MORE THAN ONE-THIRD of Americans experience chronic pain.1 Due to changing demographics in the United States, nurses may care for a slightly larger proportion of Black American patients with acute or chronic pain. This article discusses barriers to effective pain management specific to the treatment of Black Americans, a term used to describe African Americans, African/Afro-Caribbeans, and African immigrants or residents.2 Most of the research cited in this article refers to African Americans and, to a lesser extent, African/Afro-Caribbeans.
Black Americans currently comprise 13.1% of the U.S. population; by 2060, this will increase to 14.7%.3 Nurses and healthcare providers must be able to provide culturally responsive pain care. But without some basic knowledge and understanding of biopsychosocial-cultural issues that affect Black Americans' pain experience, pain management can be complicated.
Although pain is a common human experience, Black Americans experience greater disparities and inequities in pain assessment, management, and outcomes compared with White Americans and many other racial groups.1,4 An important step in reducing pain disparities is to provide effective, consistent, and culturally appropriate pain assessment, yet nurses and providers underassess (that is, they screen for pain less often or assess it inappropriately) and underestimate pain in Black Americans. This further validates these patients' concerns about the need to legitimize their pain.5-7 In turn, pain medications are underprescribed or inappropriately prescribed to Black Americans, leading to undertreatment.8-11
Disparities in analgesia are seen across the healthcare continuum, from prehospital care to inpatient admission to postdischarge for Black Americans.1,11,12 For example, in one study Black Americans with insurance had similar rates of epidural analgesia as White Americans without insurance.13 When Black Americans are prescribed opioids, they're more likely to experience financial difficulty purchasing pain medications, have restricted refills, or be unable to fill prescriptions because local pharmacies in predominantly ethnic minority neighborhoods don't stock opioids. They also undergo random drug testing at higher rates and have more scheduled office visits because healthcare providers assume that Black American patients are more likely to abuse opioid medications.14-19 Although some recent studies indicate that analgesia for racial and ethnic patients may be improving,20 the evidence clearly demonstrates that pain management in Black Americans is less than optimal.
Many Black American patients are misinformed about pain, hold cultural beliefs that interfere with pain control, or face social and economic barriers related to access to and utilization of pain medications, treatments, pain specialists, and pain self-management programs.15,21-23 When provider and system-level issues are combined with patient-level issues, pain disparities are further magnified and the cycle of patient mistrust and inequity continues.
To counter these issues and provide culturally responsive care, nurses need to recognize racial disparities, misconceptions, and cultural differences in the pain experience. Using a modified version of Josepha Campinha-Bacote's “ASKED” Model for Culturally Competent Care for African Americans,24 nurses can evaluate their ability to care for Black Americans in pain. (See I “ASKED MYSELF” for a summary of this mnemonic device.) The following modified framework, “ASKED MYSELF,” identifies key questions nurses can use to explore their awareness level.
- Awareness: Am I aware that Black Americans experience immense pain disparities related to diagnosis, treatment, and outcomes?1,25,26 Am I aware of the existence of discrimination and racism in healthcare and society,26 and did I know that perceived racial and disease-based discrimination are associated with pain in Black Americans?25,27-29 Am I aware of my biases, prejudices, or stereotypes toward Black Americans in pain, and how these may contribute to pain disparities or unequal care?
- Skill: Do I have the skill to conduct a culturally sensitive health and pain assessment with Black American patients?30 Am I accepting of Black American pain management strategies, and can I safely implement these patients' cultural practices for pain care into their medical care? Can I recognize pain-related behaviors (for example, praying, moaning, grimacing, or limiting physical activity), pain-related communication such as pain descriptors or comments such as, “I feel tired” or “I'm hurting,” that signal pain?21,31
- Knowledge: Am I knowledgeable about pain-related beliefs, practices, and cultural values, such as the use of spirituality?31-33 Am I knowledgeable about pain severity, prevalence, impact, and treatment effectiveness among Black Americans? While Black Americans experience greater pain intensity, treatment helpfulness or effectiveness in reducing pain intensity is significantly lower when compared to other populations.34-38
- Encounters: During every face-to-face encounter with Black American patients, do I ask about pain because research shows that screening for pain in Black Americans is lower?5 Do I communicate in a respectful and caring manner, not talking down to Black Americans, particularly those with lower educational and socioeconomic status?39 Two major barriers to a healthy relationship between Black American patients and healthcare providers are ineffective communication21 and limited time spent with providers,36 which both hinder rapport building and satisfaction with care.
- Desire and documentation: Do I really want to become culturally competent with Black American patients?24 Do I desire to know more about the pain experience in Black Americans? Lack of the healthcare providers' desire to get to know Black American patients is an overlooked problem in healthcare that leaves Black Americans feeling uncared for.37
Do I document pain assessment, preferences for pain care, and changes to the pain management plan for Black American patients? Inconsistent and absent pain documentation is another problem encountered by Black Americans and other ethnic underrepresented patients;38 for example, one study found documentation discrepancies in the numeric pain intensity ratings recorded in the electronic medical record and the numeric pain intensity ratings recorded on a survey given to Black American patients.39 Failure to document or inconsistent documentation of pain assessment can lead to ineffective pain management planning.
- Multidimensional: Do I understand the multidimensionality of pain in Black Americans and the effect of social determinants on their experience of pain?1 Pain discussions generally center on determining the presence of pain, measuring its intensity, and inquiring about types of treatments used, but requests for a more comprehensive pain assessment are echoed by Black Americans who proclaim that pain is more than a number.37,40 Black American adults will appreciate an assessment that inquires about life situations that trigger or impact pain and coping, and pain's interference with daily function.
- Younger or older age: Have I noticed any generational similarities and differences in perception, assessment, expressions, and treatment of pain in Black American patients? Intergroup differences show that younger Black Americans have more pain when compared with younger White Americans.41 On the other hand, intragroup differences show that younger Black Americans report higher pain intensity than older Black Americans,42 while older Black Americans tend to have more affective pain compared with older White Americans.43
- Scales: Am I using an appropriate pain assessment scale when caring for Black Americans? Black American adults may appreciate using a multicomponent scale that assesses pain intensity, function, mood, and relief. On the other hand, older Black Americans prefer the Faces Pain Scale-revised,44 and Black American children similarly prefer the Wong-Baker FACES scale and the Black American Oucher scale.45
- Elevated pain intensity: Do I really believe Black American patients when they report high pain intensity ratings? Black Americans generally report higher pain intensities, pain unpleasantness, and bothersome pain,21,46 but nurses, providers, and public individuals have been shown to underestimate pain in Black Americans, using racial cues inappropriately to assess and manage pain in Black Americans.7,47-48
- Low tolerance and threshold: Did I know Black Americans have a lower pain tolerance and threshold?49,50 This means that Black Americans are less able to tolerate high levels of pain and sense pain at lower levels. Black Americans show allelic differences in the CYP450 2D6 pathway, which is responsible for opioid metabolism,51,52 and this genetic variation may result in poor analgesia or opioid toxicity. Black American children, for example, appear to need higher doses of morphine to control pain when compared with other racial and ethnic groups.53 These biologic differences may explain both their need for analgesics at lower pain intensities and their need for higher doses of analgesics.
Some research suggests that 0.5% of Black Americans receive no benefit from codeine.4 O'Connor and colleagues33 found that Black American patients are less likely to have a 50% reduction in pain intensity scores compared with White Americans when given similar doses of morphine.
Other questions nurses should ponder include: How does my tolerance and threshold for pain project onto my observations and perception of pain in Black Americans? Do I make comments such as, “You shouldn't be in this much pain”?
- Family: With the patient's permission, do I include immediate and extended family members (including fictive kin, or individuals who aren't related biologically but are considered family socially) in my Black American patients' pain management (that is, decision making and social support)? Am I comfortable in communicating with my patients' family and friends and respecting their cultural beliefs about pain? Do I provide education on pain management for my Black American patients and their families? Several reports have shown that Black Americans request information about pain management.54,55
Facing up to disparities
Managing pain in Black Americans who've experienced long-standing pain disparities and inequities is a critical responsibility of nurses and healthcare providers. Because pain is a complex phenomenon requiring knowledge of the intricacies and intersection of biological pain mechanisms, culture, and social environment, nurses and providers can use the ASKED MYSELF framework to evaluate their knowledge and ability to engage with and care for Black American patients experiencing pain. Providers can then modify their practice to be more culturally responsive to reduce pain management disparities and improve pain outcomes and satisfaction with care. As a matter of fact, hospitals exhibiting greater cultural competency regarding pain control, nurse communication, and staff responsiveness demonstrated better hospital consumer assessment of healthcare providers and systems survey scores.55 Nurses who assess their personal pain beliefs can recognize their own cultural nuances and norms, which may impact the care they provide to patients.56
I “ASKED MYSELF”
Use the following mnemonic to assess your cultural competence to care for Black Americans experiencing pain.
- Desire and documentation.
- Younger or older age.
- Elevated pain intensity.
- Low tolerance and threshold.
Source: Adapted from Campinha-Bacote J. A culturally competent model of care for African Americans. Urol Nurs. 2009;29(1):49-54.
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