Equity In Pain Management


Health disparities are a major issue within healthcare, a concern to which pain management is not immune. In the following domains, there is evidence of disparities in treatment based on patient race and ethnicity. 

Acute Pain

  • A systematic review including 14 articles with a study population greater than 11,000 patients identified that compared with White patients, Black patients were less likely to receive analgesia for acute pain (OR 0.60 [95% CI, 0.43–0.83]), as were Hispanic patients (OR 0.75 [95% CI, 0.52–1.09]).[i]
  • Opioid prescriptions from the ED also show differences based on race/ethnicity. In one nationally representative study reviewing 156,729 pain-related visits over a 13-year period, White patients with pain were more likely to receive an opioid (31%) than Black (23%), Hispanic (24%), or Asian/other patients (28%) (P<.001 for trend).[ii]

Pediatric Pain

  • Among pediatric patients being treated for appendicitis in the ED, Black patients received opioid analgesia less frequently than White patients (12.2% [95% CI, 0.1%-35.2%] vs 33.9% [95% CI, 0.6%-74.9%], respectively; adjusted odds ratio 0.2 [95% CI, 0.06-0.8]).[i]
  • Although minority children with long-bone fractures are more likely than non-Hispanic white children to receive any analgesic, they are less likely to receive opioids or achieve optimal pain reduction.[ii]

Labor Pain

  • In one study, compared with non-Hispanic White patients, Black (OR 0.78 [95% CI, 0.74–0.83]) and White/Hispanic (OR 0.85 [95% CI, 0.78–0.93]) were less likely to receive epidural anesthesia for labor.[i] Among the concerns about this disparity is the effect on neuraxial anesthesia rates for Cesarean delivery, increasing the likelihood of associated maternal and fetal morbidity and mortality. 
  • In one study reviewing Cesarean deliveries for term births, African American patients had the highest odds of receiving general anesthesia compared with Caucasians (OR 1.7 [95% CI, 1.5–1.8; P<0.001]), with Hispanic patients also more likely to undergo general anesthesia (OR 1.1 [95% CI, 1.0–1.3]).[ii]

Regional Anesthesia

  • Black patients are less likely to receive epidural anesthesia for inguinal hernia repair (OR 0.36 [CI 0.14–0.95]) compared with White patients.[i]
  • Peripheral nerve blocks are also less likely to be done for Hispanic patients undergoing orthopedic surgery (OR 0.60 [95%CI, 0.56–0.65]) compared with White patients, which may affect postoperative pain control, patient satisfaction, and rehabilitation.[ii]

Postoperative Pain

  • Postoperative analgesia is an area with less data. 
  • Despite this, one study examining the use of patient-controlled analgesia (PCA) after abdominal surgery and found that Caucasian patients were more likely to be prescribed PCA (OR 2.84 [95% CI 1.08–7.46]) compared with non-Caucasian patients.[iii]

Lee P, Le Saux M, Siegel R, et al. Racial and ethnic disparities in the management of acute pain in US emergency departments: Meta-analysis and systematic review. Am J Emerg Med. 2019 Sep;37(9):1770–1777.

Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. 2008 Jan 2;299(1):70–8.

Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial Disparities in Pain Management of Children with Appendicitis in Emergency Departments. JAMA Pediatr. 2015 Nov;169(11):996–1002.

[1] Goyal MK, Johnson TJ, Chamberlain JM, et al. Racial and Ethnic Differences in Emergency Department Pain Management in Children with Fractures. Pediatrics. 2020 May;145(5):e20193370.

Glance LG, Wissler R, Glantz C, et al. Anesthesiology. 2007 Jan;106(1):19–25.

Butwick AJ, Blumenfeld YJ, Brookfield KF, Nelson LM, Weiniger CF. Racial and Ethnic Disparities in Mode of Anesthesia for Cesarean Delivery. Anesth Analg. 2016 Feb;122(2):472–479.

Memtsoudis SG, Besculides MC, Swamidoss CP. Do race, gender, and source of payment impact on anesthetic technique for inguinal hernia repair? J Clin Anesth. 2006 Aug;18(5):328–33.

Memtsoudis SG, Poeran J, Zubizarreta N, et al. Anesthetic Care for Orthopedic Patients: Is There Potential for Differences in Care? Anesthesiology. 2016 Mar;124(3):608–23.

Salamonson Y, Everett B. Demographic disparities in the prescription of patient-controlled analgesia for postoperative pain. Acute Pain. 2005 May;7(1):21–26.