Confronting Racism in All Forms of Pain Research: Reframing Study Designs

This scoping review examines and analyzes literature regarding ways structural racism contributes to racial disparities and health inequities in chronic pain.

Introduction

In their 2022 article, Letzen et al. explore the relationship between structural racism and chronic pain disparities in the United States. Building upon existing literature that documents racial differences in pain treatment, this article also focuses on the historical underpinnings of how structural racism has influenced chronic pain management.

Structural racism is defined by the authors as “institutional practices that are a combined set of policies, cultural attitudes, and representation that have reinforced racist ideals.” In the context of chronic pain, disparities observed among racial and ethnic minorities are not attributed to biological differences, but rather to differences in care, access to healthcare, and the effects of structural racism. Consequently, this article reviews existing literature and identifies current knowledge gaps as well as implications for future research. 

Janelle E. Letzen is a licensed clinical psychologist and pain researcher at Johns Hopkins University. Vani A. Mathur is an Associate Professor in the Department of Psychological and Brain Sciences at Texas A&M University. Mary R. Janevic is a Research Associate Professor in Health Behavior and Health Education at the University of Michigan School of Public Health.  Michael D. Burton is an Associate Professor in the Neuroscience Program at The University of Texas at Dallas.. Anna M. Hood is a Lecturer in the Division of Psychology and Mental Health at the University of Manchester. Calia A. Morais is an Assistant Professor in the Division of Hematology and Oncology at the University of Alabama at Birmingham. Staja Q. Booker is an Assistant Professor of Nursing at the University of Florida.  Claudia M. Campbell is a Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine. Edwin N. Aroke is a Tenured Associate Professor at the University of Alabama at Birmingham School of Nursing. Burel R. Goodin is a Professor in the Department of Anesthesiology at Washington University in St. Louis. Lisa C. Campbell is a Licensed Clinical Psychologist and clinical researcher at East Carolina University. Ericka N. Merriwether is an Associate Professor in the Department of Physical Therapy at New York University.

Methods and Findings

Utilizing searches through PubMed and PsychINFO, the authors conducted a scoping review of literature at the intersection of chronic pain management and structural racism. A total of 731 studies were identified using key terms, like “structural racism,” “systematic racism,” and “chronic pain.” Nineteen articles met the inclusion criteria and were included in the review. 

The following key findings emerged, categorized in a handful of themes:

1. Health Delivery and Access Disparities
   • The literature revealed that segregated health systems and less access to care for BIPOC individuals contributed extensively to disparities in healthcare delivery. 
     1. The disparities lead to lower rates of insurance coverage, which in turn restricted access to pain management services.  
2. Racism and Social Determinants of Health 
   • BIPOC individuals experience higher levels of chronic stress that can also be correlated with risk factors such as poverty, laborious work, trauma, and environmental toxins, all of which lead to higher rates of chronic pain. 
   • These findings highlight that these disparities stem from factors of structural racism, such as differences in environment, employment, and education.
3. Clinical Racism 
   • Widespread clinical racism has led to structural disparities in care, as medical education has relied on antiquated and racist beliefs that refer to differences in pain management regarding managing chronic pain for BIPOC patients. 
4. Structural Policies
   • The authors also highlighted structural policies that disproportionately affect BIPOC individuals, such as neighborhood disinvestment and the criminalization of drugs and substance use (such as opiates).
   • Additionally, the refusal to expand Medicaid – particularly in the context of the harmful effects of the aforementioned policies on historically marginalized racial groups – further contributes to disparities in care and increased rates of chronic pain.
5. Intersectionality Disparities
   • Structural racism also intersects with other forms of disadvantage and oppression, which makes intersectionality essential to fully understanding disparities. Therefore, the authors advocate for the use of multilevel modeling and geospatial analysis to evaluate health outcomes in relation to policy and neighborhood-level factors.
6. Limitations 
   • While there is a substantial amount of literature examining the relationship between chronic pain and individual experiences of racism, there is limited research focused on the effects of structural racism on chronic pain.  
   • There is a lack of standardized metrics for evaluating the effects of structural racism on chronic pain. This has resulted in limited research on the topic and has made it difficult to compare chronic pain disparities to other health disparities. 

The authors recommend three potential solutions to the inequities presented: 

• Work on facilitating community partnerships and trust within BIPOC communities
• Use antiracist frameworks to help provide evidence of discrimination and potential solutions 
• Use incentives to increase diversity in care teams 

Conclusions

The authors conclude that there needs to be additional research focused on the intersection of structural racism and chronic pain management. Expanding this research has the potential to inform the development of antiracist frameworks for chronic pain management and drive the creation of new methodologies and metrics for more effective evaluation of chronic pain. Lastly, the authors emphasize the importance of examining intersecting factors of education, employment, and residence in understanding the systemic disparities in chronic pain management experienced by BIPOC individuals.