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Racial and Ethnic Disparities in Pain Management 
Nicolette A. Harris, DAT, LAT, ATC, CSCS*; Samar Long, MSEd, AT, ATC† 
*AT Still University, Mesa, AZ; †Ohio State University, Columbus, OH 

  

 
ABSTRACT 
Pain is subjective, which makes its management a 
complicated task. The challenge of medical decision-
making associated with pain often requires health care 
providers to rely heavily on their individual discretion and 
experience. This often creates an avenue for biases to play 
a role in the selection of the best available and most 
appropriate pain management interventions. Therefore, 
the overall purpose of this review is to summarize the 
current literature related to racial and ethnic disparities in 
pain management. Electronic searches of four databases 
revealed 2,112 articles; however, only six studies met 
criteria for inclusion in this review. Even when the source of 
pain is the same, research indicates management may 
differ between racial or ethnic groups. While the treatment 
of objectively painful conditions remains relatively constant 
among races and ethnicities, inequities in pain management 
become more apparent in the treatment of conditions 
characterized by only subjective pain indicators. Further 
disparities were identified in the dosage, dosage 
reduction, and oversight of opioid analgesics between 
groups. Inequities in prescribing patterns widen existing 
healthcare disparities by contributing to undertreatment of 
pain in ethnic minorities and overtreatment of pain and 
subsequent risk of opioid abuse in Whites. Health care 
providers must use a patient-centered and evidence-based 
approach to combat the ambiguity of clinical decision-
making regarding pain. When knowledgeable of 
appropriate standard of care for pain management, 
athletic trainers can identify when a patient’s pain needs 
are unmet or when substance abuse interventions may be 
necessary.  
 
Key Phrases 
Public health, clinician-rated outcomes, patient-
rated outcomes, professional standards 

 
Correspondence 
Dr. Nicolette A Harris, AT Still University, 5850 E Still 
Circle Mesa, AZ 58206 
Email: nicolletteharris@atsu.edu  
Twitter: @YoungProf_AT 
 
Full Citation 
Harris NA, Long S. Racial and ethnic disparities in 
pain management. Clin Pract Athl Train. 2021;4(1): 
43-56. 
https://doi.org/10.31622/2021/0004.1.6.    
 
Editor’s Note: This paper is an invited paper by the authors 
for this special issue 
 
Submitted: July 30, 2020 Accepted: February 22, 2021. 

 
 
 

CLINICAL PROBLEM AND QUESTION 
 

According to Healthy People 2020, healthcare 

disparities adversely affect people who 
encounter substantial systemic obstacles to health 
based on their racial or ethnic group.1 Healthcare 
disparities have been reported across the 
continuum of care including in the treatment and 
management of pain.2 For example, scholars have 
noted Black patients receive inadequate 
treatment for pain conditions as compared to 
White patients.2-6 Primary care physicians were 
reported as being twice as likely to underestimate 
pain in Black patients as compared to all other 
ethnicities combined.4 Analgesic medications are 
often a principal component of pain management, 
and to no surprise, disparities have also been 
suggested to affect the prescribing patterns of 
these medications. Black patients have been 
prescribed pain medications at a lower frequency 
and a lower dosage than non-Black patients.2, 4, 5 
A study of analgesic administration by nursing 
staff in the emergency department (ED) found 
African Americans received analgesics in 57% of 
instances and non-Hispanic Whites in 74% of 
cases, with no significant differences in the amount 
of pain reported to medical personnel.5 

Discrepancies exist in the use of analgesic 
medication to manage pain between racial and 
ethnic groups; however, the source of inequality in 
pain management practices cannot be limited to 
a single cause. Racial disparities in pain 
management have been attributed to several 
theoretical approaches of discriminatory practices 
among health care providers.7 First, the 
application of bias, clinical uncertainty, inaccurate 
beliefs, or stereotypes contributing to health care 
behaviors may result in inequitable treatment.7 

mailto:nicolletteharris@atsu.edu
https://doi.org/10.31622/2021/0004.1.6


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For instance, providers may make assumptions 
that a Black patient will be noncompliant and 
therefore fail to prescribe medications that align 
with the standard of care.2, 3 Second, based on 
stereotypes, physicians may invalidate the 
experience of pain allowing racial bias to 
contribute to the undertreatment of pain.4, 8, 9 
Investigators have determined perceptions of 
hardship, internalized as strength or toughness, 
influence perceptions of pain and contribute to 
racial bias in pain perception.10 Lastly, many 
stereotypes of substance use and abuse in ethnic 
minority groups have been developed secondary 
to the United States (US) illegal drug epidemic of 
the 1990s.11 A perceived potential for abuse in 
non-White minority groups may bias providers not 
to prescribe analgesic pain relievers to individuals 
of minoritized groups, despite the fact that non-
medical use of prescription opioids is two times 
greater in the Whites.11 These results further 
highlight how dominant narratives of the 
experiences of people of color are built on racial 
stereotypes and can influence the care patients in 
marginalized communities receive. While provider 
bias may have good intention to protect 
minoritized communities from the use and abuse of 
opioid analgesics, in addition to causing 
undertreatment non-White patients, these 
prescribing patterns may in turn also contribute to 
higher opioid-related overdose and death rates 
in White patients11 Racial inequities are not 
limited to health care or any specific medical 
setting, but it is important for athletic trainers to 
understand the types of experiences their patients 
have after being referred for further care. We 
echo the Institute of Medicine’s call for all health 
care providers to actively eradicate contributions 
to racial and ethnic biases in health care.7  

As health care providers, the goal of athletic 
trainers is to provide the best possible care to 
every patient. We must uphold the first principle 
of the National Athletic Trainers’ Association 
(NATA) Code of Ethics by practicing with 
compassion and respecting the rights, well-being, 

and dignity of others.12 Pain is expressed 
differently based on personal experiences and 
context; therefore, providing appropriate care in 
those moments is central to ensuring the primacy 
of patient care. Advocating for patient needs can 
begin when athletic trainers develop a better 
understanding of the experience patients of color 
may have when seeking pain management. 
Research suggests that in recent years, the 
practices of medical professionals regarding pain 
management are not applied equitably among 
racial and ethnic groups due to personally held 
beliefs.13 In fact, the standard of care a patient 
receives is often influenced by their race or 
ethnicity.2, 3, 4, 5 The subjective nature of pain raises 
the concern of whether race or ethnicity can affect 
a clinician’s approach to managing pain. To our 
knowledge, there is no published literature 
discussing the influence of race and ethnicity on 
pain management in athletic training. Therefore, 
this review aims to address the following research 
question: In patients with pain of subjective or 
objective origin, does race or ethnicity affect the 
prescription of analgesic medication? 

SEARCH OF THE LITERATURE 

Data Sources and Searches 

A wide-ranging, electronic search of four 
individual databases (SPORTDiscus, EBSCOHost, 
PubMed, PsycINFO) was performed. Boolean 
terms and phrases included the following: racial 
bias AND pain perception AND athletes, ethnicity 
AND pain sensitivity AND athletes, ethnicity AND 
pain tolerance AND athletes, ethnicity AND pain 
perception AND athlete, social determinants AND 
pain perception AND athletes, minority AND pain 
perception AND athlete, pain perception AND 
cultural competence (Table 1). Additionally, 
reference lists were searched by hand for 
relevant articles.  

Study Selection 

 



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Table 1. Search Terms, Databases, and Number of Articles Retrieved 
Search Terms SPORTDiscus EBSCOHost PubMed PsycINFO Total 
Racial bias AND pain perception AND athletes 1 113 1 1 116 
Ethnicity AND pain sensitivity AND athlete 286 8 4 0 298 
Ethnicity AND pain tolerance AND athletes 710 5 4 0 719 
Ethnicity AND pain perception AND athlete 323 19 4 0 346 
Social determinants AND pain perception AND 
athletes 1 239 15 0 255 
Minority AND pain perception AND athlete 192 4 4 0 200 
Pain perception AND cultural competence 2 167 7 2 178 
Total  1515 555 39 3 2112 

Articles were included in this review if they were 
peer-reviewed and published in English, between 
2010 and 2020, and explored pain management 
in ethnically diverse patients. In attempts to 
synthesize evidence of high methodological 
quality, authors aimed to include meta-analyses, 
systematic reviews, randomized control trials, 
cohort and cross-sectional studies with satisfactory 
design, validity, and applicability to patient care. 
Editorials, commentaries, and studies of non-
scientific origin were excluded. Additionally, 
articles including patients with health conditions 
outside of those commonly seen in athletic training 
practice were also omitted.14 Furthermore, 
research studies that did not address the question 
of interest were also excluded in this review.  

Succeeding the removal of duplicate articles, both 
authors completed a dual-step process to classify 
articles for inclusion. Initially, each author (NAH, 
SL) screened the title and abstract of each 
identified article, after which, a meeting was held 
between both authors to ensure consensus on 
inclusion criteria. Next, a full-text review of 
articles was performed by both authors (NAH, SL) 
followed by a meeting resulting in agreement to 
further constrain inclusion criteria to pain 
management articles included within this study. 
Articles were excluded if consensus on the inclusion 
criteria was not reached at any point during the 
selection process.    

Assessment of Methodological Quality 

The methodological quality of each study was 
assessed using the National Institutes of Health 
(NIH) Quality Assessment Tool for Observational 
Cohort and Cross-Sectional Studies or the NIH 
Quality Assessment of Systematic Reviews and 
Meta-Analyses. The NIH Quality Assessment Tool 
for Observational Cohort and Cross-Sectional 
Studies contains 14 items, 12 of which were 
applicable to included studies.15 Two checklist 
items, participation rate, and loss to follow-up, 
were not relevant to the retrospective nature of 
studies included within this manuscript. Each of the 
12 items were eligible to receive a yes, no, not 
applicable, not reported, or cannot determine 
rating. Items that fulfilled ‘yes’ criteria were 
assigned a score of 1 point, while items that 
fulfilled ‘no’ criteria or that were not reported 
received 0 points toward a total quality score of 
12.15 Items not applicable to the included study 
were not counted negatively toward the overall 
methodological quality score. Likewise, the NIH 
Quality Assessment of Systematic Reviews and 
Meta-Analyses is a checklist of 8 items.15 Each item 
meeting the quality standard was scored 1 point 
while those that did not meet the item standard or 
did not report sufficient information to evaluate 
item criterion were assigned a score of 0.15 Cohort 
or cross-sectional studies were eligible to achieve 
a maximum score of 12 and systematic reviews or 
meta-analyses a maximum of 8.15 For purposes of 



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comparison, quality assessment scores were 
weighted by dividing raw scores by the number 
of applicable items and multiplying by 10. Each 
study was scored using the NIH Quality 
Assessment Tools by both authors. Disagreement in 
scores between authors were resolved through 
discussion. Weighted scores of 6 or higher were 
deemed high-quality studies, while weighted 
scores under 6 were considered low-quality. A 
rating of good-quality translates into a low risk of 
bias.  

Grade of Recommendation 

Recommendations resulting from the conclusions of 
this manuscript were graded using the Strength of 
Recommendation Taxonomy (SORT). The SORT 
was first used to classify the level evidence 
provided to each individual study.16 Level 1 
evidence is demarcated by good-quality studies 
such as meta-analyses and systematic reviews 
which are patient-oriented, while Level 2 evidence 
is patient-oriented but lacks quality or consistency 
in findings.16 Level 3 is used to categorize disease-
oriented evidence or evidence derived from case 
series and studies.16 After a level of evidence was 
assigned to each individual study, we used the 
SORT to provide a weighted grade for the 
collective strength of evidence supporting each 
conclusion. Grades of A were reserved for 
conclusions constructed from Level 1 evidence with 
consistent results across studies.16 A grade of B 
was given to conclusions resulting from studies of 
Level 2 evidence.16 Conclusions formulated from 
Level 3 evidence were given a grade of C.  
Grade B and C recommendations should be 
incorporated into clinical practice on an 
individualized and case-by-case basis.16 

Data Extraction, Analysis, and Synthesis 

The study design, participants, sources of pain, 
outcome measures, interventions, results and 
conclusions were extracted from all included 
studies (Table 2). Data were analyzed by authors 
using the NIH quality assessment tools15 and 

SORT16 based on study content and context 
relevant to the research question. Data synthesis 
was expressed using a qualitative synthesis of the 
context of findings relevant to the research 
question. Synthesis of medication administration 
based on patient demographics was grouped by 
treatment setting and prescribing patterns of 
analgesic drugs.  

SUMMARY OF FINDINGS 

Search Results and Study Inclusion 

Our preliminary search resulted in a total of 
2,112 articles for potential inclusion in this review. 
Of these articles, there were 1,496 that were 
identified as duplicates and subsequently 
excluded. The remaining 561 were screened by 
title after which 518 were excluded for being 
irrelevant for the subject of this paper. The 
abstracts of the remaining for 43 articles were 
screened by authors for inclusion. After appraising 
abstracts, an additional 8 articles were excluded 
for study designs that failed to assess the use of 
analgesic medication for the management of pain. 
Therefore, 35 articles persisted to full-text 
evaluation and data extraction (Figure 1). An 
additional 29 articles were excluded during the 
data extraction process: 7 studies featured 
experimental pain; 5 studies did not adequately 
answer the research question; 5 studies 
investigated only the assessment of pain; 3 studies 
focused on linguistic barriers; 2 studies did not 
report the source of pain; 2 studies did not 
address pain as an outcome; 2 articles did not 
report race or ethnicity; 1 article did not provide 
age range data; 1 article had pain outside the 
professional scope of athletic training; and 1 
study looked at incidence or prevalence/trends. A 
total of six articles remained from which data was 
extracted and summarized into findings.17-22 

General Characteristics of Included Studies 

This review included one meta-analysis,18 two 
studies presenting with cross-sectional designs,21,22  



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and three studies categorized as retrospective 
cohorts17, 19-20 (Table 2). All study participants 
were adults, age 18 or older, presenting to the ED 
or an outpatient clinic for pain-related conditions. 
A majority of the studies were conducted with 
White, Non-Hispanic, Black/African American, 
and Hispanic Latinos. Demographic variables 

including age, gender, and race/ethnicity were 
collected from participants across all studies in 
addition to the source of pain. Pain sources 
included non-definitive conditions such as 
toothache, back pain, and abdominal pain, as 
well as definitive conditions such as long bone 
fracture, kidney stones, appendicitis, or 
gallbladder disease.  

Furthermore, a range of outcomes were reported 
within the included studies regarding the 
prescription and receipt of analgesic drugs. 
Outcome measures focused on the prescription, 
administration, and dose reduction of opioid and 
non-opioid analgesic medications. Opioid 
medications included, but were not limited to, 
fentanyl, morphine, oxycodone, hydrocodone, 
methadone, tramadol with or without 
acetaminophen, aspirin, and ibuprofen 
combinations. Likewise, non-opioids involved non-
steroidal anti-inflammatory drugs, salicylates, 
analgesics combinations, anti-migraine agents, 
and COX-2 inhibitors. Additional outcomes 
included total dosage of analgesic medication, 
type of insurance, wait time to see a provider, 
length of visit in the ED, concurrent 
benzodiazepine prescription, and total 
medications overall. A single study17 investigated 
the outcome of dose reduction of opioid pain 
relievers within a two-year follow-up period. 

Data Synthesis Summary 

In regard to non-opioid medications, no racial or 
ethnic differences in the prescription of analgesics 
were found in the ED or ambulatory settings.18 
Specifically, when the use of opioids for the 
management of pain-related complaints in the ED 
was investigated, no racial or ethnic disparities 
were found to exist in prescription or 
administration for definitive and objectively 
painful conditions such as toothaches and kidney 
stones.19 Additionally, no statistically significant 
interactions were discovered between race or 
ethnicity and opioid administration for individuals 
presenting to the ED with definitive pain confirmed  

SPORTDiscus 

2010-2020 

1515 
citations 

EBSCOHost 

2010-2020 

555 
citations 

PubMed 

2010-2020 

39 citations 

PsycInfo 

2010-2020 

2 citations 

 

561 non-
duplicate 

citations screened 

Inclusion & 
exclusion 
criteria 
applied 

8 articles 
excluded 

after abstract 
screen 

35 articles 
retrieved  

Inclusion & 
exclusion 
criteria 
applied 

29 articles 
excluded 

after full-text 
screen and 

data 
 

6 articles included 

518 articles 
excluded 
after title 

screen 

Figure 1. Study Selection Process 



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Table 2. Summary of Included Studies (n=6)  
Source  Study Design Participants Source of Pain Outcome 

Measures  Interventions Results  Key Conclusions 

Meghani, 
Byun, and 
Gallagher 

Meta-analysis N/A  

Traumatic/surgical 
(bone fracture, 
postoperative); non-
traumatic, non-surgical 
(migraine, back pain, 
abdominal pain, 
osteoarthritis); cancer 
pain; and mixed pain.  

Prescription of 
any analgesic, 
opioid 
analgesic, and 
non-opioid 
analgesic 
medications.  
 

Opioid and non-opioid 
analgesic medications 

No disparities were found 
in prescription of any 
analgesia for 
Hispanics/Latinos, but 
Hispanics/Latinos were 
22% less likely than 
Whites to receive opioids 
treatment. Blacks/African 
Americans were 22% less 
likely than Whites to 
receive any analgesia and 
29% less likely than 
Whites to receive opioid 
treatment for similar 
painful conditions. No 
disparities were found in 
prescription of opioids to 
Hispanics/Latinos for 
traumatic/surgical pain, 
but strong differences 
were found in prescription 
of opioids for non-
traumatic/nonsurgical pain 
types for which Hispanics 
were 30% less likely than 
Whites to receive opioids. 
Blacks/African Americans 
were 34% less likely to be 
prescribed opioid 
medication for non-
traumatic/nonsurgical pain. 

Opioid treatment 
disparities are 
present between 
Hispanic/Latinos 
and Black/African 
Americans which 
present health 
care safety and 
quality concerns.  

Rasu and 
Knell 

Cross 
sectional 

Adults 
(n=690,205,290) 
aged 18 or older 
treated for 
Chronic Problem-
Routine or Chronic 
Problem-Flare up 
visits in US 
outpatient 
settings. 

Non-Malignant Chronic 
Pain (NMCP) of 
neuropathic, 
inflammatory, muscle, 
mechanical/compressive, 
or general chronic pain 
origin.  

Opioid 
prescribing; 
age, gender, 
ethnicity, pain 
diagnosis, 
number of total 
medications, 
region of 
prescribing, 
payment type, 
physician 

Opioids including 
morphine, codeine, 
fentanyl, hydrocodone, 
hydromorphone, 
levorphanol, meperidine, 
methadone, oxycodone, 
propoxyphene, and 
tramadol with or without 
acetaminophen, aspirin, 
and ibuprofen.  

Hispanics and patients with 
private insurance were less 
likely to receive opioids 
for chronic pain 
management.  

Differences exist 
between those 
prescribed and 
not prescribed 
opioids. Further 
research is 
needed on 
prescription and 
monitoring of 
opioids to diminish 



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specialty, and 
patient 
relationship 
with provider.  
 

treatment 
disparities. 

Singhal, 
Tien, and 
Hsia 

Retrospective 
cohort  

Adults 
(n=16,428) age 
18-65 with non-
definitive or 
definitive pain 
conditions   

Non-definitive conditions 
including toothache, 
back pain and 
abdominal pain as well 
as definitive conditions 
involving long-bone 
fractures and kidney 
stones.  

Numerical pain 
score (0-10); 
Race/ethnicity 
(non-Hispanic 
white, non-
Hispanic black, 
Hispanic and 
non-Hispanic 
other); age, 
sex, type of 
insurance, 
location of the 
ED. Point of 
care: opioid 
prescribed at 
emergency 
department 
(ED) discharge, 
administered in 
the ED, or both.  

Opioids including narcotic 
analgesics or narcotic 
analgesic combinations. 
Non-opioids included 
nonsteroidal anti-
inflammatory agents, 
salicylates, analgesic 
combinations, anti-
migraine agents, and 
COX-2 inhibitors.  

Non-Hispanic Blacks were 
less likely to received 
opioid prescription at ED 
discharge for back pain 
and abdominal pain, but 
not for toothache, 
fractures, and kidney 
stones as compared to 
non-Hispanic Whites.  

Racial/ethnic 
disparities in 
opioid 
prescription and 
administration 
exist for most non-
definitive 
conditions but not 
for definitive 
conditions. 
Differential 
prescription of 
opioids by 
race/ethnicity 
may lead to 
widening of 
existing health 
disparities and 
the burden of 
opioid abuse 
among non-
Hispanic whites.  

Buonora et. 
al.   

Retrospective 
cohort  

Adults (n=1,097) 
aged 18 or older 
prescribed with 3 
or more opioid 
pain relief 
prescriptions at 
least 21 days 
apart with stable 
dosage.  

Non-cancer related pain 

Opioid pain 
relievers (OPR) 
dose reduction 
within two 
years following 
the end of each 
patient’s 
baseline 
period. 
Reduction was 
defined as a 
reduction in 
daily OPR dose 
of at least 30% 
in any 6-month 
follow-up 
period relative 

Opioid dose or 
concurrent 
benzodiazepine use.  

Black race and female 
gender were associated 
with greater odds of 
opioid dose reduction.  

Clinical decision-
making regarding 
OPR dose 
reduction may be 
influenced more 
by social factors 
such as race and 
gender rather 
than clinical 
factors such as 
dosage and 
concurrent drug 
use which may 
indicate actual 
risk.  



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to baseline. 
Clinical 
variables 
included 
baseline daily 
OPR dose and 
concurrent 
benzodiazepine 
prescription 
and 
race/ethnicity 
and gender.  

Rosenbloom 
et al.  

Retrospective 
cohort  

Patients (n=553) 
aged 12-55 
visiting 
emergency 
department (ED) 

Appendicitis or 
gallbladder disease 

Race/ethnicity; 
sex; receipt of 
opioid 
analgesic 
medication; 
receipt of non-
opioid 
medications 
anti-emetic 
medications, 
wait time to see 
a provider (in 
minutes) and 
length of visit in 
the ED (in 
minutes).  

Opioids included 
fentanyl, morphine, 
hydromorphone/Dilaudid, 
oxycodone, hydrocodone, 
hydrocodone-
acetaminophen/Vicodin, 
tramadol, and 
oxycodone-
acetaminophen/Percocet. 
Non-opioids included 
acetaminophen/Tylenol, 
ibuprofen/Motrin, and 
ketorolac/Toradol. 
Antiemetics included 
ondansetron/Zofran, 
famotidine/Pepcid, and 
metoclopramide/Reglan.  

No interaction was 
identified between sex 
and race/ethnicity on the 
odds of receiving opioids. 
No significant difference in 
opioid administration was 
found between non-
Caucasians as compared 
to Caucasians. Non-
Caucasians did not 
different from Caucasians 
on receipt of non-opioid 
analgesics or antiemetics. 
Wait time to see provider 
nor length of hospital also 
did not differ between 
ethnicity.  
 

No statistically 
significant 
interaction 
between 
race/ethnicity 
and sex for 
administration of 
opioid analgesia 
to patients 
presenting to ED 
for appendicitis 
or gallbladder 
disease.  

Romanelli 
et al.  

Cross 
sectional 

Patients 
(n=11,576) aged 
18 or older with 
emergency 
department (ED) 
discharge 
diagnosis of long 
bone fracture. 

Long bone fracture on a 
single limb 

Prescription for 
an opioid 
analgesic at ED 
discharged; 
total morphine 
milligram 
equivalent 
(MME) units or 
oral 
medications.  

Opioids including oral 
hydrocodone, parenteral 
hydromorphone, 
parenteral morphine.  

Rates of opioid prescribing 
were no different by 
race/ethnicity however 
among patients with an 
opioid prescription, total 
MME units prescribed were 
less for Hispanics, blacks, 
and Asians relative to non-
Hispanic whites.  

Racial and ethnic 
minorities 
received similar 
frequencies of 
opioid prescribing 
for cases of long 
bone fracture, but 
small potency 
differences exist. 
More research is 
needed on why 
potency 
differences exist.  



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to originate from the appendix or gallbladder.20 

Moreover, two studies confirmed the frequency of 
opioids prescribed at discharge was similar 
between racial and ethnic groups for patients 
presenting to the ED for long bone fracture.19, 21 

In contrast, racial and ethnic disparities were 
established for non-definitive and more 
subjectively painful conditions such as back and 
abdominal pain where a distinct source of pain 
was not always clearly identifiable.19 Chronic pain 
conditions are associated with drug-seeking 
behavior; therefore, it is worth investigating how 
this knowledge may affect providers decisions on 
drug administration. Previous research has found 
that non-Hispanic Whites have a higher frequency 
of opioid addiction.17,19 However, despite this 
fact, both Hispanics/Latinos and Black/African 
American patients remain at significant risk of 
under-prescribing. Hispanics/Latinos were less 
likely receive opioids for the treatment of non-
definitive pain conditions when visiting 
ambulatory care facilities.18, 22 Likewise, Non-
Hispanic Blacks were less likely to receive a 
prescription for opioid pain medication at 
discharge despite lower opioid abuse and 
addiction rates as compared to non-Hispanic 
Whites.19 Specifically, Black/African Americans 
were 22% less likely to receive any analgesic and 
29% less likely to receive opioid analgesics as 
compared to White counterparts with similar pain 
conditions.18 Similarly, with respect to patient 
reported sex, Black and female patients had 
greater odds of dose reduction of opioid pain 
relievers as compared to White and male patients 
within the same urban academic health system.17 

These findings are in line with previous research 
indicating that Black patients received tighter 
oversight as compared to Whites undergoing 
treatment with opioid medications.23 This is 
suggestive of a reverse disparity in the strategies 
used to monitor opioid use between racial and 
ethnic groups.23 

Methodological Quality Results 

Five of the six included studies were rated as high-
quality (Table 3). The mean quality score for the 
six included studies was 7.92, indicating overall 
good methodological quality. One study19 failed 
to clearly state the research question. Likewise, 
one study22 failed to clearly define independent 
variables. Two studies20,21 failed to assess 
exposure(s) more than once over time and 
examine different levels of exposure as related 
to the outcome. One study21 did not adjust for key 
confounding variables, while all studies failed to 
blind the exposure status of the participants.17-22  

Table 3. Methodological Quality 

Source  
Quality 

Assessment 
Score 

Quality 
Rating 

Meghani, Byun, and 
Gallagher 10 High 

Rasu and Knell 5.83 Low 
Singhal, Tien, and Hsia 8.33 High 
Buonora et. al.   9.16 High 
Rosenbloom et al.  7.5 High 
Romanelli et al.  6.67 High 

 

Table 4. Level of Evidence  

Source  
Level of 
Evidence 
Rating 

Meghani, Byun, and Gallagher 1 
Rasu and Knell 2 
Singhal, Tien, and Hsia 1 
Buonora et. al.   1 
Rosenbloom et al.  2 
Romanelli et al.  2 

 

Grade of Recommendation 

Conclusions regarding racial and ethnic disparities 
in pain management were graded using the SORT 
(Table 5). Conclusions have been allocated into 5 
primary areas: non-opioid analgesic treatments, 
opioid analgesics for the treatment of objective 
sources of pain, opioid analgesics for the 
treatment of subjective sources of pain, opioid 



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52 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

tapering or dose reduction, and risk of opioid 
abuse or overdose death.  

Non-opioid Analgesic Medications 

1. Racial/ethnic inequalities appear to exist 
in the prescription of non-opioid 
analgesic medications. Black/African 
Americans are less likely to receive 
prescription of any analgesic medication 
as compared to White counterparts with 
similar subjectively painful, non-specific 
conditions.18 (Grade = A) 

Opioid Analgesics for Treatment of Objective 
Sources of Pain  

2. There is no apparent racial or ethnic 
disparity in opioid prescription nor 
administration for treatment of 
objectively painful conditions. The 
frequency of opioid prescription is similar 
between races/ethnicities for conditions 
resulting from verified pain sources such 
as toothaches, kidney stones or gallstones, 
long bone fractures, and appendicitis. 19, 

20, 21, 22 (Grade = B)  

Opioid Analgesics for Treatment of Subjective 
Sources of Pain 

3. Disparities seem to exist between 
races/ethnicities for the prescription of 
opioids for the treatment of conditions in 
which the source of pain may not be 
readily verifiable. Both Blacks/African 
Americans and Latinos/Hispanics are 
significantly less likely to receive an 
opioid medication for the treatment of 
non-traumatic or non-surgical pain 
conditions such as non-specific back or 
abdominal pain.18, 19 (Grade =A) 

Opioid Abuse Risk 

4. Racial/ethnic inequalities may occur in the 
tapering and reduction of opioid doses. 

Black/African American have greater 
odds of opioid dose reduction as 
compared to Non-Hispanic Whites.17 
(Grade = A)  

5. There are evident racial/ethnic 
disparities in the risk of opioid abuse and 
opioid overdose death. Non-Hispanic 
Whites have a higher risk of opioid abuse 
and opioid related overdose death.17, 19 
(Grade = A)  

DISCUSSION AND CLINICAL IMPLICATIONS 

Findings of this review suggest racial and ethnic 
minorities are at significant risk for the 
undertreatment of pain conditions. This is evident 
by the fact that disparities exist in the prescribing 
of analgesic pain medication. While inequalities 
were less stark for Hispanic/Latino patients, 
Black/African American patients were 
significantly less likely to receive prescription of 
any analgesic medication to treat their pain at 
discharge from the ED.18 However, when pain 
type was considered, these disparities were 
eliminated for conditions with objective sources of 
pain such as surgery or trauma; yet disparities 
persisted for subjectively painful conditions in 
which a source of pain could not be clearly 
identified.18  

These findings extended to the prescription and 
administration of opioid pain relievers. We 
concluded, with good confidence, that there are 
no apparent racial or ethnic disparities in the 
administration of opioid pain relievers in the ED or 
at ambulatory discharge for patients with 
definitive conditions such as toothaches and 
kidney stones19, long bone fracture19, 21, or from 
the appendix or gallbladder.20 All of the 
previously mentioned conditions have a clear 
diagnostic process that can be confirmed with 
objective data, which could also influence why 
disparities were unfounded. To the contrary, 
racial and ethnic disparities emerge in the 
prescription of opioid analgesic medications for 



Racial and Ethnic Disparities in Pain Management  
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

subjectively painful conditions.18, 19 Both 
Hispanic/Latino and Black/African American  

 

patients were less likely to be prescribed an 
opioid medication for the treatment of back pain, 
abdominal pain, or migraine headache.18 In 
instances where the provider was required to 
extend trust to the patient regarding conditions 
reliant on subjective confirmation racial disparities 
were apparent. Racial and ethnic differences in 
the management of pain using opioid pain 
appraise the severity of the patient’s pain as well 

as judge their risk of misuse or abuse by their 
sociocultural characteristics.17 

Over and above the fact that Black/African 
American patients obtained fewer opioid 
prescriptions, we also concluded that this 
population received lower doses of medication 
plus tighter oversight when compared to non-
Hispanic Whites with equivalent diagnoses.17, 21 

Specifically, the odds of dose reduction were 
82% higher in Black/African American patients 
when compared to White patients within the same 
time interval.17 Inconsistencies in the prescription 
and administration of these drugs between 
ethnicities may suggest implicit biases on part of 
the health care provider. Again, evidence 
suggests racial and ethnic inequalities in pain 
management may be reflective of a health care 
provider’s ability to appraise the severity of pain 
in Latino/Hispanic and Black/African American 
patients.17 Failure in appraisal may lead 
providers to underestimate the severity of 
symptoms and be conservative in the prescription 
of opioid medications to non-White patients in 
medically ambiguous situations.19 This unconscious 
bias leads to a pattern of discrimination which 
denies vulnerable patient populations access to 
pain relief. 18 Undertreatment of pain has the 
potential to accelerate existing health disparities 
and further promote poor health outcomes in 
racial and ethnically diverse communities that 
already experience greater barriers to obtaining 
appropriate health care.17, 19   

Inequity in pain management does not only affect 
ethnic minorities. In the case of opioid monitoring, 
it appears that non-Whites actually receive care 
that is more in-line with that of expert 
recommendations, while Whites experience 
inappropriate laxity in the monitoring of their 
opioid treatment and the implementation of risk 
reduction strategies.23 The use of opioids for pain 
management presents high potential for addiction 
and abuse of these medications in non-Hispanic 
Whites.19 The fact that these individuals are much 

Table 5. Grades of Recommendation  
Conclusion Source(s) Grade 

Racial/ethnic 
inequalities appear to 
exist in the prescription 
of non-opioid analgesic 
medications.  
 

Meghani et 
al. A 

No apparent 
racial/ethnic disparities 
exist in opioid 
prescription or 
administration for 
treatment of objectively 
painful conditions.  
 

Singhal et 
al; 

Rosenbloom 
et al; 

Romanelli 
et al. 

A 

Racial/ethnic disparities 
are present in the 
prescription of opioid 
analgesics for 
subjectively painful 
conditions.  

Singhal et 
al; 

Meghani et 
al. 

A 

Racial/ethnic 
inequalities may occur in 
the tapering and 
reducing of opioid 
doses.   

Buonora et. 
al. B 

There are evident 
racial/ethnic disparities 
in the risk of opioid 
abuse and opioid 
overdose death.  

Buonara et 
al. A 



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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

more likely to be administered and prescribed 
high-dose opioid medications for long-term 
duration is a potential contributing factor to why 
Whites have an age-adjusted death rate that is 
more than three times that of non-Hispanic 
Blacks.19 Ethnic disparities in prescribing practices 
may contribute not only to undertreatment of pain 
in non-Hispanic Blacks, but also promote the 
misuse, abuse, and potential opioid overdose 
death in non-Hispanic Whites.19 These findings 
suggest the assessment of a patient’s treatment 
risks may rely on the clinician’s interpretation of 
the patient’s self-reported pain and the clinician’s 
judgement about the patient’s potential misuse of 
opioids.19 The highly subjective nature of these 
decisions and the influence of implicit bias leave 
room for assumption and unchallenged 
misconceptions to play a role in the selection of 
pain management interventions. To combat this, 
we advocate for a universal approach to the 
prescription of opioid analgesics medications as 
well as in the management and risk-reduction for 
patients with definitive and non-definitive pain 
conditions.23  

The treatment of pain is complicated by its 
inherently subjective nature, but identification and 
acknowledgement of implicit racial or ethnic 
biases, as well as use of an evidence-based 
approach, may assist health care providers in 
clinical decision-making during times of medical 
ambiguity. Individual patient factors such as 
cultural traditions, religious beliefs, and previous 
lived experiences need to be valued by clinicians 
for their potential to affect the pain experience in 
patients from various racial and ethnic 
backgrounds.24 Likewise, all providers within the 
interdisciplinary health care team should be 
knowledgeable regarding current and 
appropriate standards of care. When properly 
educated on the standard of care and health 
inequities, athletic trainers can serve as vital 
patient advocates.25 Furthermore, we can 
evaluate and document the effectiveness of these 
analgesic medications to determine when a 

patient’s pain needs are not being met or when 
intervention for substance misuse or abuse may be 
warranted.26 

CLINICAL BOTTOM LINE 

Clinicians have a responsibility to act in their 
patients’ best interest and provide high-quality 
patient care. Therefore, they need to remain 
aware of the role implicit bias may play in 
treatment decisions. Analgesic medications are 
often a principal component of pain management. 
Findings of this review concluded equity exists in 
the prescription of analgesics for definitive injuries 
such as long bone fractures, yet disparities are 
present in the prescription of analgesic drugs for 
more subjective conditions like back or abdominal 
pain between racial and ethnic groups.18, 19, 20, 21 
Furthermore, evidence suggests that ethnic 
minorities may suffer from lower medication 
dosing and stricter opioid oversight from 
prescribing providers.17, 21 Racial and ethnic 
disparities in prescribing of these drugs may 
contribute not only to the inadequate 
management of pain for non-White communities 
but contribute to the high rates of abuse and 
overdose-related death characteristic of the 
opioid epidemic within the non-Hispanic White 
population.17 

Respect for the patient’s values, preferences and 
subjective reports of pain are important factors 
for all clinicians to consistently consider during 
clinical decision-making. It is particularly 
important that athletic trainers be aware of the 
current standards of care for managing pain 
through the use of analgesic medications. 
Furthermore, we should be knowledgeable and 
actionable regarding the signs of opioid misuse, 
abuse, and addiction. This will require 
acknowledging pain in patients, detecting the 
source of pain, evaluating pain at routine 
intervals, and developing an interdisciplinary plan 
with physicians and other health care 
professionals for successful pain management.26 

Because athletic trainers regularly work with 



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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

patients recovering from surgery and other 
painful conditions in which analgesics are 
prescribed, future research directions should 
specifically investigate racial and ethnic 
disparities in the prescription, administration, and 
abuse of these medications in the athletic 
population.  

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https://doi.org/10.1093/pm/pny137
https://doi.org/10.1111/j.1526-4637.2011.01310.x
https://doi.org/10.1111/j.1526-4637.2011.01310.x
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https://doi.org/10.1371/journal.pone.0159224
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https://doi.org/10.1093/pm/pnx025
https://doi.org/10.1370/afm.1242
https://doi.org/10.2217/pmt.12.7

	ABSTRACT

