Disparities In Pain Care Research Articles

Improving Pain Management for Marginalized Communities: Educating the Next Generation of Health Care Professionals

Inadequately managed pain has immense negative impacts on children, families, health care systems, and societies. Historically and presently, inadequately treated pain disproportionally affects marginalized communities. Deficiencies in pain education for health care providers are widely recognized as a leading contributor to poorly managed pain. Existing training for providers prioritizes physiological systems and pharmacological interventions for pain, despite decades of evidence supporting the biopsychosocial model and interdisciplinary treatment of pain. Moreover, education for health care providers rarely acknowledges the role of bias, prejudice, and systemic racism in perpetuating disparities in pain care. To address this gap, we sought to develop an innovative curriculum for health care teams to combat racial injustice related to pain management. This curriculum was developed and refined collaboratively with community partners representing diverse expertise, including lived experiences of pain, interdisciplinary pain management, cultural humility and authentic allyship, and curriculum development and evaluation. Four modules delivered across 1 to 2 hours were developed and pilot-tested extensively with multidisciplinary providers across a large pediatric health system. Learner feedback indicated high acceptability and informed iterative changes to the curriculum. Additional research is needed to examine impacts of the curriculum on health care provider knowledge and behavior (eg, clinical decision-making) and patient-reported outcomes as well as to test dissemination and implementation strategies. PerspectiveWe present the development and evaluation of a curriculum for health care professionals to combat racial injustice in pain management. By engaging diverse community partners, using design thinking, applying an antiracist lens, and designing for dissemination, we aim to equip the next generation of providers to deliver equitable pain care.

Racial Bias in Pediatric Pain Perception

Racial disparities in pediatric pain care are prevalent across a variety of health care settings, and likely contribute to broader disparities in health, morbidity, and mortality. The present research expands on prior work demonstrating potential perceptual contributions to pain care disparities in adults and tests whether racial bias in pain perception extends to child targets. We examined the perception and hypothetical treatment of pain in Black and White boys (experiment 1), Black and White boys and girls (experiment 2), Black and White boys and adult men (experiment 3), and Black, White, Asian, and Latinx boys (experiment 4). Across this work, pain was less readily perceived on Black (vs White) boys’ faces—though this bias was not observed within girls. Moreover, this perceptual bias was comparable in magnitude to the same bias measured with adult targets and consistently predicted bias in hypothetical treatment. Notably, bias was not limited to Black targets—pain on Hispanic/Latinx boys’ faces was also relatively underperceived. Taken together, these results offer strong evidence for racial bias in pediatric pain perception. PerspectiveThis article demonstrates perceptual contributions to racial bias in pediatric pain recognition. Participants consistently saw pain less readily on Black boys’ faces, compared with White boys, and this perceptual bias consistently predicted race-based gaps in treatment. This work reveals a novel factor that may support pediatric pain care disparities.

Documenting Race and Gender Biases in Pain Assessment and a Novel Intervention Designed to Reduce Biases

Disparities in pain care are well-documented such that women and people of color have their pain undertreated and underestimated compared to men and White people. One of the contributors of the undertreatment of pain for people of color and women may be the inaccurate assessment of pain. Understanding the pain assessment process is an important step in evaluating the magnitude of and intervening on pain disparities in care. In the current work, we focus on documenting intersectional race and gender biases in pain assessment and present the results of a novel intervention for reducing these biases. Across 3 studies (N = 532) and a mini meta-analysis using real videotaped people in pain as stimuli, we demonstrate that observers disproportionately underestimated women of color’s pain compared to all other groups (men of color, White women, and White men). In study 3 (N = 232), we show that a novel intervention focused on behavioral skill building (ie, practice and immediate feedback) significantly reduced observers’ pain assessment biases toward marginalized groups compared to all other types of trainings (raising awareness of societal biases, raising awareness of self-biases, and a control condition). While it is an open question as to how long this type of intervention lasts, behavioral skills building around assessing marginalized people’s pain more accurately is a promising training tool for health care professionals. PerspectiveThis article demonstrates the underestimation of pain among people of color and women. We also found support that a novel intervention reduced observers’ pain assessment biases toward marginalized groups. This could be used in medical education or clinical care to reduce intersectional pain care disparities.

Pain Care Disparities and the Use of Virtual Care Among Racial-Ethnic Minority Groups During COVID-19

Background and ObjectiveCOVID-19 led to an unprecedented reliance on virtual modalities to maintain care continuity for patients living with chronic pain. We examined whether there were disparities in virtual specialty pain care for racial-ethnic minority groups during COVID-19.Design and ParticipantsThis was a retrospective national cohort study with two comparison groups: primary care patients with chronic pain seen immediately prior to COVID-19 (3/1/19–2/29/20) (N = 1,649,053) and a cohort of patients seen in the year prior (3/1/18–2/28–19; n = 1,536,954).Main MeasuresWe assessed use of telehealth (telephone or video) specialty pain care, in-person care specialty pain care, and any specialty pain care for both groups at 6 months following cohort inclusion. We used quasi-Poisson regressions to test associations between patient race and ethnicity and receipt of care.Key ResultsPrior to COVID-19, there were Black-White (RR = 0.64, 95% CI [0.62, 0.67]) and Asian-White (RR = 0.63, 95% CI [0.54, 0.75]) disparities in telehealth use, and these lessened during COVID-19 (Black-White: RR = 0.75, 95% CI [0.73, 0.77], Asian-White: RR = 0.81, 95% CI [0.74, 0.89]) but did not disappear. Individuals identifying as American Indian/Alaska Native used telehealth less than White individuals during early COVID-19 (RR = 0.98, 95% CI [0.85, 1.13] to RR = 0.87, 95% CI [0.79, 0.96]). Hispanic/Latinx individuals were less likely than non-Hispanic/Latinx individuals to use telehealth prior to COVID-19 but more likely during early COVID-19 (RR = 0.70, 95% CI [0.66, 0.75] to RR = 1.06, 95% CI [1.02, 1.09]). Disparities in virtual pain care occurred over the backdrop of overall decreased specialty pain care during the early phase of the pandemic (raw decrease of n = 17,481 specialty care encounters overall from pre-COVID to COVID-era), including increased disparities in any VA specialty pain care for Black (RR = 0.81, 95% CI [0.80, 0.83] to RR = 0.79, 95% CI [0.77, 0.80]) and Asian (RR = 0.91, 95% CI [0.86, 0.97] to RR = 0.88, 95% CI [0.82, 0.94]) individuals.ConclusionsDisparities in virtual specialty pain care were smaller during the early phases of the COVID-19 pandemic than prior to the pandemic but did not disappear entirely, despite the rapid growth in telehealth. Targeted efforts to increase access to specialty pain care need to be concentrated among racial-ethnic minority groups.

Toward reducing racialized pain care disparities: Approaching cannabis research and access through the lens of equity and inclusion.

There is growing interest in cannabis use for cancer pain. This commentary aims to discuss the evidence surrounding cannabis use for cancer pain in the context of the long-racialized landscape of cannabis policies and the disparity in pain control among cancer patients holding minoritized racial identities. Much evidence surrounding both the benefits and harms of cannabis use in cancer patients, and all patients in general, is lacking. Although drawing on the research in cancer that is available, it is also important to illustrate the broader context about how cannabis' deep roots in medical, political, and social history impact patient use and health care policies. There are lessons we can learn from the racialized disparities in opioid risk mitigation strategies, so they are not replicated in the settings of cannabis for cancer symptom management. Additionally, the authors intentionally use the term "cannabis" here rather than "marijuana.: In the early 1900s, the lay press and government popularized the use of the word "marijuana" instead of the more common "cannabis" to tie the drug to anti-Mexican prejudice.

What factors predict anti‐Black bias in pain perception? An internal meta‐analysis across 40 experimental studies

AbstractRacial disparities in pain care affecting Black Americans are mirrored by a similar perceptual bias: perceivers see pain less readily on Black (vs. White) faces. Here, we examine the findings of the initial wave of research on this phenomenon, described herein as anti‐Black bias in pain perception. Specifically, we conducted an internal meta‐analysis across 40 studies conducted in the U.S. with primarily White samples (N = 6252) assessing the generalizability, robustness, and psychological correlates of anti‐Black bias in pain perception. We also assessed the evidence for accounts of this bias focused on intergroup processes, racialized stereotypes and prejudice, dehumanization, and contact. This meta‐analysis strongly confirms our prior findings. Moreover, anti‐Black bias in pain perception is consistently associated with bias in treatment recommendations. These effects are robust to differences in stimuli, samples, and perceiver gender and race. Notably, both Black and White perceivers demonstrate more conservative perceptual thresholds for seeing pain on Black faces, suggesting this bias is not merely a consequence of group membership. Further, increased dehumanization of and decreased intergroup contact with Black individuals predicts biased pain perception and treatment recommendations, though these effects were small. These results demonstrate the robustness of anti‐Black bias in pain perception and establish a strong foundation for future inquiry.

Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): a Qualitative Analysis of a Tailored Coaching Program for Black Patients with Chronic Pain.

Racial inequities in pain treatment are well-documented and persist despite national priorities focused on health equity. The COOPERATE (Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity) intervention was a patient-centered, tailored intervention aimed at improving health equity by targeting patient activation-the knowledge and confidence to manage one's health. COOPERATE led to significant and sustained increases in patient activation, significant short-term increases in communication self-efficacy (confidence to communicate with clinicians), and more intervention participants experienced clinically significant (≥ 30%) reductions in pain at 3months than control group participants. To understand how participants experienced the intervention, including their perspectives on its effects on their health and healthcare experiences. Semi-structured qualitative interviews. Black veterans with chronic pain who participated in the COOPERATE intervention. Participants described acquiring new tools and cultivating skills to use in their clinic visits, including preparing for their visit (writing an agenda, listing questions); asking focused, effective questions; and expressing concerns and communicating goals, values, and preferences. Participants indicated that by putting these tools to use, they felt more confident and able to take ownership of their own pain care; for some, this led to better pain management and improved pain. Participants expressed mixed views of disparities in pain care, with some believing race and racism did not play a role in their care, while others valued being part of an intervention that helped equip them with tools to exercise autonomy over their healthcare. Black patients with chronic pain described gaining greater confidence to self-manage and communicate with their clinicians after participating in the COOPERATE intervention. With its focus on empowering individuals, the COOPERATE intervention represents a promising approach to help advance equity in pain care.

Evaluating and refining a pain quality information visualization tool with patients and interpreters to facilitate pain assessment in primary care settings

ABSTRACTInformation visualization (InfoViz) tools offer a potential solution to pain communication challenges. Incongruencies in communication styles between patients with limited English proficiency (LEP), interpreters, and providers contribute to significant disparities in pain care and outcomes. This study’s purpose is to evaluate and refine a culturally appropriate InfoViz pain quality assessment tool for LEP Hmong patients. We conducted a three-part iterative user-centered study with LEP Hmong, bilingual Hmong, and Hmong interpreters with (1) participatory design sessions to evaluate and refine pain infographics for inclusion on the tool, (2) card-sorting to organize the infographics to match the mental models of LEP patients, and (3) a tool assessment to identify which tool accurately represented LEP patients’ mental models and was preferred in clinical settings. Fifty-five participants provided three common themes for pain infographics refinement: culturally-relevant colors, infographics resembling human anatomy, and action-specific squiggle lines. The card-sorting sessions revealed three organizational themes: sensation (n = 15; 71.4%), localization (n = 6; 28.6%), and severity of pain quality (n = 5; 24.3%). Most participants selected the localization as the most accurate tool and preferred it in clinical settings. Using a multi-step, user-centered approach resulted in a culturally appropriate pain InfoViz tool for LEP Hmong patients.

Qualitative Analysis of Patient Perspectives of Buprenorphine After Transitioning From Long-Term, Full-Agonist Opioid Therapy Among Veterans With Chronic Pain

Guidelines recommend consideration of modification, tapering, or discontinuation of long-term, full-agonist opioid therapy when harms outweigh benefits; one alternative to tapering or discontinuing full-agonist opioids for the management of chronic pain is switching to the partial agonist buprenorphine. As the use of buprenorphine for pain expands, understanding the patient experience during and after the transition to buprenorphine is critical. We conducted 45- to 60-minute semistructured qualitative interviews with 19 patients to understand the experiences of patients with chronic pain actively maintained on buprenorphine after previously receiving full-agonist, long-term opioid therapy. Patients were recruited from 2 medical centers via provider referral. Through thematic analysis, 5 overall themes were identified, including satisfaction with buprenorphine, the importance of preconceptions about buprenorphine, experiences with transitions, patient-provider communication, and potential contributions to racial disparities in pain care. While we heard a range of experiences, most patients were satisfied with buprenorphine, reporting either equivalent pain control to their previous regimens or reporting less analgesia but improved functioning due to a reduction in side effects (eg, mental clarity). Patients also emphasized the importance of a nonjudgmental, patient-centered approach, including education about the risks and benefits of buprenorphine. The few Black patients interviewed all reported limited access to pain care, which is consistent with the well-documented existence of racial disparities in access to pain treatment. As buprenorphine is used more frequently for pain management, provider education focused on pain treatment disparities, patient-centered approaches informed by motivational interviewing, and increasing acceptance of buprenorphine as an option for pain are needed. PerspectiveQualitative analyses of patient experiences transitioning from full-agonist opioids to buprenorphine for chronic pain revealed general satisfaction. Patients reflected on functioning, tradeoffs between analgesia and side effects, patient-centered care, and access to treatment, highlighting how future research should focus on outcomes valued by patients.

Mental Health Diagnoses are Not Associated With Indicators of Lower Quality Pain Care in Electronic Health Records of a National Sample of Veterans Treated in Veterans Health Administration Primary Care Settings

Prior research has demonstrated disparities in general medical care for patients with mental health conditions, but little is known about disparities in pain care. The objective of this retrospective cohort study was to determine whether mental health conditions are associated with indicators of pain care quality (PCQ) as documented by primary care clinicians in the Veterans Health Administration (VHA). We used natural language processing to analyze electronic health record data from a national sample of Veterans with moderate to severe musculoskeletal pain during primary care visits in the Fiscal Year 2017. Twelve PCQ indicators were annotated from clinician progress notes as present or absent; PCQ score was defined as the sum of these indicators. Generalized estimating equation Poisson models examined associations among mental health diagnosis categories and PCQ scores. The overall mean PCQ score across 135,408 person-visits was 8.4 (SD = 2.3). In the final adjusted model, post-traumatic stress disorder was associated with higher PCQ scores (RR = 1.006, 95%CI 1.002–1.010, P = .007). Depression, alcohol use disorder, other substance use disorder, schizophrenia, and bipolar disorder diagnoses were not associated with PCQ scores. Overall, results suggest that in this patient population, presence of a mental health condition is not associated with lower quality pain care. PerspectiveThis study used a natural language processing approach to analyze medical records to determine whether mental health conditions are associated with indicators of pain care quality as documented by primary care clinicians. Findings suggest that presence of a diagnosed mental health condition is not associated with lower quality pain care.

Assessing Pain Research: A Narrative Review of Emerging Pain Methods, Their Technosocial Implications, and Opportunities for Multidisciplinary Approaches.

Pain research traverses many disciplines and methodologies. Yet, despite our understanding and field-wide acceptance of the multifactorial essence of pain as a sensory perception, emotional experience, and biopsychosocial condition, pain scientists and practitioners often remain siloed within their domain expertise and associated techniques. The context in which the field finds itself today—with increasing reliance on digital technologies, an on-going pandemic, and continued disparities in pain care—requires new collaborations and different approaches to measuring pain. Here, we review the state-of-the-art in human pain research, summarizing emerging practices and cutting-edge techniques across multiple methods and technologies. For each, we outline foreseeable technosocial considerations, reflecting on implications for standards of care, pain management, research, and societal impact. Through overviewing alternative data sources and varied ways of measuring pain and by reflecting on the concerns, limitations, and challenges facing the field, we hope to create critical dialogues, inspire more collaborations, and foster new ideas for future pain research methods.

The Impact of Patient Race and Prior Misuse Behaviors on Opioid Tapering Decisions

Given the recent opioid crisis, providers are being encouraged to taper prescription opioids for chronic pain. Racial disparities in pain treatment are well documented, but little is known about how patient race may influence provider opioid tapering decisions. Research and theory also suggest that patient race may interact with opioid use and adherence behaviors to impact provider tapering decisions. In this online study, 136 providers made opioid tapering decisions for 8 computer-simulated patients (4 Black, 4 White) with chronic pain. Text vignettes described all patients as taking prescription opioids, but half reported previous "yellow flag" misuse behaviors (e.g., early refill) and half reported medication adherence. Multilevel modeling indicated that patient history of opioid misuse increased providers' odds of changing the opioid prescription (OR=4.7, p=.03) and of endorsing the goal of discontinuing opioids (vs. maintaining at a lower dose; OR=11.0, p<.01). Patient history of opioid misuse also increased providers' odds of starting a long-acting opioid and decreasing the dose of the current opioid (vs. discontinuing opioids immediately; OR=4.2, p=.06). For providers who started a long-acting opioid, there was a significant race-by-misuse interaction on their target MED/day. For White patients, a history of opioid misuse increased providers' odds of prescribing a higher dose of the long-acting opioid (OR=3.4, p<.01), but no differences emerged for Black patients. Neither patient race nor opioid use history impacted the rate of tapering or the MED/day target for short-acting opioids. Our results indicate that the clinically-relevant information of patient opioid use history impacted provider opioid tapering decisions. Although patient race largely did not affect the tapering decisions assessed herein, prior work has found Black patients undergo more opioid-related monitoring than White patients. Future studies are needed to further understand the nuances of racial disparities in pain care during the opioid crisis. Grant support from National Institutes of Health under Award Numbers R01MD008931 and R01MD008931-05S.

Qualitative Content Analysis of a Virtually Delivered Auricular Point Acupressure Intervention for Self-Managing Chronic Pain

PURPOSE: Current treatments have not adequately managed chronic pain contributing to high prevalence, disability, and healthcare costs. Further, inadequate access to pain management has resulted to pain care disparities. With the pandemic, availability of pain treatments are limited due to fewer in-person visits and distancing requirements thereby delaying pain care even more. Hence, we tested vAPA, a virtually delivered, self-management intervention using Auricular Point Acupressure (APA) via mobile app and virtual consultations.

Seeing no pain: Assessing the generalizability of racial bias in pain perception.

Racial disparities in pain care may stem, in part, from perceptual roots. It remains unresolved, however, whether this perceptual gap is driven by general deficits in intergroup emotion recognition, endorsement of specific racial stereotypes, or an interaction between the two. We conducted four experiments (total N = 635) assessing relationships between biases in pain perception and treatment and biases in the perception of anger, happiness, fear, and sadness. Participants saw Black and White male targets making increasingly painful and angry (Experiment 1), happy (Experiment 2), fearful (Experiment 3), or sad expressions (Experiment 4). The effect of target race consistently varied based on the emotion displayed. Participants repeatedly saw pain more readily on White (vs. Black) male faces. However, while participants also saw sadness less readily on Black faces, perception of anger, fear, and happiness did not vary by target race. Moreover, the tendency to see pain less readily on Black faces predicted similar differences in recognizing (particularly negative) expressions, though only racial bias in pain perception facilitated similar biases in treatment. Finally, while endorsement of racialized threat stereotypes facilitated recognition of angry expressions and was marginally associated with impeded recognition of happy expressions on Black faces, gaps in pain perception were not reliably related to stereotype endorsement. These data suggest that while racial bias in pain perception is associated with a general bias in recognizing negative emotion on Black male faces, the effects of target race on pain perception are particularly robust and have distinct consequences for gaps in treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Racial disparities in observers' attention to and estimations of others' pain.

Research has demonstrated racial disparities in pain care such that Black patients often receive poorer pain care than White patients. Little is known about mechanisms accounting for the emergence of such disparities. The present study had 2 aims. First, we examined whether White observers' attentional processing of pain (using a visual search task [VST] indexing attentional engagement to and attentional disengagement from pain) and estimation of pain experience differed between White vs Black faces. Second, we examined whether these differences were moderated by (1) racially biased beliefs about pain experience and (2) the level of pain expressed by Black vs White faces. Participants consisted of 102 observers (87 females) who performed a VST assessing pain-related attention to White vs Black avatar pain faces. Participants also reported on racially biased beliefs about White vs Black individuals' pain experience and rated the pain intensities expressed by White and Black avatar faces. Results indicated facilitated attentional engagement towards Black (vs White) pain faces. Furthermore, observers who more strongly endorsed the belief that White individuals experience pain more easily than Black individuals had less difficulty disengaging from Black (vs White) pain faces. Regarding pain estimations, observers gave higher pain ratings to Black (vs White) faces expressing high pain and White (vs Black) faces expressing no pain. The current findings attest to the importance of future research into the role of observer attentional processing of sufferers' pain in understanding racial disparities in pain care. Theoretical and clinical implications are discussed, and future research directions are outlined.

Racism in Pain Medicine: We Can and Should Do More

Racism in Pain Medicine: We Can and Should Do More

Women with Chronic Low Back Pain and Low Socio-economic Status: Self-efficacy and Multi-site Pain Predictors

Chronic low back pain (CLBP) prevalence is higher among women and those with low socioeconomic status (SES). Without adequate self-efficacy and subsequent self-management, patients gradually develop chronic multisite pain after one year of having CLBP alone. Guided by Bandura's framework, we investigated the predictors of self-efficacy and multisite pain among adult women with CLBP and low SES, toward improving pain management and minimizing pain care disparities.

Gender Stereotypes Explain Disparities in Pain Care and Inform Equitable Policies

Despite women experiencing and reporting more pain than men, women receive less intensive and effective treatment for their pain. The current work leverages the well-developed social psychological literature on gender stereotypes, specifically stereotypes of emotionality, to understand gender biases in pain care. Specifically, gender stereotypes about emotionality may generate beliefs that women dramatize, overemphasize, or even fabricate their experiences of pain relative to men. This mistrust in women’s experiences of pain could undermine efficacy and equality of care. Research needs to directly examine the role of provider stereotype endorsement in pain care disparities, how these stereotypes influence patient–provider interactions, and whether these stereotypes may be implicit in health care policies. Established interventions and potential policy reform could combat gender-emotionality stereotypes and thereby mistrust of women’s reports in the context of pain treatment.

Self-Efficacy and Multisite Pain Predictors among Economically Disadvantaged Women with Back Pain

BackgroundChronic low back pain (CLBP) prevalence is higher among women and those with low socioeconomic status. Without adequate self-efficacy and subsequent self-management, patients gradually develop chronic multisite pain after one year of having CLBP alone. AimThis study investigated the predictors of self-efficacy and multisite pain among adult, economically disadvantaged women, where pain prevalence is higher. DesignCross-sectional, descriptive study. SettingPain management center. SubjectsParticipants (n = 50) with primary diagnosis of chronic low back pain. MethodsAfter Institutional Review Board approval, data collection was conducted using valid and reliable instruments measuring several variables. Controlling for age and race, multiple linear regression was used for analyses. Results and ConclusionsFor all predictors of self-efficacy, a significant regression equation was identified (p < .01) with R2 of .413 and variance of .643. Pain catastrophizing was a significant individual predictor (p < .05). A significant regression equation was also found for all predictors of multisite pain (p < .001) with R2 of .528 and variance of .726. Individual predictors (p < .05) were age, physical function, and numbers of pain treatments and chronic medical conditions. Study findings suggest that significant predictors can be key to advancing pain research, education, practice, and healthcare policy toward improving pain management. Particularly among this population, pain catastrophizing needs to be targeted in pain management. To minimize development of multisite pain, further investigation of identified predictors including number of chronic medical conditions and pain treatments received are necessary. Multimodal, but targeted approaches addressing these predictors are recommended, instead of costly, indiscriminate multimodal therapy. Targeted interventions can help reduce pain care disparities among socioeconomically disadvantaged women, identify high risk groups for prompt intervention, facilitate better pain response to treatments, and minimize further disability.

Neural and sociocultural mediators of ethnic differences in pain.

Understanding ethnic differences in pain is important for addressing disparities in pain care. A common belief is that African Americans are hyposensitive to pain compared to Whites, but African Americans show increased pain sensitivity in clinical and laboratory settings. The neurobiological mechanisms underlying these differences are unknown. We studied an ethnicity/gender-balanced sample of African Americans, Hispanics, and non-Hispanic Whites using fMRI during thermal pain. Higher pain report in African Americans was mediated by discrimination and increased fronto-striatal circuit activations associated with pain rating, discrimination, experimenter trust, and extra-nociceptive aspects of pain elsewhere. In contrast, the Neurologic Pain Signature, a neuromarker sensitive and specific to nociceptive pain, mediated painful heat effects on pain report largely similarly in African American and other groups. Findings identify a brain basis for higher pain in African Americans related to interpersonal context and extra-nociceptive central pain mechanisms, and suggest that nociceptive pain processing may be similar across ethnicities.