black, 

71,471 White) 

 Analyses stratified by age (<65 and > 65), since racial 

differences in “dual use” is greatest for those > 65. 

 Analyses incorporated:

 Race

 Most recent pain intensity rating

 New or established primary care patient status

 Interaction between race and most recent pain intensity rating 

 Healthcare facility and race within facility.

 Outcome: prescription of opioids in the year 

following the first pain diagnosis

Burgess et al, Journal of Pain, Accepted
Results – for patients < 65

 Blacks with moderate (4-6) or high levels (7-10) of 

pain were less likely to receive opioids than whites 

(p = 0.0025; p = 0.0011); 

 No differences between black and white patients with 

low levels of pain intensity (1-3) and those with pain 

intensity ratings of 0 (no pain). 

Burgess et al, Journal of Pain, Accepted
Results – for patients 65 and older

 Among patients with pain intensity ratings of zero, 

blacks were more likely than whites to receive opioid 

prescriptions (p = .0087), 

 No significant racial differences in opioid 

prescriptions for all other Veterans. 

 Difficult to interpret – older Whites are more likely to have 

a dual source of care and hence may be more likely to get 

prescriptions for opioids outside the VA

Burgess et al, Journal of Pain, Accepted
3. Are there racial differences in pain 

outcomes?* 

 Among chronic pain patients treated for pain in the 

VA, African Americans were significantly less likely 

than whites to report that their pain treatment was 

good, very good, or excellent (55% versus 60%, OR: 

0.83, p = .0002). 

 However, when we adjusted for non-response bias using 

propensity score methods, the effect of race on perceived 

effectiveness of pain treatment was non-significant 

*Unpublished research
 Next steps:

 Conduct additional analyses, stratifying by Veterans (<65 and 

> 65) 

3. Are there racial differences in pain 

outcomes (continued)?
3. Are there racial differences in pain 

outcomes (continued)?

 Next steps:

 Examine impact of prior opioid prescription on satisfaction 

with pain treatment and functional interference due to pain.

 Preliminary results (not stratified by age) suggest that 

having a prior prescription of opioids is not associated 

with greater perceived effectiveness of pain treatment or 

lower pain interference, for most Black and White patients 

with pain.

 Exception – For Whites with pain levels of 1-3, 

perceived treatment effectiveness was higher for those 

who received opioids
Implications for Research

 More research is needed on whether disparities in opioid 

prescribing contribute to racial disparities in MSK pain.

 Research is needed to test strategies to improve pain 

management among populations that experience disparities. 

 Current VA pain strategy focuses on self-management as the 

foundation of chronic pain management

 Newly funded study (VA HSR&D #13-030-2, PI Burgess), “A 

proactive walking trial to reduce pain in Black Veterans” will 

test the effectiveness of a proactively delivered counseling 

program to promote walking and decrease pain in Black 

Veterans with musculoskeletal diagnoses (Co-I’s: Abraham, 

Ackerman, Allen, Fu, Goulet, Heapy, Krebs, Krein, Meis, Kerns, Saenger, Taylor)
Implications: Reducing Disparities in 

Treatment

 Role of communication in reducing disparities

 Non-whites have encounters with providers that are 

shorter, less positive, less participatory and with less 

“psychosocial” talk (Cooper, 2006)

 Discussing use of prescription pain/arthritis medications 

with pharmacy staff differed by race/gender: white men 

(40.3%), white women (34.6%), black men (30.2%), and black 

women (19.8%) (LaCivita, 2009; Alabama NSAID safety 

study) 

 Small study of cancer patients found that short 

education/coaching intervention (with a communication 

component) eliminated racial disparities in pain 

(Kalauokalani, 2007)
Whiteboard

 Any other implications for research, policy and 

practice? Other thoughts?
Thank you!

 Questions? Comments?
References 

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Anderson, K. O., Green, C. R., & Payne, R. (2009). Racial and ethnic disparities in pain: causes and consequences of 

unequal care. J Pain, 10(12), 1187-1204. 

Burgess DJ, Gravely A, Nelson D, van Ryn, M, Kerns R, Bair M, Higgins D, Farmer M, Partin MR. (Accepted). Racial 

disparities in prescription of opioid analgesics for chronic non-cancer pain in a national sample of veterans. Journal of Pain.

Burgess DJ, Gravely A, Nelson D, van Ryn M, Bair MJ, Kerns, RD, Higgins DM, Partin MR. (2013). A National Study of 

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