Avoid racial and cultural bias in pain management

Research has shown evidence of ethnic bias in regard to pain management, says Knox H. Todd, MD, MPH, associate professor of emergency medicine at Emory University School of Medicine in Atlanta, GA. "Although the underuse of analgesics applies to all [emergency department] ED patients, I think we’ve established that ethnic bias exists."

Studies reviewed records from patients with isolated long bone fractures of upper or lower extremities.1-4 "The majority white culture tended to receive more analgesics than the minority population of African or Hispanic patients," says Todd. "We were able to show identical complaints of pain with identical injuries, and whites were more likely to receive analgesics."

Here are some ways to avoid ethnic bias:

Make assessment for pain mandatory. "The quickest route to more consistent treatment would be to institute guidelines for pain management that are protocol driven and don’t require active participation by nurses or physicians," Todd recommends. (See ED quality assurance process inserted with this issue.)

Give a non-narcotic analgesic at triage. If all patients complaining of pain are given analgesics at triage, ethnic bias will not be an issue, says Todd. "We need to move the point of analgesic delivery much closer to the patient’s complaint," he adds. "For example, any patient who presents with an ankle sprain at triage can certainly receive 600 of ibuprofen prior to getting an x-ray. With time, that becomes a reflex action."

There is no problem in giving a non-narcotic analgesics, whatever the patient’s eventual diagnosis, notes Todd. "Narcotics added to a base of non narcotic therapy is a reasonable way to go," he says.

Track reasons for unscheduled returns. Monitoring unscheduled returns due to pain and comparing them for ethnic groups is a way to ensure consistent treatment, says Todd. "One of the blind spots we have is not knowing what happens two or three days down the road, after the patient leaves the ED," he notes. "If you look at unscheduled returns, many of those are due to inadequate pain management."

Audit for ethnic bias in your ED. "If you look for it, you will probably find it," says Todd. "To do a quick audit, choose a typical stereotypic pain stimulus like a fracture, something that is fairly objectively diagnosed. Then simply compare pain management among ethnic groups for a period of time."

Fractures are a good candidate for this type of audit, since the severity can be quantified, says Todd. "Avoid hip fractures or sprains, because they’re not as easy to define," he recommends. "It’s not difficult to do a year’s worth of past charts, and it’s become even easier with information systems, to query for differences in analgesia with ethnic groups."

Consider which pain scales should be used. A study assessed whether numeric or word pain scales are more effective with patients who don’t speak English.5 "We looked at whether some cultural groups might prefer a word descriptor scale or a numerical scale," says Martha Neighbor, MD, FACEP, at San Francisco General Hospital (CA). "We found both scales can be used very effectively."

The study found that there was very little difference in patient preference for one of the scales, and both scales were valid. Patients should be offered their choice of either of these simple pain rating scales to evaluate pain and the effectiveness of pain-relieving interventions, says Neighbor.

Use multi-lingual laminated cards. Word and numerical rating scales should be developed in the prevalent languages of your community, says Neighbor. "When non-English speaking patients present at the triage desk in pain, you can show them laminated cards that ask them to describe the intensity of their pain," she suggests.

Multi-lingual laminated cards can assess severity of pain consistently among different cultural groups, says Neighbor. "If you can’t rate the severity objectively, then, obviously, the providers are left to surmise how much pain [the patient is] having, based on how they look, and different cultural groups don’t necessarily manifest their pain the same," she notes. "Some are stoic and quiet, while others overly dramatize the degree of pain they are having."


1. Todd KH. Pain assessment and ethnicity. Ann Emerg Med 1996;27:421-423.

2. Todd KH, Lee A, Hoffman JR. The effect of ethnicity on assessment of pain severity in patients with isolated extremity trauma. JAMA 1994;271:925-928.

3. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 1993;269:1537-1539.

4. Todd KH, Warner C, D’Adamo A, et al. Ethnicity and emergency department analgesia. Acad Emerg Med 1997;4:424.

5. Puntillo K, Neighbor ML. Two methods of assessing pain intensity in English and Spanish-speaking patients. JEN 1997;23: 597-601.