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Previous studies have shown differences in pain experiences between racial and ethnic groups. Examples are higher levels of pain perception for African Americans with the acquired immunodeficiency syndrome (AIDS), arthritis, and glaucoma. These differences appear to vary by pain site with more pain reported only in certain pain sites and with variations in pain type. For instance, pain in childbirth may be more unpleasant for some racial/ethnic groups by measures of pain behaviors and pain descriptors without significant differences in pain intensity. The authors suggest that studies of racial and ethnic differences in pain experiences should use sensory, affective, and behavioral aspects. One study showed no racial/ethnic differences for cancer-related pain intensity. Yet, participants reported differences in the affective terms used to describe their pain.

Pain coping mechanisms and success may vary according to race/ethnicity. Emotional response to pain and level of interference with typical daily activities were reported more often in African American groups compared to Whites.

For this study a four-stage model was used that included pain intensity, immediate affective response, negative emotions related to pain, and pain associated behaviors (see Table 1 for descriptions of the four stages).

This study tested the four-stage model to determine differences in levels of pain reports between African Americans and non-Hispanic Whites and the differential relationships in pain stages. The sample included 912 women and 645 men, more than half of who were married/cohabitating. 69.6% were self-reported non-Hispanic Whites and 30.4% were African American. Of the 1084 Whites, 606 were women and 478 were men. Most of this group had either myofascial pain, neuropathic pain, or low back pain with a duration split fairly evenly across categories 6-24 months, 24-60 months, and >60 months. Only 7% had experienced their reported pain for less than 6 months. In the African American group there were 306 women and 167 men. The type of pain and duration, mean level of education, and marital/cohabitation status were similar between the two groups.

Validated VAS tools were used to determine levels of pain intensity and unpleasantness seen in the first two stages of pain processing. Validated and reliable VAS tools were used to determine levels of emotional factors such as depression, anxiety, anger, fear, and frustration. An interview was conducted using four subscales from the Getto and Heaton Psychosocial Pain Inventory. Items included pain behaviors, social reinforcement for pain behaviors, reduction in family-related responsibilities, and avoidance activities such as rest.

While there were no mean differences between the White and African American groups for pain intensity, the other three stages were consistently reported at higher levels by the African American group: unpleasantness (p=0.0001); emotional factors (p<0.001); and behavioral factors (p=0.023). The African American group reported all emotional factors except for “frustration” at significantly higher levels with greatest differences seen in depression and fear. Pain-related behaviors were reported at higher levels for behavior and impact of pain on usual daily activities. There was a link between pain-related emotions and behaviors seen in the African American group. However, there were no significant differences between Whites and African Americans for social reinforcement of pain-related behaviors or reduction in family responsibilities. Self-attribution of pain and fearful interpretations of pain as an indicator of serious illnesses were associated with more fear and depression.

Several factors that have been explored in previous studies were not included in this research. Relationships have been described between psychosocial issues such as coping styles, attitudes about care, pain attribution, locus of control beliefs, and interpretations of pain. For instance, African American and Italian patients were reported to be more likely to attribute their pain to something that they did, compared with Irish or Puerto Rican patients. African Americans were more likely than Whites to interpret pain as an indication of serious illness. Whites tended to trust their physician and reported greater satisfaction with physician methods and style than other racial/ethnic groups. African Americans in tertiary care were shown to be more skeptical about the benefits of medical care for pain that other racial/ethnic groups. The authors of the study reported here suggest than these factors can contribute to a more negative emotional and behavioral response by African Americans.

Four stages of pain were explored in African American and Whites at a pain clinic. While intensity reports were similar for both groups experiencing primarily myofascial, neuropathic, and low back pain, the emotional and cognitive responses were often significantly different. The authors suggest that differences may have some origin in psychosocial differences between groups, such as a greater impact of reduced function on lower-income brackets and those who may experience workplace discrimination (more common in the African American group). The impact of pain for the African American group was more linked to emotional responses compared to Whites.

In this study, African Americans experienced greater emotional suffering for a similar intensity of pain compared to Whites. Negative emotions have been previously linked to reduced functioning. While the authors note that the findings may not apply to individuals, they suggest that pain management strategies for African Americans would benefit from the inclusion of treatment for depression and mood and that interventions should be targeted to affect and pain behaviors.

The findings of this study were consistent with findings in previous studies that African American patients reported higher levels Stages II, III, and IV of pain. Particularly significant findings included a greater level of depression and fear. The authors conclude that race/ethnicity has its greatest effect on later stages of pain and note that psychosocial factors may have contributed to these effects, though not measured for this study.