Chronic Pain in Black Adults: Getting Your Pain Taken Seriously

Chronic pain affects tens of millions of Americans. For Black adults, the clinical encounter around pain carries an additional layer: documented evidence that clinicians routinely underestimate, under-document, and undertreat pain in Black patients. A 2016 study in PNAS found that roughly half of medical students and residents believed at least one false biological claim about Black bodies, including that Black patients have thicker skin or less sensitive nerve endings. Those trainees assigned lower pain scores to Black patients and recommended weaker treatments. The problem is not Black patients' pain thresholds. The problem is what some clinicians believe about Black patients.

The research record on this question is consistent across three decades of published literature. The Institute of Medicine's 2011 report Relieving Pain in America identified racial disparities in pain management as a specific public health failure, noting that minority patients were undertreated across virtually every pain type studied. A 2003 landmark review in Pain Medicine, led by Carmen Green at the University of Michigan, documented that racial and ethnic minorities were undertreated for pain in every clinical setting examined: postoperative care, the emergency department, cancer pain, and chronic noncancer pain. The finding held across condition type and care setting.

A 2019 systematic review and meta-analysis published in the American Journal of Emergency Medicine quantified the gap: across 14 studies involving more than 10,000 patients, Black patients in the emergency department had 40% lower odds of receiving any analgesia for acute pain (odds ratio 0.60, 95% CI 0.43 to 0.83). A separate retrospective review of 868 emergency department records found that Black patients with musculoskeletal pain received fewer opioids and fewer discharge analgesics despite presenting with the same chief complaints. A national veterans cohort study of nearly 100,000 patients found that Black veterans under age 65 with moderate to high pain intensity were prescribed opioids at significantly lower rates despite reporting equivalent pain intensity levels.

The 2016 PNAS study by Hoffman, Trawalter, Axt, and Oliver is the most-cited explanation for the mechanism. The researchers surveyed medical students and residents and found that approximately half endorsed at least one false belief about the biology of Black patients, including myths about pain sensitivity and skin thickness. Commonly endorsed myths included that Black patients have a higher pain tolerance, thicker skin, and less sensitive nerve endings. Participants who endorsed more of these false beliefs assigned lower pain scores to Black patients in clinical vignettes and made less accurate treatment recommendations. Participants without those false beliefs showed no such bias. The problem, the study concluded, is the persistence of false beliefs in medical training, not an inherent property of clinical judgment. The Hoffman study's PMID is 27044069 and it is freely available on PubMed.

A 2020 systematic review in the Journal of Advanced Nursing synthesized 20 studies from 2007 to 2017 and identified three consistent factors shaping why injured Black patients received less pain treatment: provider characteristics, racial myths about pain sensitization, and an assumed criminality that led some clinicians to attribute drug-seeking to Black patients presenting with pain. These three factors compound: a clinician who holds a racial myth about pain tolerance and also suspects drug-seeking behavior will underprescribe, document inadequately, and under-refer. The patient leaves with no relief and no paper trail to bring to the next provider.

The burden of inadequate pain treatment falls hardest in conditions that already disproportionately affect Black adults. Black women with fibromyalgia face delayed diagnoses, partly because the diagnostic criteria were developed on predominantly non-Black study populations, and partly because fibromyalgia-related pain reports from Black patients are more likely to be attributed to other causes or dismissed. Sciatica and chronic low back pain are among the most common pain complaints presenting to emergency departments, and the data on opioid prescribing for back pain by race are consistent: Black patients are prescribed opioids less often for the same complaint. Sickle cell disease, which primarily affects Black Americans, is a condition in which pain crises are both severe and objectively rooted in pathophysiology, yet sickle cell patients routinely report being disbelieved and undertreated in emergency settings.

Documentation is your most effective tool. Clinicians respond to written records. A pain journal with daily entries, numeric pain scores (0 to 10), and specific notes on how pain limits your function (cannot walk one block without stopping, cannot sleep more than three hours, cannot lift my child) gives a clinician concrete information that is harder to dismiss than a verbal report. Write it down for at least two weeks before an appointment where you plan to discuss your pain. Bring the journal. Leave a copy in your chart by asking the nurse or medical assistant to scan it.

Three questions to ask specifically at the appointment, taken directly from clinical advocacy frameworks:

• What is your pain treatment plan for me? This forces an explicit answer. "We'll see how it goes" is not a plan.
• What is the specific treatment you are recommending, and what are the alternatives? Every treatment decision has alternatives. Asking for them signals that you know this.
• If my pain is not adequately controlled by the next appointment, what is the next step? This installs a checkpoint and documents that you raised the question.

If a clinician dismisses your pain report, attributes it to anxiety or stress without ruling out physical causes, refuses to document your pain score in the chart, or declines to refer you to a pain specialist, you have several concrete options. First, ask to have your pain score and your concern about its management documented in the visit notes. You are entitled to request this. Second, ask for a referral to a pain management specialist. Primary care clinicians are not required to manage complex chronic pain. Third, file a complaint with the hospital's patient relations or patient advocacy office. Federal nondiscrimination regulations require facilities to respond to documented complaints. Fourth, seek a second opinion.

Research on what to ask a new doctor consistently shows that patients who frame requests as information-seeking rather than demands get more complete responses. Phrases like "Can you help me understand why this level of pain management is appropriate for my situation?" or "What would you recommend if my pain were not improving?" keep the conversation open. If a clinician responds with defensiveness or dismissiveness to those questions, that is itself a signal about whether this clinical relationship will serve you.

Research on racial concordance in clinical care shows that Black patients report higher trust, more complete information-sharing, and greater satisfaction when seeing Black clinicians. You do not have to see a Black clinician to get good pain care, but you are entitled to seek one if prior clinical relationships have been dismissive. Find a Black or Black-serving pain management specialist, rheumatologist, or primary care physician in your area using the blackhealth.org directory. When evaluating a new clinician for chronic pain care, ask during the first appointment whether they have treated other patients with your condition, what their approach is to multimodal pain management (combining medication with physical therapy, behavioral approaches, or interventional options), and how they handle pain that does not respond to first-line treatment.

For Black adults with conditions that carry documented pain-bias risk, such as fibromyalgia, sickle cell disease, or chronic back pain, establishing care with a specialist before a pain crisis is significantly more effective than presenting cold to an emergency department. A specialist who knows your history, your baseline pain levels, and your treatment plan can document all of this in your record. That record follows you across encounters and gives any emergency clinician a factual baseline rather than a blank slate that some will fill in with assumptions.