Background & Aims

The most common form of chronic low back pain (cLBP) is non-specific[1], such that there is no known pathoanatomical cause of pain. As such, patients may experience stigmatizing reactions from family, friends, or healthcare providers, causing them to feel blamed and dismissed[2-5]. Additionally, compared to non-Hispanic Whites, the prevalence of chronic pain is higher among non-Hispanic Black individuals[6-10], who face additional injustices including race-based discrimination. Thus, it is important to understand how chronic pain stigma may intersect with the experience of racial discrimination within a minoritized group of Black individuals with cLBP. The present study examined the intersection between chronic pain stigma and racial discrimination, and how they synergistically related to psychological factors and pain. We then explored whether psychological factors contributed to the relationship between the intersection of chronic pain stigma and racial discrimination with pain.

Methods

Non-Hispanic Black participants with non-specific cLBP completed validated measures of chronic pain stigma, lifetime experience of racial discrimination, depression, pain catastrophizing, and clinical pain severity and interference. A composite variable of the intersectionality of chronic pain stigma and racial discrimination (ISD) was created using median splits. Participants who were ? the median for stigma and discrimination were labeled as “high ISD” and those < the median for stigma and discrimination were labeled as “low ISD.” Participants who were > the median on stigma but < the median on discrimination were labeled as “high stigma” and those who were < the median on stigma but > the median on discrimination were labeled as “high discrimination.” ANCOVAs were conducted to examine group differences in psychological factors and pain. Parallel mediation analyses were conducted to examine the extent to which psychological factors mediated the association between ISD and pain.

Results

Of all participants (N=153, Mage=45.73, 60% female), 29% were categorized as high ISD, 24% as low ISD, 25% as high stigma, and 22% as high discrimination. Participants in the high ISD and high stigma groups reported significantly greater depression, catastrophizing, pain severity, and pain interference than participants in the low ISD and high discrimination groups (ps<.01). There were no significant differences between the high ISD and high stigma groups, nor were there differences between the low ISD and high discrimination groups (ps>.05). As such, for the purpose of the mediation analyses, participants in the high ISD and high stigma groups were combined into one “high stigma” group, and participants in the low ISD and high discrimination groups were combined into one “low stigma” group. Mediation analyses showed that both depression and catastrophizing significantly mediated the association between high stigma and greater pain severity and interference.

Conclusions

The majority of research on racial disparities in pain has adopted a deficit framework focusing on between-group comparisons, often using White individuals as a reference group[11,12]. We used a within-group approach to gain deeper insight into how chronic pain stigma and racial discrimination synergistically relate to pain, specifically within a minoritized group of Black participants. We found that participants with high levels of stigma reported greater depression, catastrophizing, pain severity, and pain interference compared to participants with low levels of stigma, regardless of their experience with racial discrimination. Further, participants with high stigma reported greater depression and pain catastrophizing, which contributed to their higher levels of pain severity and interference. Future studies should examine the role of everyday experiences of racial discrimination, as the timeframe of these experiences may differentially intersect with stigma and impact pain outcomes.

References

[1] Koes, B.W., M. Van Tulder, and S. Thomas, Diagnosis and treatment of low back pain. Bmj, 2006. 332(7555): p. 1430-1434.

[2] Toye, F. and K. Barker, ‘Could I be imagining this?’–the dialectic struggles of people with persistent unexplained back pain. Disability and rehabilitation, 2010. 32(21): p. 1722-1732.

[3] Werner, A. and K. Malterud, It is hard work behaving as a credible patient: encounters between women with chronic pain and their doctors. Social science & medicine, 2003. 57(8): p. 1409-1419.

[4] Toye, F. and K. Barker, Persistent non-specific low back pain and patients’ experience of general practice: a qualitative study. Primary Health Care Research & Development, 2012. 13(1): p. 72-84.

[5] Holloway, I., B. Sofaer-Bennett, and J. Walker, The stigmatisation of people with chronic back pain. Disability and rehabilitation, 2007. 29(18): p. 1456-1464.

[6] Andersson, G.B., Epidemiological features of chronic low-back pain. The lancet, 1999. 354(9178): p. 581-585.

[7] Carey, T.S. and J.M. Garrett, The relation of race to outcomes and the use of health care services for acute low back pain. Spine, 2003. 28(4): p. 390-394.

[8] Meucci, R.D., A.G. Fassa, and N.M.X. Faria, Prevalence of chronic low back pain: systematic review. Revista de saude publica, 2015. 49.

[9] Selim, A.J., et al., Racial differences in the use of lumbar spine radiographs: results from the Veterans Health Study. Spine, 2001. 26(12): p. 1364-1369.

[10] Shmagel, A., R. Foley, and H. Ibrahim, Epidemiology of chronic low back pain in US adults: data from the 2009–2010 National Health and Nutrition Examination Survey. Arthritis care & research, 2016. 68(11): p. 1688-1694.

[11] Janevic, M.R., et al., Making pain research more inclusive: why and how. The journal of pain, 2022. 23(5): p. 707-728.

[12] Letzen, J.E., et al., Confronting racism in all forms of pain research: Reframing study designs. The journal of pain, 2022. 23(6): p. 893-912.

[13] Feliu-Soler, A., et al., Current status of acceptance and commitment therapy for chronic pain: a narrative review. Journal of pain research, 2018. 11: p. 2145.

[14] Luoma, J.B. and M.G. Platt, Shame, self-criticism, self-stigma, and compassion in acceptance and commitment therapy. Current opinion in Psychology, 2015. 2: p. 97-101.

[15] Ehde, D.M., T.M. Dillworth, and J.A. Turner, Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. American Psychologist, 2014. 69(2): p. 153.

[16] Brintz, C.E., et al., Feasibility and acceptability of an abbreviated, four-week mindfulness program for chronic pain management. Pain Medicine, 2020. 21(11): p. 2799-2810.

[17] De Ruddere, L. and K.D. Craig, Understanding stigma and chronic pain: a-state-of-the-art review. Pain, 2016. 157(8): p. 1607-1610.

[18] Matthias, M.S., et al., The patient–provider relationship in chronic pain care: providers’ perspectives. Pain Medicine, 2010. 11(11): p. 1688-1697.

[19] Vowles, K.E. and M. Thompson, The patient-provider relationship in chronic pain. Current pain and headache reports, 2012. 16: p. 133-138.

[20] Farin, E., L. Gramm, and E. Schmidt, The patient–physician relationship in patients with chronic low back pain as a predictor of outcomes after rehabilitation. Journal of Behavioral Medicine, 2013. 36(3): p. 246-258.

[21] Dorflinger, L., R.D. Kerns, and S.M. Auerbach, Providers’ roles in enhancing patients’ adherence to pain self management. Translational behavioral medicine, 2013. 3(1): p. 39-46.

[22] Butow, P. and L. Sharpe, The impact of communication on adherence in pain management. PAIN®, 2013. 154: p. S101-S107.

[23] Hirsh, A.T., et al., A randomized controlled trial testing a virtual perspective-taking intervention to reduce race and SES disparities in pain care. Pain, 2019. 160(10): p. 2229.

[24] Gronholm, P.C., et al., Interventions to reduce discrimination and stigma: the state of the art. Social psychiatry and psychiatric epidemiology, 2017. 52: p. 249-258.

Presenting Author

Madelyn Crago

Poster Authors

Madelyn Crago

BSc

Brigham and Women's Hospital/Harvard Medical School

Lead Author

Jenna Wilson

PhD

Brigham and Women's Hospital; Harvard Medical School

Lead Author

Burel Goodin

Washington University in St. Louis

Lead Author

SAMANTHA MEINTS

PhD

Dept. of Anesthesiology, Perioperative & Pain Medicine, Brigham & Women’s Hospital, Boston, MA, USA

Lead Author

Topics

  • Mechanisms: Psychosocial and Biopsychosocial