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Mechanisms explaining the relationship between pain-related injustice appraisals and functional outcomes in youth with chronic pain have yet to be examined. In studies of adults, greater pain-related injustice is associated with worse depressive symptoms and greater pain through greater anger. No study to date has examined anger expression as a mediator in the relationships between pain-related injustice appraisals and physical and psychosocial functioning in youth with chronic pain. The current sample consisted of 385 youth with varied pain conditions (75% female, 88% White, Mage=14.4 years) presenting to a university-affiliated pain clinic. Patients completed self-report measures assessing anger expression (anger-out and anger-in), pain-related injustice, pain intensity, functional disability, and emotional, social, and school functioning. Bootstrapped mediation analyses indicated that only anger-out (indirect effect= -.12, 95% CI: -.21, -.05) mediated the relationship between pain-related injustice and emotional functioning, whereas both anger-out (indirect effect= -.17, 95% CI: -.27, -.09) and anger-in (indirect effect= -.13, 95% CI: -.09, -.001) mediated the relationship between pain-related injustice and social functioning. Neither mode of anger expression mediated the relationship between pain-related injustice and pain intensity, functional disability, or school functioning. Collectively, these findings implicate anger as one mechanism by which pain-related injustice impacts psychosocial outcomes for youth with chronic pain. Perspective: Anger expression plays a mediating role in the relationship between pain-related injustice appraisals and psychosocial outcomes for youth with chronic pain. Anger represents one target for clinical care to decrease the deleterious impact of pain-related injustice on emotional and social functioning.

The bidirectional relationship between pain and working memory (WM) deficits is well-documented but poorly understood. Pain catastrophizing—exaggerated, negative cognitive and emotional responses toward pain—may contribute to WM deficits by occupying finite, shared cognitive resources. The present study assessed the role of pain catastrophizing as both a state-level process and trait-level disposition in the link between acute pain and WM. Healthy, young adults were randomized to an experimentally-induced ischemic pain or control task, during which they completed verbal and non-verbal WM tests. Participants also completed measures of state- and trait-level pain catastrophizing. Simple mediation analyses indicated that participants in the pain group (vs. control) engaged in more state-level catastrophizing about pain, which led to worse verbal and non-verbal WM. Moderated mediation analyses indicated that the indirect (mediation) effect of state-level pain catastrophizing was moderated by trait-level pain catastrophizing for both verbal and non-verbal WM. Participants in the pain group who reported a greater trait-level tendency to catastrophize about pain experienced greater state-level catastrophizing about pain during the ischemic task, which led to worse verbal and non-verbal WM performance. These results provide evidence for pain catastrophizing as an important mechanism and moderating factor of WM deficits in acute pain. Future research should replicate these results in chronic pain samples, investigate other potential mechanisms (e.g., sleep disturbances), and determine if interventions that target pain catastrophizing directly can ameliorate cognitive deficits in people with pain. Perspective This article presents a laboratory study examining the relationships among pain, pain catastrophizing, and working memory in healthy participants. The results shed new light on these relationships and raise the possibility that interventions that reduce catastrophizing may lead to improved cognitive function among people with pain.

Little is known about the factors that influence providers' perceptions of patient risk for aberrant opioid use. Patient gender may interact with prior opioid misuse to influence these perceptions. We asked 131 physicians to view videos and vignettes for 8 virtual patients with chronic pain. Gender (male/female) and previous prescription opioid misuse (present/absent) varied across patients; the vignettes were otherwise balanced on demographic and clinical characteristics. For each patient, providers assessed four risk domains: opioid-related adverse events, opioid misuse/abuse, opioid addiction, and opioid diversion. Results indicated a significant gender-by-misuse interaction for risk of opioid misuse/abuse. When previous misuse behaviors were absent, providers rated men at higher risk; there was no gender difference when previous misuse behaviors were present. A significant gender-by-misuse interaction was found for risk of opioid-related adverse events. Providers perceived men to be higher risk when previous misuse behaviors were absent; there was no gender difference when previous misuse behaviors were present. A significant gender-by-misuse interaction was found for risk of opioid addiction. Providers rated women at higher risk when previous misuse behaviors were present, and men at higher risk when previous misuse behaviors were absent. There were significant main effects of gender and misuse for risk of opioid diversion. Providers rated men and those with previous misuse behaviors at higher risk. These results demonstrate that patient gender and previous opioid misuse have unique and interactive effects on provider perceptions of prescription opioid-related risks. Studies are needed to identify the mechanisms underlying these effects, such as gender-based stereotypes about risk-taking and drug abuse.

The COVID-19 (SARS-CoV-2) pandemic has changed the social environment in which people live and work, as well as the social systems they rely on.39,88 To contain the spread of coronavirus and to prepare for a dramatic increase in demand for limited hospital/medical facilities and resources, societies have enforced physical distancing measures. Consequently, there have been limitations on the use of public transportation, public spaces, and work, education, and recreational facilities. Furthermore, access to vital, but nonurgent, healthcare services (including pain management services) has been restricted. These changes have affected the way people connect with each other, manage their health and wellbeing, and fulfil their social roles. For some, these changes may present opportunities (eg, increased time with family, normalisation of flexible working, and reduced demand for travel). For others, however, these social changes can also represent significant threats to health and wellbeing. The negative impact of social changes prompted by the COVID-19 crisis may disproportionately affect individuals living with long-term painful conditions. Living with chronic pain can threaten an individuals' fundamental social needs for autonomy (agency or independence), belonging (social connection), and justice (fairness). In turn, for some, experiencing heightened social threat can maintain and exacerbate chronic pain.48 In this review, we draw attention to the potential for social and systemic changes associated with attempts to contain the spread of COVID-19 to precipitate, maintain, and exacerbate pain by increasing the social threats faced by individuals with chronic pain (Fig. ​(Fig.1).1). We also suggest strategies for mitigating the social impact of COVID-19 on those living with chronic pain, for instance by learning from the resilience demonstrated by people in pain who have found ways to deal with social threat. Finally, we suggest several time-critical, high-impact research questions for further investigation (Fig. 1). Open in a separate window Figure 1. Schematic representation of how the COVID 19 pandemic (A) exacerbates existing levels of social threat (B), thereby inducing several social challenges (C) for people with chronic pain, and ultimately increasing the risk for the development, maintenance, and exacerbation of chronic pain complaints (D). Possible protecting processes and interventions countering the effects of the pandemic are portrayed as well (E).

Previous studies have documented that racial minorities and women receive poorer pain care than their demographic counterparts. Providers contribute to these disparities when their pain-related decision-making systematically varies across patient groups. Less is known about racial and gender disparities in children with pain or the extent to which providers contribute to these disparities. In a sample of 129 medical students (henceforth referred to as "providers"), Virtual Human methodology and a pain-related version of the Implicit Association Test (IAT) were used to examine the effects of patient race/gender on providers’ pain assessment/treatment decisions for pediatric chronic abdominal pain, as well as the moderating role of provider implicit pain-related race/gender attitudes. Findings indicated that providers rated Black patients as more distressed (mean difference [MD] = 2.33, P < .01, standard error [SE] = .71, 95% confidence interval [CI] = .92, 3.73) and as experiencing more pain-related interference (MD = 3.14, P < .01, SE = .76, 95% CI = 1.63, 4.64) compared to White patients. Providers were more likely to recommend opioids for Black patients than White patients (MD = 2.41, P < .01, SE = .58, 95% CI = 1.05, 3.76). Female patients were perceived to be more distressed by their pain (MD = 2.14, P < .01, SE = .79, 95% CI = .58, 3.70) than male patients, however there were no gender differences in treatment recommendations. IAT results indicated that providers held implicit attitudes that Black Americans (M = .19, standard deviation [SD] = .29) and males (M = .38, SD = .29) were more pain-tolerant than their demographic counterparts; however, these implicit attitudes did not significantly moderate their pain assessment/treatment decisions. Future studies are needed to elucidate specific paths through which the pain experience and care of children differ across racial and gender groups. PERSPECTIVE: Providers’ pain assessment (ie, pain distress/pain interference) and treatment (ie, opioids) of pediatric pain differs across patient race and to a lesser extent, patient gender. This study represents a critical step in research on pain-related disparities in pediatric 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.

We conducted a randomized controlled trial of an individually tailored, virtual perspective-taking intervention to reduce race and socioeconomic status (SES) disparities in providers' pain treatment decisions. Physician residents and fellows (n = 436) were recruited from across the United States for this two-part online study. Providers first completed a bias assessment task in which they made treatment decisions for virtual patients with chronic pain who varied by race (black/white) and SES (low/high). Providers who demonstrated a treatment bias were randomized to the intervention or control group. The intervention consisted of personalized feedback about their bias, real-time dynamic interactions with virtual patients, and videos depicting how pain impacts the patients' lives. Treatment bias was re-assessed 1 week later. Compared with the control group, providers who received the tailored intervention had 85% lower odds of demonstrating a treatment bias against black patients and 76% lower odds of demonstrating a treatment bias against low SES patients at follow-up. Providers who received the intervention for racial bias also showed increased compassion for patients compared with providers in the control condition. Group differences did not emerge for provider comfort in treating patients. Results suggest an online intervention that is tailored to providers according to their individual treatment biases, delivers feedback about these biases, and provides opportunities for increased contact with black and low SES patients, can produce substantial changes in providers' treatment decisions, resulting in more equitable pain care. Future studies should examine how these effects translate to real-world patient care and the optimal timing/dose of the intervention.

Chronic pain is a leading cause of work absenteeism and disability compensation. Previous work demonstrates that patients with chronic illness often seek advice, such as whether or not to pursue disability benefits, from peers with similar health conditions. The current study examined the extent that social factors influence patients with chronic pain (“peers”) when making disability judgments and recommendations for other patients with chronic pain. Participants (N = 71) made pain-related and disability ratings for fictional vignette patients that varied in weight (normal vs obese), fault of accident, and physical work demands. Results of repeated measures analyses of variance indicated that participants rated patients with obesity, who were not at fault, and who held a physically demanding job as experiencing more severe pain symptoms and disability and were more likely to recommend they seek disability benefits. Participants who had applied for disability benefits themselves rated patients as more disabled than participants who had not applied for disability. These data suggest that patients with chronic pain are influenced by patient and contextual factors when making pain-related and disability judgments for peers. These judgments may impact patient decision making via peer support programs and online forums. Perspective This study suggests that patients with chronic pain are influenced by patient weight, fault of accident, and physical work demands when making judgments about pain and disability for peers. Future studies should examine the extent such peer-to-peer recommendations influence actual disability-seeking behaviors for pain.

Pain appraisals are closely tied to pain and functional outcomes. Pain-related injustice and pain catastrophizing appraisals have both been identified as important cognitive-emotional factors in the pain experience of youth. Although pain-related injustice and catastrophizing have been linked to worse pain outcomes – as primary predictors and intermediary variables – little is known about whether they operate as independent or parallel mediators of the relationship between pain and functioning in youth. We tested pain-related injustice and catastrophizing appraisals as candidate mediators of the relationship between baseline pain intensity and 3-month functional outcomes in adolescents. Youth with chronic pain (N = 89, 76% female, 89% White, average age = 15 years) completed measures assessing pain intensity, pain-related injustice, and catastrophizing at baseline, as well as measures assessing functional disability and overall quality of life 3 months later. Multiple mediation analyses indicated that injustice mediated the relationship between pain intensity and 3 month quality of life. Exploratory analyses of specific quality of life domains indicated that injustice mediated the relationship between pain intensity and 3 month emotional functioning, whereas catastrophizing mediated the relationship between pain intensity and 3 month social functioning. The findings suggest these pain-related appraisals play different intermediary roles in the relationships among pain and future psychosocial outcomes. Perspective Pain-related injustice and catastrophizing appraisals play different intermediary roles in the relationships among pain and future psychosocial outcomes in youth with chronic pain. Treatments targeting pain-related injustice appraisals in pediatric populations are needed to complement existing treatments for catastrophizing.

Race disparities in pain care are well-documented. Given that most black patients are treated by white providers, patient-provider racial discordance is one hypothesized contributor to these disparities. Research and theory suggest that providers' trait-level intergroup anxiety impacts their state-level comfort while treating patients, which, in turn, impacts their pain treatment decisions. To test these hypothesized relationships, we conducted a planned secondary analysis of data from a randomized controlled trial of a perspective-taking intervention to reduce pain treatment disparities. Mediation analyses were conducted on treatment decision data from white providers for black virtual patients with chronic pain. Results indicated that white providers with higher trait-level intergroup anxiety reported lower state-level comfort treating black patients and were thereby more likely to recommend opioid (indirect effect = 0.76, 95% confidence interval [CI]: 0.21-1.51) and pain specialty (indirect effect = 0.91, 95% CI: 0.26-1.78) treatments and less likely to recommend nonopioid analgesics (indirect effect = -0.45, 95% CI: -0.94 to -0.12). Neither trait-level intergroup anxiety nor state-level comfort significantly influenced provider decisions for physical therapy. This study provides important new information about intrapersonal and interpersonal contributors to race disparities in chronic pain care. These findings suggest that intergroup anxiety and the resulting situational discomfort encroach on the clinical decision-making process by influencing white providers' decisions about which pain treatments to recommend to black patients. Should these findings be replicated in future studies, they would support interventions to help providers become more aware of their trait-level intergroup anxiety and manage their state-level reactions to patients who are racially/ethnically different from themselves.

A growing pediatric and adult literature highlights the role of injustice appraisals in adjustment to pain. However, interpersonal injustice dynamics have remained largely unexplored. The present study investigated the factor structure and criterion validity of parentally adjusted versions of the Injustice Experience Questionnaire, assessing child-oriented (IEQ-Pc) and self-oriented appraisals (IEQ-Ps) in the context of child pain. Participants were triads of healthy children (N .407, M-age = 12) and both their parents and dyads of children with chronic pain (N .319, M-age = 14) and 1 parent. In both samples, children completed measures of functional disability and quality of life (physical, emotional, social, and academic); parents completed the IEQ-Pc, IEQ-Ps, and a measure of parental catastrophizing about child pain. Across samples, a confirmatory oblique two-factor model (Severity/Irreparability-Blame/Unfairness) provided a better fit to the data compared to a one-factor model; nevertheless, the two-factor solution was considered suboptimal. A post hoc exploratory factor analysis consistently revealed 1 factor. In terms of criterion validity, the IEQ-Pc and IEQ-Ps demonstrated differential associations depending on the child's pain versus healthy status, independent of parental catastrophizing. Further, findings in the healthy sample indicated that fathers' self-oriented injustice appraisals related to lower child social function. In the clinical sample, parental child-oriented injustice appraisals related to greater child functional disability and lower physical, emotional, social, and academic function. Current findings support the unique role of parental injustice appraisals, assessed by the IEQ-Pc and IEQ-Ps, in understanding child pain, but also suggest these may only partially capture the phenomenology of parental injustice appraisals in the context of child pain. Perspective: This manuscript presents an examination of the construct and criterion validity of 2 parentally adjusted versions of the Injustice Experience Questionnaire. These measures could be valuable tools for clinicians in examining how parents respond to their child's pain as it impacts both the child's life and the parents'. (C) 2020 U.S. Association for the Study of Pain. Published by Elsevier Inc. All rights reserved.

Compared with men, women report more pain and are at increased risk for having pain discounted or misattributed to psychological causes. Overweight individuals experience high rates of pain and may receive suboptimal care because of provider bias. Research suggests the social consequences of being overweight are worse for women than men, and that gender and weight uniquely and interactively affect pain experience and care. Healthy participants (n = 616) viewed 6 videos of back pain patients (1 female and 1 male of normal weight, overweight, and obese categories) performing a functional task. Participants provided judgements/ratings regarding patient pain (intensity, interference, exaggeration), potential sources of patient pain (medical, psychological), and treatment recommendations (opioids, psychological therapy, seek workplace accommodations). Results suggest that the pain of normal and overweight women and obese men was discounted (judged as less intense, less interfering, more exaggerated, and less attributable to medical factors) and judged as less in need of treatment (treated with less opioids and workplace accommodations). Across all weight categories, women's pain was attributed more to psychological factors and was more likely to receive recommendations for psychological therapy than men's pain. These findings highlight the differential effect of patient weight on pain-related judgements about women and men. Perspective This article examines the relationships among patient weight, patient gender, and observers' pain appraisals and treatment recommendations. These findings highlight the differential effect of patient weight on pain-related judgements about women and men and indicate the need for research to determine how these judgements affect treatment decisions in clinical settings.

Chronic pain is prevalent in children/adolescents and contributes to high rates of healthcare utilization. Research suggests injustice perceptions about pain are important in adult patients and a possible treatment focus. We conducted a preliminary evaluation of the psychometric properties of the Injustice Experiences Questionnaire (IEQ) and the relationship between injustice perceptions, pain, and functioning in chronic pain patients (N = 139, mean age = 15 years, 72% female) presenting to a pediatric pain clinic. Patients completed measures assessing pain intensity, injustice perceptions about pain, catastrophizing, overall functional disability, emotional functioning, social functioning, and school functioning. The IEQ showed good reliability and validity. Higher levels of perceived injustice were associated with higher levels of pain intensity, catastrophizing, and functional disability, and with poorer emotional, social, and school functioning. Additionally, perceived injustice remained significantly associated with pain intensity, functional disability, emotional functioning, social functioning, and school functioning after accounting for relevant demographic and clinical factors. This is the first study to suggest that injustice perceptions are important in the experience of pediatric chronic pain patients. Future studies should more thoroughly examine the psychometric properties of the IEQ in children/adolescents and elucidate the causal nature of these relationships, which will inform treatment efforts to improve pediatric pain care. Perspective This initial investigation suggests that injustice perceptions about pain can be reliably and validly measured and are tied to important clinical outcomes in children/adolescents. Future studies that replicate and extend these preliminary results are necessary to determine the extent to which injustice perceptions are an important target for intervention.

Pediatric chronic pain is associated with numerous negative outcomes including increased physical disability, increased rates of depression and anxiety, and decreased quality of life. Pain catastrophizing – broadly conceptualized as including rumination, magnification, and helplessness cognitions surrounding one’s pain – has been linked with poor functional outcomes in children with chronic pain. Pain catastrophizing in pediatric chronic pain is often considered a key factor on which to focus treatment efforts. However, absent a systematic review that integrates the relevant literature, this call for routine assessment and targeted treatment may be premature. The present study aimed to: 1) meta-analytically quantify the relationship between catastrophizing and pain and functional/psychosocial outcomes (functional disability/physical functioning, anxiety, depression, and quality of life) in children with chronic pain, and 2) examine potential moderators of these relationships. Using a random effects model, a total of 111 effect sizes from 38 studies were analyzed. Effect sizes ranged from medium to large, with anxiety, depression, and quality of life demonstrating a strong association with catastrophizing. Pain intensity and physical disability had a moderate association with catastrophizing. These relationships were robust, minimizing potential publication bias. None of the examined moderators were significant. The strong relationships found between catastrophizing and anxiety, depression, and quality of life suggest that successfully intervening on catastrophizing could have far reaching implications in improving pain outcomes in pediatric chronic pain.

Pain is experienced within and influenced by social environments. For children with chronic pain, the child-parent relationship and parental beliefs about pain are particularly important and may influence pain outcomes. Pain-related injustice perceptions have recently been identified as an important cognitive-emotional factor for children with pain. The current study aimed to better understand the pain-related injustice perceptions of children with chronic pain and their parents. The sample consisted of 253 pediatric chronic pain patients (mean age = 14.1 years, 74% female) presenting to a tertiary pain clinic. Patients completed measures of pain intensity, pain-related injustice perceptions, stress, functional disability, and quality of life. Parents completed a measure of pain-related injustice perceptions about their child's pain. Child-parent dyads were categorized into 1 of 4 categories based on the degree of concordance or discordance between their scores on the injustice measures. One-way analysis of variances examined differences in pain intensity, stress, functional disability, and quality of life across the 4 dyad categories. Our findings indicated that both the degree (concordant vs discordant) and direction (discordant low child-high parent vs discordant high child-low parent) of similarity between child and parent injustice perceptions were associated with child-reported pain intensity, stress, functional disability, and quality of life. The poorest outcomes were reported when children considered their pain as highly unjust, but their parents did not. These findings highlight the important role of parents in the context of pain-related injustice perceptions in pediatric chronic pain.

Prior work suggests that providers are influenced by patient race and weight when making pain-related decisions. Providers with stronger implicit (automatic) attitudes about race and weight may be more likely to be influenced by these patient-level characteristics when making treatment decisions. In this multi-part study, we (a) examined the influence of patient race and weight on providers’ pain treatment decisions, (b) measured providers’ implicit attitudes about race and weight with two separate Implicit Association Tests, and (c) explored the extent to which providers’ attitudes predicted their treatment decisions. Ninety medical students (“providers”) viewed four videos of women with chronic low back pain completing a standardized sit-to-stand task who varied by race (Black/White) and weight (overweight/obese). Text vignettes with additional patient information accompanied the videos. For each patient, providers rated their likelihood of recommending opioids, a psychology referral, and disability compensation. Repeated measures ANOVAs indicated no main effects of patient race or weight on providers’ opioid decisions; however, providers were more likely to recommend a psychology referral for patients with obesity versus overweight [F(1,89)=9.79, p

Research has found race differences in pain sensitivity and tolerance. Evidence suggests how people compare themselves to similar others influences interpretations of their own health and well-being. We examined participants’ perceptions of their pain sensitivity compared to their perceptions of the pain sensitivity of “typical” members of their race (self-other comparison) and how these self-other comparisons related to race differences in actual pain tolerance. Black and White undergraduates (N=132; 48.5% Black) completed the Race/Ethnicity Expectations of Pain Questionnaire and a cold pressor task. First, we examined participants’ beliefs related to race differences in pain using a paired samples t-test to understand the perceived pain sensitivity of the comparison groups. Then, we examined how participants’ self-other comparison ratings for pain moderated the relationship between race and actual pain tolerance using a robust multiple-group moderation analysis. Results indicated participants rated the “typical” Black person as less pain sensitive than the “typical” White person (t(131)=-6.83, p

Black individuals have a lower tolerance for experimental pain than white individuals. Black and white individuals also differ in their use of pain coping strategies, which may explain the race differences in pain sensitivity. We examined the extent to which situation-specific pain coping mediated black-white differences in pain sensitivity. We hypothesized that 1) black participants would demonstrate lower pain tolerance than white participants, 2) black participants would use different pain coping strategies than white participants, and 3) the differential use of these strategies would mediate the relationship between race and pain tolerance. Healthy college undergraduates (N = 190) participated in a cold pressor task and then completed the Coping Strategies Questionnaire–Revised to assess their situation-specific pain coping. Compared with white participants, black participants demonstrated lower pain tolerance, engaged in more situation-specific catastrophizing and praying, and ignored pain less frequently. Catastrophizing and praying were inversely related to pain tolerance and were significant mediators of the relationship between race and pain tolerance. The indirect effect of praying was stronger than that of catastrophizing. Race differences in pain sensitivity may be due, in part, to differences in the use of catastrophizing and praying as coping strategies. These results may help guide treatments addressing maladaptive pain coping. Perspective This study suggests that race differences in pain sensitivity may be due, in part, to the differential use of catastrophizing and praying strategies. Psychosocial treatments for pain should encourage patients to take an active role in their pain management.

Decision-making in chronic pain care requires synthesizing complex information from many sources. Treatment guidelines have been described as “unclear and confusing,” which can lead to inconsistent pain care, non-clinically relevant information influencing decisions, and perpetuation of racial and socioeconomic disparities. Increased understanding of the factors influencing providers’ treatment decisions and the extent to which providers are aware of their decision-making process may help to reduce disparities and improve care. We used computer-simulated patients to examine the impact of provider and patient race (Black/White) and socioeconomic status (low/high) on providers’ treatment decisions. After making treatment decisions for twelve patients, providers rated the extent to which race and SES influenced their decisions. Repeated measures ANOVAs examined the extent to which providers demonstrated statistically reliable treatment differences across patient race and SES. Providers were then categorized by their reported use of patient race and patient SES while making treatment decisions. Although 41% of White providers and 31% of non-White providers demonstrated race-biased decision-making, only 6% of White providers and 10% of non-White providers reported using patient race in their decisions. A similar proportion of providers across three socioeconomic strata (low, medium, and high) demonstrated SES-biased decisions (41%, 43%, and 38%, respectively), and these rates were consistent with providers’ reported use of patient SES information (provider SES low: 44%, medium: 43%, and high: 48%). These results suggest providers have low awareness of making different pain treatment decisions for Black vs. White patients, whereas they have better awareness about their treatment decisions for low vs. high SES patients. Moreover, decision-making awareness did not substantially differ across provider race or SES. Future research is needed to determine the extent to which increasing providers’ decision-making awareness leads to better pain care. Supported by a grant from the National Institute on Minority Health and Health Disparities, USA (R01MD008931).

Sex differences are well-documented in chronic pain care. The reasons for these differences are multi-faceted and include provider-level factors, such as their perceptions of and treatment decisions for patients. To better understand provider factors, we recruited 400 medical residents and fellows who viewed 12 text vignettes and videos of computer-simulated male and female patients with chronic low back pain. Providers rated their likelihood of recommending different treatments for pain (opioid medications, physical therapy, pain specialist referrals) and the extent to which they perceived the patients to be exaggerating their pain. Paired samples t-tests indicated that providers were significantly more likely to recommend opioids (t(399)=-2.59, p=.01, d=.13) for male patients, but were more likely to recommend physical therapy (t(399)=2.53, p=.01, d=.13) and pain specialist referrals (t(399)=3.03, p

Compared with white individuals and men, black individuals and women show a lower tolerance for experimental pain stimuli. Previous studies suggest that pain catastrophizing is important in this context, but little is known about which components of catastrophizing contribute to these race and sex differences. The purpose of the current study was to examine the individual components of catastrophizing (rumination, magnification, and helplessness) as candidate mediators of race and sex differences in experimental pain tolerance. Healthy undergraduates (N = 172, 74% female, 43.2% black) participated in a cold pressor task and completed a situation-specific version of the Pain Catastrophizing Scale. Black and female participants showed a lower pain tolerance than white (P .01, d = .70) and male (P .01, d = .55) participants, respectively. Multiple mediation analyses indicated that these race and sex differences were mediated by the rumination component of catastrophizing (indirect effect = -7.13, 95% confidence interval (CI), -16.20 to -1.96, and 5.75, 95% CI, .81-15.57, respectively) but not by the magnification (95% CI, -2.91 to 3.65 and -1.54 to 1.85, respectively) or helplessness (95% CI, -5.53 to 3.31 and -.72 to 5.38, respectively) components. This study provides new information about race and sex differences in pain and suggests that treatments targeting the rumination component of catastrophizing may help mitigate pain-related disparities.This study suggests that differences in pain-related rumination, but not magnification or helplessness, are important contributors to race and sex differences in the pain experience. Interventions that target this maladaptive cognitive style may help reduce disparities in pain.

Sex, race/ethnic, and age differences in pain have been reported in clinical and experimental research. Gender role expectations have partly explained the variability in sex differences in pain, and the Gender Role Expectations of Pain questionnaire (GREP) was developed to measure sex-related stereotypic attributions about pain. It is hypothesized that similar expectations exist for age- and race-related pain decisions. This study investigated new measures of race/ethnic- and age-related stereotypic attributions of pain sensitivity and willingness to report pain, and examined the psychometric properties of a modified GREP. Participants completed the Race/Ethnicity Expectations of Pain questionnaire, Age Expectations of Pain questionnaire, and modified GREP. Results revealed a 3-factor solution to the race/ethnicity questionnaire and a 2-factor solution to the age questionnaire, consistent with theoretical construction of the items. Results revealed a 4-factor solution to the modified GREP that differed from the original GREP and theoretical construction of the items. Participants' pain-related stereotypic attributions differed across racial/ethnic, age, and gender groups. These findings provide psychometric support for the measures examined herein and suggest that stereotypic attributions of pain in others differ across demographic categories. Future work can refine the measures and examine whether select demographic variables influence pain perception, assessment, and/or treatment. Perspective The findings suggest that one's expectations of the pain experience of another person are influenced by the stereotypes one has about different genders, races, and ages. The 3 pain expectation measures investigated in the current study could be used in future work examining biases in pain assessment and treatment.

Research generally indicates that providers demonstrate modest insight into their clinical decision processes. In a previous study utilizing virtual human (VH) technology, we found that patient demographic characteristics and facial expressions of pain were statistically significant predictors of many nurses' pain-related decisions. The current study examined the correspondence between the statistically identified and self-reported influences of contextual information on pain-related decisions. Fifty-four nurses viewed vignettes containing a video of a VH patient and text describing a postsurgical context. VH sex, race, age, and facial expression varied across vignettes. Participants made pain-assessment and treatment decisions on visual analogue scales. Participants subsequently indicated the information they relied on when making decisions. None of the participants reported using VH sex, race, or age in their decision process. Statistical modeling indicated that 28 to 54% of participants (depending on the decision) used VH demographic cues. 76% of participants demonstrated concordance between their reported and actual use of the VH facial expression cue. Vital signs, text-based clinical summary, and VH movement were also reported as influential factors. These data suggest that biases may be prominent in practitioner decision-making about pain, but that providers have minimal awareness of and/or a lack of willingness to acknowledge this bias. Perspective The current study highlights the complexity of provider decision-making about pain management. The VH technology could be used in future research and education applications aimed at improving the care of all persons in pain.

Pain assessment and treatment is influenced by patient demographic characteristics and nonverbal expressions. Methodological challenges have limited the empirical investigation of these issues. The current analogue study employed an innovative research design and novel virtual human (VH) technology to investigate disparities in pain-related clinical decision making. Fifty-four nurses viewed vignettes consisting of a video clip of the VH patient and clinical summary information describing a post-surgical context. Participants made assessment (pain intensity and unpleasantness) and treatment (non-opioid and opioid medications) decisions on computerized visual analogue scales. VH demographic cues of sex, race, and age, as well as facial expression of pain, were systematically manipulated and hypothesized to influence decision ratings. Idiographic and nomothetic statistical analyses were conducted to test these hypotheses. Idiographic results indicated that sex, race, age, and pain expression cues accounted for significant, unique variance in decision policies among many nurses. Pain expression was the most salient cue in this context. Nomothetic results indicated differences within VH cues of interest; the size and consistency of these differences varied across policy domains. This study demonstrates the application of VH technology and lens model methodology to the study of disparities in pain-related decision making. Assessment and treatment of acute post-surgical pain often varies based on VH demographic and facial expression cues. These data contribute to the existing literature on disparities in pain practice and highlight the potential of a novel approach that may serve as a model for future investigation of these critical issues.

Pain assessment is subject to bias due to characteristics of the individual in pain and of the observing person. Few research studies have examined pain assessment biases in an experimental setting. The present study employs innovative virtual human technology to achieve greater experimental control. A lens model design was used to capture decision-making policies at the idiographic and nomothetic level. Seventy-five undergraduates viewed virtual humans (VH) that varied in sex, race, age, and pain expression. Participants provided computerized ratings with Visual Analogue Scales on the VH's pain intensity, pain unpleasantness, negative mood, coping, and need for medical treatment. Idiographic analyses revealed that individuals used pain expression most frequently as a significant cue. Nomothetic analyses showed that higher pain expression VH and female VH were viewed as having higher pain intensity, higher pain unpleasantness, greater negative mood, worse coping, and a greater need to seek medical treatment than lower pain expression VH and male VH, respectively. Older VH were viewed as having worse coping and a greater need to seek medical treatment than younger VH. This innovative paradigm involving VH technology and a lens model design was shown to be highly effective and could serve as a model for future studies investigating pain-related decision making in healthcare providers.

Although the Hispanic population is a burgeoning ethnic group in the United States, little is known about their pain-related experience. To address this gap, we critically reviewed the existing literature on pain experience and management among Hispanic Americans (HAs). We focused our review on the literature on nonmalignant pain, pain behaviors, and pain treatment seeking among HAs. Pain management experiences were examined from HA patients' and health care providers' perspectives. Our literature search included variations of the term "Hispanic" with "AND pain" in PubMed, Embase, Web of Science, ScienceDirect, and PsycINFO databases. A total of 117 studies met our inclusion criteria. We organized the results into a conceptual model with separate categories for biological and/or psychological and sociocultural and/or systems-level influences on HAs' pain experience, response to pain, and seeking and receiving pain care. We also included information on health care providers' experience of treating HA patients with pain. For each category, we identified future areas of research. We conclude with a discussion of limitations and clinical implications. Perspective In this critical review of the literature we examined the pain and management experiences of the HA population. We propose a conceptual model, which highlights findings from the existing literature and future areas of research.

Compared with white individuals, black individuals experience greater pain across clinical and experimental modalities. These race differences may be due to differences in pain-related coping. Several studies examined the relationship between race and pain coping; however, no meta-analytic review has summarized this relationship or attempted to account for differences across studies. The goal of this meta-analytic review was to quantify race differences in the overall use of pain coping strategies as well as specific coping strategies. Relevant studies were identified using electronic databases, an ancestry search, and by contacting authors for unpublished data. Of 150 studies identified, 19 met inclusion criteria, resulting in 6,489 participants and 123 effect sizes. All of the included studies were conducted in the United States. Mean effect sizes were calculated using a random effects model. Compared with white individuals, black individuals used pain coping strategies more frequently overall (standardized mean difference [d] = .25, P .01), with the largest differences observed for praying (d = .70) and catastrophizing (d = .40). White individuals engaged in task persistence more than black individuals (d = -.28). These results suggest that black individuals use coping strategies more frequently, specifically strategies associated with poorer pain outcomes. Future research should examine the extent to which the use of these strategies mediates race differences in the pain experience.Results of this meta-analysis examining race differences in pain-related coping indicate that, compared with white individuals, black individuals use coping strategies more frequently, specifically those involving praying and catastrophizing. These differences in coping may help to explain race differences in the pain experience.

Although racial disparities in pain care are widely reported, much remains to be known about the role of provider and contextual factors. We used computer-simulated patients to examine the influence of patient race, provider racial bias, and clinical ambiguity on pain decisions. One hundred twenty-nine medical residents/fellows made assessment (pain intensity) and treatment (opioid and nonopioid analgesics) decisions for 12 virtual patients with acute pain. Race (black/white) and clinical ambiguity (high/low) were manipulated across vignettes. Participants completed the Implicit Association Test and feeling thermometers, which assess implicit and explicit racial biases, respectively. Individual- and group-level analyses indicated that race and ambiguity had an interactive effect on providers' decisions, such that decisions varied as a function of ambiguity for white but not for black patients. Individual differences across providers were observed for the effect of race and ambiguity on decisions; however, providers' implicit and explicit biases did not account for this variability. These data highlight the complexity of racial disparities and suggest that differences in care between white and black patients are, in part, attributable to the nature (ie, ambiguity) of the clinical scenario. The current study suggests that interventions to reduce disparities should differentially target patient, provider, and contextual factors. Perspective This study examined the unique and collective influence of patient race, provider racial bias, and clinical ambiguity on providers' pain management decisions. These results could inform the development of interventions aimed at reducing disparities and improving pain care.

Sex differences in pain are frequently reported in the literature. However, less is known about possible sex differences in the experience of pain secondary to a disability. The current study explored these issues in persons with limb loss (n = 335, 72% men) who were recruited as part of a postal survey. Participants provided ratings of phantom limb pain (PLP), residual limb pain (RLP), and general pain intensity. Participants also completed measures of pain-related interference, catastrophizing, coping, and beliefs. Results indicated that a greater proportion of males than females (86% vs 77%, respectively) reported the presence of PLP; however, this difference was no longer prominent when cause of limb loss was controlled. No sex differences were found in the presence of RLP, or in average intensity ratings of PLP or RLP. In contrast, females reported greater overall average pain intensity and interference than males. Females also endorsed significantly greater catastrophizing, use of certain pain-coping strategies, and beliefs related to several aspects of pain. This study did not find prominent sex differences in pain specific to limb loss. However, several sex differences in the overall biopsychosocial experience of pain did emerge that are consistent with the broader literature. Perspective The current study contributes to the literature on sex differences in the experience of pain. Although males and females with limb loss did not significantly differ in their disability-specific pain, sex differences in their broader experience of pain were significant and are worthy of future clinical and empirical attention.

Pain-related fear and pain catastrophizing are 2 central psychologic factors in fear-avoidance models. Our previous studies in healthy subjects indicated that pain-related fear, but not pain catastrophizing, was associated with cold pressor pain outcomes. The current study extends previous work by investigating pain-related fear and pain catastrophizing in a group of subjects with shoulder pain, and included concurrent measures of experimental and clinical pain. Fifty nine consecutive subjects seeking operative treatment of shoulder pain were enrolled in this study (24 women, mean age = 50.4, SD = 14.9). Subjects completed validated measures of pain-related fear, pain catastrophizing, and clinical pain intensity and then underwent a cold pressor task to determine experimental pain sensitivity. Multivariate regression models used sex, age, pain-related fear, and pain catastrophizing to predict experimental pain sensitivity and clinical pain intensity. Results indicated that only pain-related fear uniquely contributed to variance in experimental pain sensitivity (beta = -.42, P.01). In contrast, sex (beta = -.29, P = .02) and pain catastrophizing (beta = .43, P.01) uniquely contributed to variance in clinical pain intensity. These data provide additional support for application of fear-avoidance models to subjects with shoulder pain. Our results also suggest that pain-related fear and pain catastrophizing may influence different components of the pain experience, providing preliminary support for recent theoretical conceptualizations of the role of pain catastrophizing.This study provided additional information on how specific psychological variables potentially influence experimental and clinical pain. In this sample of subjects with shoulder pain, we replicated findings from our previous studies involving healthy subjects, as fear of pain was uniquely associated with experimental pain sensitivity. In contrast, pain catastrophizing emerged as the sole psychological variable related to clinical pain intensity.

Pain-related fear and catastrophizing are important variables of consideration in an individual's pain experience. Methodological limitations of previous studies limit strong conclusions regarding these relationships. In this follow-up study, we examined the relationships between fear of pain, pain catastrophizing, and experimental pain perception. One hundred healthy volunteers completed the Fear of Pain Questionnaire (FPQ-III), Pain Catastrophizing Scale (PCS), and Coping Strategies Questionnaire-Catastrophizing scale (CSQ-CAT) before undergoing the cold pressor test (CPT). The CSQ-CAT and PCS were completed again after the CPT, with participants instructed to complete these measures based on their experience during the procedure. Measures of pain threshold, tolerance, and intensity were collected and served as dependent variables in separate regression models. Sex, pain catastrophizing, and pain-related fear were included as predictor variables. Results of regression analyses indicated that after controlling for sex, pain-related fear was a consistently stronger predictor of pain in comparison to catastrophizing. These results were consistent when separate measures (CSQ-CAT vs PCS) and time points (pretask vs “in vivo”) of catastrophizing were used. These findings largely corroborate those from our previous study and are suggestive of the absolute and relative importance of pain-related fear in the experimental pain experience. Perspective Although pain-related fear has received less attention in the experimental literature than pain catastrophizing, results of the current study are consistent with clinical reports highlighting this variable as an important aspect of the experience of pain.

Disability demonstrates strong univariate associations with pain and negative mood. These relationships are more complex at the multivariate level and might be further complicated by sex differences. We investigated sex differences in the relationships of pain and negative mood to overall disability and to disability in specific functional domains. One hundred ninety-seven consecutive patients with low back, myofascial, neck, arthritis, and fibromyalgia pain were recruited from university pain clinics and completed measures of disability and negative mood. Overall disability and disability in voluntary activities were significantly associated with pain and negative mood (factor score) for both sexes. Significant sex differences emerged in the strength of the disability-mood relationship, with women evincing a stronger relationship. Disability in obligatory activities was also significantly related to pain and negative mood for both sexes; however, there were no sex differences in the strength of these relationships. Mediation analyses indicated that, in men, negative mood partially mediated the relationship between pain and both overall disability and disability in voluntary activities; mediation was not supported for disability in obligatory activities. In women, negative mood fully mediated the relationship between pain and all 3 types of disability. These data suggest that disability is more directly related to pain in men. In women, the effect of pain on disability appears to operate through negative mood. Perspective Results of this study demonstrate that sex differences exist in the relationships of pain, mood, and disability. Men and women might thus benefit from treatment interventions that differentially target these variables.