A Black doctor needed pain medicine and didn’t get it
When I suffered from appendicitis a few years ago, I was admitted to the hospital and had emergency surgery. I woke the next day with all sorts of tubes and IVs. They had clearly saved my life, which I appreciate to this day. But, the most prevalent thing I can remember about those times was the severe abdominal pain I had after the surgery. As a physician I worked in the hospital every day but, I had never been admitted to the hospital as a patient. This was a new perspective and experience I will never forget.
The pain medicine didn’t work for me
The surgeon had ordered an intravenous pain medication which I was to get every four hours. Because I was in such severe pain, I wondered whether the nurse had actually given the medication after I woke up. Upon asking, she confirmed that she had. I lay there and suffered for another three hours and then again requested pain medicine that I thought would help better than the last time. The nurse administered the pain medicine, and this time I noted a severe cramping pain that built to a crescendo of severe pain. I began to think to myself, is this pain medicine causing my worsening pain? I brushed off this seemingly silly thought and waited another four hours for an additional administration of pain medicine.
After another request, the nurse again gave me the same medicine, and again my pain rose, from a 9 out of 10 to what my patients would call a 20 out of 10. Until that moment, I never understood why my patients sometimes rated their pain far beyond 10. I told the nurse I needed something different, because what she was giving me was not only not helping, it was making my symptoms worse. She gave me a look I had never gotten in my life: the look that said I was a “drug-seeking patient.” Now on the defensive, I told her I had never been on any pain medicine in my life. I explained that I didn’t even take the pain medicine my dentist gave me when my wisdom teeth were pulled. She nodded with an “I don’t believe you” look and left the room.
A “drug-seeking” doctor?
I wondered how this nurse could know that I was a physician, know that I trained at a prestigious hospital, know that I taught at a medical university, know that I just had major surgery just hours earlier, yet still see me as drug-seeking. There was only one answer.
As it turns out, my experience was not a unique one.
Differences in the treatment of pain in African Americans
With the added burden of worse disease outcomes and early death from many health problems, it is no surprise that African Americans also face a significant racial gap in the treatment of pain. A 2019 review of emergency department studies found that Black patients were less likely than white patients to receive any pain medicine. Whether the cause is access and insurance, bias and discrimination in the healthcare system, or poor communication with clinicians, African Americans are more likely to have their pain under-treated or not treated at all. Based on a number of studies, African Americans are more likely to have their pain discounted or underestimated, and less likely to be screened for pain. Even though I was a doctor and nothing in my chart suggested I might become addicted, the nurse discounted my complaints and saw me as “drug-seeking.”
Unequal treatment continues
The unequal treatment of pain in African Americans spans a lifetime. A study of nearly one million children diagnosed with appendicitis found that, compared with white children, Black children were less likely to receive any pain medicine for moderate pain and less likely to receive opioids for severe pain. Similar gaps have been found in adults, including after surgery. As Anderson and colleagues concluded in their review, “Racial and ethnic disparities in pain: causes and consequences of unequal care”:
“This review reveals the persistence of racial and ethnic disparities in acute, chronic, cancer, and palliative pain care across the lifespan and treatment settings, with minorities receiving lesser quality pain care than White Americans.”
Black patients less likely to get pain medicine for similar symptoms
Another study involving a medical record review of equal pain symptoms in racially matched patients found African Americans with lower rates of receiving pain medications, and the cause was ultimately attributed to physician discretion . . . which means physicians have the “freedom to decide.” Unfortunately, this “freedom to decide” is where many African Americans get the short straw.
Part of the problem may be false beliefs that linger in medicine. In a 2016 study, about half of the white medical students and residents surveyed held at least one false belief about biological differences between Black and white people, such as Black people having thicker skin. Those who held these beliefs rated a Black patient’s pain as lower and were less accurate in their treatment recommendations.
In my case, it was nursing discretion, because it took several more hours for the nurse to tell my surgeon, who then promptly changed my medication. Doctors and nurses report concerns about addiction as their main reason for not starting or increasing pain medicine. Addiction is a real problem in the U.S., but there are screening tools that help identify which patients are at higher risk.
Make no mistake about it, the opioid crisis is real and deadly, and clinicians need to be careful not to cause another addiction. My issue here is the disparity, or difference, in how pain is treated today. Leaving someone in pain when a treatment is available is cruel. Clinicians should err on the side of compassion and use the evidence on which patients are at higher risk for addiction, rather than a patient’s race.
The precision medicine connection
Precision medicine means choosing treatment based on your genes, your history and your test results rather than assumptions. Pain care is one place where it can help African Americans be treated more fairly and more safely.
1. Your genes affect how some pain medicines work
Codeine, tramadol and, to a lesser degree, hydrocodone and oxycodone must be activated by a liver enzyme called CYP2D6. Many people of African ancestry carry reduced-function versions of this gene (such as CYP2D6*17 and *29), so these medicines may give them less relief. Others carry extra copies of the gene and turn codeine and tramadol into their active form too quickly, which can cause dangerous side effects. National pharmacogenetic guidelines recommend avoiding codeine and tramadol in people whose CYP2D6 works very poorly or very fast. A patient who says a pain medicine “doesn’t work” may be telling the truth about their genes, not seeking drugs.
2. Pharmacogenetic testing is available
A one-time cheek swab or blood test can show how your body handles CYP2D6 medicines, along with many others, such as some antidepressants and heart medicines. The results last a lifetime. If pain medicines have not worked for you, or have caused unusual side effects, ask your doctor whether a pharmacogenetic test makes sense. These same guidelines note that the evidence for other pain genes, such as OPRM1 and COMT, is not yet strong enough to guide treatment.
3. Sickle cell disease pain is an emergency
Sickle cell disease, which mostly affects people of African ancestry, causes sudden, severe pain crises, and patients often report being labeled as drug-seeking. American Society of Hematology guidelines call for assessment and pain medicine within one hour of arriving at the emergency department, with doses tailored to the individual patient. If you or a loved one has sickle cell disease, ask your hematologist for a written pain plan to bring to the hospital.
4. Safety limits for over-the-counter pain relievers
Medicines like ibuprofen and naproxen (NSAIDs) can raise blood pressure and harm the kidneys, a real concern because high blood pressure and kidney disease are more common in African Americans. If you have either condition, ask your doctor before taking NSAIDs regularly. Acetaminophen (Tylenol) is often safer for the kidneys, but too much can damage the liver, so stay within the dose on the label.
To learn more, read Better Black Health, written for patients and families. Clinicians can find a deeper review in Precision Medicine for African Americans (Springer, 2nd ed., 2025).
What should I do?
As patients, we have just as much right to have our pain treated as anyone else. Having our pain under-treated or untreated is unacceptable given all of the treatment options available. Tell your nurse or doctor clearly if a medicine is not working or is making you feel worse, and ask that your surgeon or the doctor on call be notified. You can call the hospital’s patient advocate or ombudsman, whose job is to protect every patient’s rights. You can also request a different nurse or physician.
Collectively, we need to ensure that our medical needs are met in an equitable yet safe manner.
