Comerford 1

Taylor Comerford
Honors Pain Seminar
Term Paper
March 14, 2017

Disparate Pain Treatment in a ‘Post-Racial’ America: A Racial Project

Introduction

Despite existing in an era of asserted colorblindness, race most profoundly shapes the

experiences of modern Americans (Omi and Winant 106). More so than socioeconomic status or

gender, racial projects have impacted the lives of all those residing in the United States through

the historic construction and constant redefinition of ethnicity (Omi and Winant 125). A

pertinent example of a racial project was the war on drugs, initiated by the rhetoric of President

Richard Nixon, and translated into tangible policy by President Ronald Reagan (Beckett and

Sasson 48). Such campaigns, while not explicitly addressing race, were motivated by the

purpose of linking hard drugs, such as crack cocaine and heroin, to African American

communities. While the war on drugs has translated into other politically faceted forms of

systematic oppression, such as the phenomena of mass incarceration, it is also paralleled in the

disparate treatment of acute and chronic pain provided to black individuals. In this paper I will

outline a basic understanding of racial formation and its political implications, address

widespread prejudicial attitudes prevalent in both the white and medical communities, and

present the professional treatment of pain in terms of statistical discrepancy. I assert that

disparities in pain treatment, especially in terms of prescription drugs, are innately a racial

project intended to promote harmful stereotypes, and associations between the black community

and illegal drug usage.

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Racialized Politics and Racial Projects

To fundamentally understand the issues of healthcare inequity and the politicization of

drugs, it is integral to have a fundamental understanding of racial politics and projects. Ethnicity

has evolved over the course of American history starting from a biological model, which

characterized race in terms of physical or genetic differences (Omi and Winant 115). Currently

race is conceptualized socially, a less archaic model1 (Omi and Winant 120). This perspective

understands race as a societally created phenomena, in which characteristics or assumptions are

used to generalize a group of people (Omi and Winant 120). Because of this process, race is

considered a master category, or the most powerful grouping one can experience; it affects one’s

role socially, politically, and economically, and sets one’s position in the societal hierarchy (Omi

and Winant 106).

Furthermore, as a facet of society, race is also utilized in a political role, notably through

racial projects. The concept is an “interpretation, representation, or explanation of racial

identity” for the purpose of “organizing or redistributing resources” (Omi and Winant 125). In

essence, racial projects are a tool through which groups are portrayed in a specific way to

intentionally shape policy or action, which therefore impacts the experiences of that group. A

notable example of this concept is the process by which “Affirmative Action” was undermined

through the presentation of minority races as being given “special privileges” by the Democratic

Party of which they were not deserved (Beckett 86). This characterization both reorganized the

resource of college education away from people of color, and redistributed votes to garner

support for the Republican party in subsequent elections (Beckett 86).

1
It is important to note that the National Institutes of Health (NIH) both recognizes and promotes this
understanding of race throughout the medical field. Even within the medical field biological conceptions
of race are viewed as anachronistic and fallacious.
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These campaigns are infrequently benevolent, and are often used to further policies that

are discriminatory and marginalizing in nature. Furthermore, the United States has entered an

era of “colorblindness”, in which highly racialized language is no longer socially acceptable,

therefore making racial appeals more difficult to identify (Huddy and Feldman 426). This

decisive shift following the Civil Rights movement has changed the manifestation of racism in

American significantly (Huddy and Feldman 426). While most of the white majority

understands racism in terms of individual acts of explicit prejudice, such as racial slurs, sects of

Neo-Nazism like the Klu Klux Klan, or ethnically motivated violence, these forms of abject

racism are no longer social desirable (Huddy and Feldman 425). People out of fear of judgment

and the desire to be accepted suppress prejudicial beliefs, often to the point of subconsciousness

(Huddy and Feldman 425). Modern racism is in actually a set of discriminatory or stereotypical

beliefs that are often unconsciously held or actively unvoiced.

This shift in racial conception has direct implications on the ways in which racial projects

are carried out. As a direct result of this transition, white political elites developed a new method

of framing policy to address the fundamental prejudices of their constituents without explicit

racism (Haney Lopez 180). This concept is known as dog whistle politics, and is a melding of

implicit racism, political context, and racial project (Haney Lopez 171). Dog whistle rhetoric is

a successful tool in that it touches upon stereotypical views of minorities held by the white

majority without ever mentioning race (Haney Lopez 180). In this way an individual can support

such policies without ever having to admit his or her racism, and while simultaneously feeling

that his or her bias has been vindicated.

Implications in the War on Drugs

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The dog whistle style of political rhetoric gained popularity in the Nixon and Reagan

presidencies as tools to win election. Starting with the neutral phrases “tough on crime” and

“law and order”, Richard Nixon tacitly connected the white fear of crime2 to widespread

prejudice against people of color (Beckett 86). While very broadly addressing the issue of rising

crime rates, he was able to portray black communities as disproportionately responsible for the

supposed spike criminal activity.

The process by which blacks were associated with crime was very similar to the means

by which blacks were tied to welfare abuse; at the crux of both procedures was the media.

(Gilens 111). Firstly, images of arrested or incarcerated black men were proliferated throughout

television coverage, and magazine and newspaper articles (Beckett and Sasson 50; DuVernay).

This portrayed a crime “epidemic” at the center of which was the black community (Beckett and

Sasson 50; DuVernay). Furthermore, the specific cases graphically presented by news outlets

disproportionately featured violent crimes committed by blacks, and often against white victims

(Beckett 82; DuVernay).

While it seems unbelievable that such a phenomena was both systematic and intentional,

in 2016, Harper’s magazine published a 22-year-old interview with Nixon’s “top advisor and key

figure in the Watergate scandal”, Jon Ehrlichman (“Report: Aide says Nixon's war on drugs

targeted blacks, hippies”). This recorded dialogue confirms decades of theorization by those

who study race politics and political science. The segment blatantly describes the actions of

Nixon’s cabinet and the previously abstract motivations behind them. In his own words,

Ehrlichman states

2
86% of Americans felt rising crime rates were the nations most pressing issue (Beckett 86).
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“We knew we couldn't make it illegal to be… black, but by getting the public to associate

the … blacks with heroin. And then criminalizing both heavily, we could disrupt those

communities. We could arrest their leaders. raid their homes, break up their meetings,

and vilify them night after night on the evening news. Did we know we were lying about

the drugs? Of course we did” (“Report: Aide says Nixon's war on drugs targeted blacks,

hippies”).

Assertions of dog whistle politics are often criticized as lacking salient evidence to prove racially

motivated action. This candid explanation of the Nixon administration however, blatantly proves

that the historic actions were targeted at the black community and indicative of racial prejudice.

At the end of Nixon’s presidency, the focus of this anti-crime campaign had directly

shifted to illegal drug sales and abuse. The Reagan administration took this trend a step further

in his campaign against illegal drugs (Beckett 92). Heavy sentences for small drug offenses

funneled more individuals into prisons then ever before in American history (Beckett 92). The

burden of this incarceration was felt by black communities, in which policing was the most

aggressive (Beckett 92). By 1992, 51 percent of those admitted to prisons were black, and 90

percent of those incarcerated for drug crimes were people of color (Beckett 89).

While statistics on mass incarceration are poignant, what is most important in

understanding the lingering affects of the war on drugs is the sentiment it built. Further disparate

portrayals of black Americans having criminal involvement with illegal drugs primed whites to

have deeply inaccurate and prejudicial views. By the simple and unconscious process

association, the white majority was conditioned to associate African Americans with drug crime

and abuse (DuVernay). However, while 13 percent of drug users are black, African Americans
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make up 35 percent of drug arrests and 74 percent of drug-related prison sentences3 (Beckett 97).

These claims of black criminality are statistically inaccurate, and are less representative of actual

crime commission than the discriminatory policing practices used in black communities.

Despite the objective reality, the white American majority held deeply rooted beliefs

about the role of black communities in drug sales and related crime, drug addiction, and

criminality (DuVernay). These racist attitudes still exist today. As late as the 1990s, 62 percent

of whites believed that African Americans were lazier than whites and 78 percent believed that

blacks were more likely to support themselves with welfare than employment (Beckett 87).

Furthermore, black men especially have been historically and currently viewed as “criminal

predators” (Beckett 87; DuVernay). While research has established that this has lead to racial

profiling and inequity in the criminal justice system, it is also deeply reflected in the attitudes of

American civilians (DuVernay). The breadth and simultaneous depth of these beliefs permeate

the white majority. Such sentiment shapes opinions, actions, and political support (or lack

thereof) towards people of color and the policies that effect them.

Chronic and Acute Pain

For the sake of this study, primary care, pain care and those who seek them will be the

focus of analysis, rather than methods of self-management or alternative solutions like religion.

The three major categorizations of pain treated by physicians are acute, chronic, and cancer pain4

(Loeser 220). Acute pain results from injury to bodily tissue, which triggers “nociceptors, their

3
Prison sentencing is different than actually prison stay, which was noted to be 90% black previously.
This is due to options such as parole or early release that are much more commonly awarded to white
defendants.
4
for the sake of effective analysis, the scope of this paper will not include cancer pain in subsequent
presentation of statistical or attitudinal disparity
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central connections, and the autonomic nervous system of the region” (Loeser 221). Chronic

pain is a reflection of serious, unhealed injury to the nervous systems, resulting in ongoing and

long-lasting pain without easily identified tissue damage (Loeser 221). The areas affected by

chronic pain are not the source of injury, or in some cases, even tangible body parts, as true for

patients suffering phantom limb syndrome (Loeser 221). This makes the condition extremely

difficult to diagnose, and even more so to treat. Lastly, cancer pain is an enigma in the fact that

it is a combination of both previous categories (Loeser 221). It is an acute pain caused by

ongoing damage to cells cause either by the illness itself, or in treatment with radiation or

chemotherapy (Loeser 221). It is also considered a chronic pain due to the longevity of

symptoms (Loeser 221).

The diagnosis and treatment of these categories of pain have immense implications even

without consideration of racial attitudes. Acute pain is not as difficult to diagnose, as there is

recognizable tissue damage that can be identified if not from simple observation, by

comprehensive medical tools, such as CAT scans, MRIs, or fMRIs. It is commonly treated

firstly to heal damaged tissue (i.e. a cast for a fractured bone or sutures to close a laceration), and

finally to relieve pain symptoms (Loeser 221). This is commonly addressed through

medications, which range from nonsteroidals for minor injuries to analgesics and anesthetics for

more serious pain (Loeser 220).

Chronic pain, however is not as simple, and is often complicated by assumptions that

stem from a singular understanding of acute pain. Many healthcare professionals are unable to

successfully identify or treat such pain, as they are primary trained to address acute issues

(Loeser 216). Furthermore, the majority of chronic pain patients are those whom have had acute

injuries, however those impairments have healed without a subsequent loss of pain (Loeser 222).
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The absence of tissue damage at the source of pain, or “pain without nociception”, is befuddling

in the sense that it is contradictory to the way medicine is taught and practiced (Loeser 216).

Unlike acute pain, chronic symptoms are insignificantly affected by analgesics, such as

oxycodone, fentanyl, or morphine, and are not affectively solved by tissue removal, such as tooth

pulling (Loeser 216). As patient-provider interaction time has decreased, and medicine has

become commodified, it is much less likely for chronic pain suffers to receive accurate

treatment, if any. These patients are also much less likely to be satisfied or trusting in the

dyadic relationship they hold with their doctor (Solomon et al. 100). Because practitioners face

“[pressure]… to both diagnose and treat pain syndromes”, it has become commonplace to

prescribe analgesics, which both ineffectively treat chronic pain and cause severe complications

with addiction and tissue damage (Ling et al. 300). Furthermore, because such claims of illness

“defy objective modalities”, physicians frequently, to put it colloquially, ‘give up’, or accuse he

patient of falsifying pain and refuse treatment (Ling et al. 304). In this manner, the process of

treating chronic pain is structurally flawed and in need to serious reform.

Racial Disparity and Medicine

While race plays a profound role in shaping the style and quality of treatment provided to

African American pain patients, it is not an obvious example of a racial project (Etienne 509).

While the war on drugs is very tangible example of such a campaign, the link between its legacy

and modern pain care is not as concrete, and the commonalities between the two phenomena are

not as apparent.

Attitudes
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The first connection between pain treatment and the criminalization of drugs is the link

between certain analgesics and the illegal substance heroin. Prescription opioids that are

derivatives of morphine are chemically similar to heroin (Martin and Fraser 388). The two

substances are divergent in terms of potency and purity. Heroin is a stronger substance because

it is combined with acetic anhydride, a chemical reagent, whereas morphine and other similar

prescription drugs are more chemically pure. This is due to the process of “cutting”, in which

street drugs like heroin are combined with other possibly harmful substances, making them

cheaper to produce, but potentially dangerous. As both heroin and prescription drugs like

oxycodone are opioids, this assumption of deviance surrounding the street drug is easily

associated with analgesics as well. It is not abstractly speculative to assume this racial bias would

follow doctors and nurses into hospitals. Because the stigma of crime and addiction are paired

both with heroin and black communities, this implicit stereotype would affect the rate of

prescription for black patients.

Contributing to such such discriminatory sentiments, there have been recent studies on

the role of prescription painkillers as a gateway for heroin addiction, because it is a more potent

and cost-effective alternative (Mars et al. 257). To some extent this belief is backed by scientific

findings. In a study of two urban metropolises, Philadelphia and San Francisco, a majority of

heroin addicts5 had transitioned to the street drug after abusing prescription opioids, without

having a history of abusing other illegal substances (esp. marijuana or crack cocaine) (Mars et al.

257). However, the statistics of such a phenomena are not the most important facet of this issue.

It is the influence such findings have on the medical professionals that observe them. This

established link between prescription drug use and future heroin addiction could deeply augment

5
It is noteworthy that the majority of these addicts surveyed were white drug abusers
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preexisting resistance to prescribe analgesics to African Americans, and create a foundation for

negative racial projects.

Qualitative studies of commonly held beliefs in the medical field further indicate a trend

in which prevalent assumptions about the black race are completely contradictory to patient

realities. Aside from the aforementioned association of drug abuse and crime involvement, there

exists a widespread, but tacit belief that blacks are more impervious to pain than their white

counterparts. (Anderson et al. 1190; Etienne 509; “The Long History of Discrimination in Pain

Medicine”). This supposition, however, could not be farther from reality; experiments

consistently have shown that the white population not only has a higher pain tolerance, but also

is more responsive to pain reduction strategies, which include both analgesic drugs and non-

medical solutions (Anderson 1190). These attitudes elucidate more than a simple connection

between current medical practices and Regan-era sentiment. Disparities in pain treatment follow

the common trend of racial projects. Implicitly bigoted attitudes are the foundation for these

highly racialized campaigns, and are are the basis with which discriminatory behavior is

motivated and internally justified.

It is also important to emphasize the disparity of racial representation within the medical

field, and how such inequity allows biased attitudes and stereotypes to flourish. In the data

collected by the 2000 Census, only 4.4 percent of American medical doctors were African

American, as were 8.8 percent of nurses, and 8.4 percent of physician assistants (“Fact Sheet:

The Need for Diversity in the Health Care Workforce”). Furthermore, only 5.1 percent of

pharmacists were black (“Fact Sheet: The Need for Diversity in the Health Care Workforce”).

These statistics indicate that those providing care, diagnosing ailments, prescribing treatment,

and distributing medication are overwhelmingly white, despite African Americans being 13.2
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percent of the population (“Fact Sheet: The Need for Diversity in the Health Care Workforce”).

This lack of descriptive representation is disturbing in that problematic behaviors and biases

often remain unchecked. Without the significant employment of minorities in medical positions,

procedures that reflect implicit racism are less likely to be questioned or exposed for their

prejudicial nature. This structure augments stereotypes and behaviors that reflect such beliefs.

The Influence of Bias on the Distribution of Resources

A second element of racial projects is the use of such charged beliefs to organize and

distribute resources. However, such a process can be carried out through a multiplicity of

methods. While the aforementioned example of the war on drugs is conventionally structured

and easy to identify, racial projects often exhibit subtler forms. In contrast to the politically

implemented, top-down, and systematic approach of Reagan’s campaign, medical disparity is

much more nuanced. It takes place at more individual levels, has more tacit implications, and

occurs in an unconventional setting. Despite these differences, racialized pain treatment has

equally profound implications on communities of color.

The resources affected by prejudice in pain care are the quality of treatment and pain

medication. This can be most easily observed in statistical data for acute pain. Such treatment in

many aspects is the most objective form pain care provided by physicians. The injury or illness

is very simply observed, diagnosed, and treated in an almost formulaic process. However, this

assumption is utterly fallacious in the treatment of African Americans. In a simple study of

long-bone fractures treated in emergency care facilities, black patients were 66 percent more

likely to not be given analgesic pain treatment than their white counterparts, despite equivalent

notations of pain in their medical charts (Anderson et. al 1188). Even in the most concrete cases
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of injury, black patients are less likely to receive adequate relief, despite suffering the same

trauma and experiencing equivalent pain.

Furthermore, in post operative pain treatment, “white patients received significantly

higher doses of opioid analgesics than did black... patients” (Anderson et al. 1190; Tamayo-

Sarver et al. 1). Generally, when both populations were prescribed an analgesic for any injury or

illness, 54 percent of whites were given an opioid, in contrast to only 27 percent of blacks

(Tamayo-Sarver 3). This is notable as opioids are considered significantly more addictive that

other forms of analgesics (Ling et al. 301). In addition, “there is a perception among many

individuals that African Americans as a group- regardless of socioeconomic status- tend to abuse

or use drugs at a higher rate…” (“Study: Whites More Likely to Abuse Drugs Than Blacks”).

This understanding clearly indicates a connection between how doctors view their patients of

color and the extent to which they presume addiction to be a risk.

Because analgesics are the most common and effective method utilized to relieve acute

pain symptoms, unequal prescription of such treatment is indicative of racial bias. Emblematic

of a racial project, the commodity of pain medication has been organized and distributed to

specific racial groups.

The findings on acute pain treatment are incredibly concrete in comparison to the nature

of chronic pain, however similarly dramatic conclusions can be drawn. In broad population

studies, African Americans, regardless of gender, reported more chronic pain than whites

(Anderson et al. 1190). Furthermore, this pain had a greater comorbidity with mental illnesses

such as depression and PTSD (Anderson et al. 1190). Despite the high prevalence of chronic

pain syndrome, it was also noted the African American patients spend less time with

practitioners, and therefore receive less comprehensive diagnostics (“The Long History of
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Discrimination in Pain Medicine”). The brevity of patient-provider communication during

appointments lends itself to incorrect or complete lack of diagnosis. In this manner, African

American patients frequently suffer chronic pain without an understanding of their condition or

any form of treatment. This places the burden of chronic pain disproportionately on the black

community.

Implicit attitudes about black patients explain the aforementioned disparity in drug

prescriptions. It has been clearly established that whites, including white doctors, hold the tacit

belief that blacks are more prone to addiction. This logic is relevant in terms of chronic pain, as

African Americans complaining of pain without tissue damage could be viewed as malingering

to gain access to prescription drugs for sale or consumption.

However, because analgesics have no positive affect on the condition of those with

chronic pain, this phenomenon could be seen as a silver lining to racial disparity. In this manner,

less African American chronic pain patients would become addicted or harmed by opioids that

have been erroneously prescribe (“The Long History of Discrimination in Pain Medicine”).

However, these patients have been condemned to suffer without treatment or recognition of pain.

Even if black communities have been shielded abstractly from addiction, this is still

representative of deeply problematic attitudes, and these patients are still disabled by their

untreated chronic pain.

The interpretation of black patients as impervious to pain, drug addicts, and criminals has

shaped the way in which medical car for pain is provided. This has lead to an unequal standard

of care in which blacks are not adequately diagnosed and treated. This is an incredibly harmful

racial project.
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The Implications of Racial Projects

The implications of disparate treatment extend much further than the simple denial of

adequate healthcare. Racial projects have disturbing consequences on the groups they target. As

a whole, inadequate pain care provided to back individuals impacts the livelihoods of

communities profoundly.

As such prejudice is reflected in a significant proportion of physician encounters,

attitudes are strongly shaped and communities are deeply impacted. This can be seen in the

extensive mistrust of the healthcare system by black Americans (Anderson et al. 1191). To

demonstrate this with an example of non-life threatening care, only 46 percent of African

American patients, as opposed to 72 percent of white patients, seek medical treatment for

migraine headaches (Anderson et al. 1191). The process of racial bias in treatment is an

effective form of healthcare disenfranchisement in communities of color. In this manner racial

projects in the healthcare system effectively disparages people of color and discourages them

from utilizing health services.

Both inadequate treatment and the lack of utilization of healthcare by African Americans

has serious implications towards the overall health and mortality rates within black communities.

With more serious conditions, a refusal to seek professional medical assistance is the difference

between life and death (Anderson et al. 1191). As more African Americans feel disenfranchised

from healthcare, and therefore do not utilize it, more blacks will be disabled or killed by treatable

conditions. For example, the child death rate in communities of color is 12.5 per thousand, and

14.5 per thousand in low income areas (Massey 347). This is significantly higher than in white

communities, where there is a stable and trusting relationship with healthcare professionals.
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It is also evident that housing in the United States is incredibly segregated6, therefore the

burden of aforementioned health disparities is exclusively imposed on to black communities

(Hosang 234). Furthermore, as less individuals utilize healthcare services (due to mistrust of the

medical field, rising death rates, etc.), hospitals and other institutions are incentivized to move

out of these communities in order to generate more profits (Massey 348). Therefore, the lack of

convenience in terms of time and expense to travel to hospitals increases, making it more

difficult for people of color to secure healthcare (Massey 348). This decreases the overall access

to healthcare, even for people of color who want to utilize such services. Furthermore, the time

to reach such facilities in periods of emergency increases as hospitals move to other

communities, augmenting mortality as individuals are unable to reach the hospital efficiently

(Massey 348). The restriction of access to healthcare, as the result of discriminatory practices by

practitioners, demonstrates how racial projects within the medical field indirectly marginalize

minority communities.

The disparity in pain treatment also has economic impacts on both individuals and

communities of color. Patients who do not receive diagnosis or treatment for pain (or both) are

severely impacted in terms of income earning ability (Groce 1499). Especially for undiagnosed

black patients of chronic pain, the illness would have highly disabling effects, “exacerbating” the

inability of these individuals to secure long-term employment or a livable income (Groce 1499).

Furthermore, this economic effect does not only impact the individual, but families and entire

communities of which the patient is a part of. Families are often forced to take on the burden of

care for disabled individuals (i.e. patients with untreated chronic pain), which further inhibits the

number of household members from holding a job, and the overall income of the unit (Groce

6
This is the result of racial projects in housing that allowed relators and homeowners to actively and
explicitly discriminate in the sale of homes to black buyers.
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1499). The role inequitable pain treatment plays in the proliferation of poverty is a clear effect

of racial projects in healthcare.

Furthermore, educational opportunities are impacted by the affects of inadequate medical

care. Public education is funded massively by property tax, and as previously noted,

neighborhoods in the United States are deeply segregated by race. As economic distress caused

by poor healthcare is felt unequally in black communities, the amount of money garnered by tax

revenue is decreased. This lowers the funding available to public schools in black

neighborhoods. Because education is viewed as greatly increasing economic opportunity, the

lack thereof in black communities clearly inhibits the ability of youth to escape the cycle of

poverty. In this way the economic effects of disparate pain treatment trickle down into the

quality of education provided to the children of minorities.

Because racism is so systematically created in the United States, actions taken by one

institution echo into the multitudinous intersections of ethnicity. The impact of racial projects in

pain care are profound and endless. Doctors who allow unconscious bias to impact the quality of

treatment they give to black patients do not intend to activate such extensive and devastating

forms of systematic oppression. However, this is the reality. The true costs of negative racial

projects are the losses of opportunity and livelihood.

Conclusion

Race, as a master category, profoundly shapes the life experiences of all Americans.

Because of ethnicity has such an incredible impact, racial projects are essential tools that can not

only create equality, but also foster injustice. As the eras of law and order and the war on drugs

built stereotypes about black criminality, the consistent disparity in healthcare reinforces such
 Comerford 17

inequity. Implicitly discriminatory attitudes have lead many medical professionals to

marginalize people of color through unequal care, especially for pain. If such stratification is

ignored and unaddressed, more serious consequences will be felt in minority communities,

pushing American society further from the ideal of equality that is desired so strongly.
 Comerford 18

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