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There is a need to understand different cultures when considering pain assessment and
management. This extends beyond the language spoken, because an individual’s culture also
influences their beliefs, expectations, methods of communication and norms of behaviour, as
do the culture and attitudes of the health care provider (Green et al, 2003; Davidhizar & Giger,
2004). It is important for clinicians to be aware of both verbal and non‐verbal indicators of pain
and be sensitive to both emotive and stoic behaviours in an individual’s response. Some
cultural attitudes may limit pain‐relief seeking behaviour. For example, it may be perceived by
some patients as inappropriate to use a nurse’s time to ask for analgesics or asking for pain
relief may be seen as a weakness (Green et al, 2003).
Communication problems may make it difficult to adequately help non‐English speaking
patients with interactive pain management (eg PCA use, requesting analgesia when needed),
gain consent for invasive analgesic techniques (eg epidural or plexus catheters) and assess
their degree of pain (Howe et al, 1998 Level IV). When language is an obstacle, care should be
used when enlisting non‐professional interpreters to translate, because family members and
friends of the patient may impose their own values when conveying the information to the
clinician, and the patient may be reluctant to openly express themselves in front of people
they know.
Cultural differences in response to pain in both the experimental and clinical settings have
been reported. A review of studies investigating differences in responses to experimentally
induced pain found that cultural differences influenced pain tolerance but not pain threshold,
and concluded that intrinsic difficulties in the translation of pain descriptors between different
cultures makes pain tolerance the more relevant pain measure (Zatzick & Dimsdale, 1990). In a
comparison of experimental pain sensitivity in three ethnic groups, African Americans and
Hispanic Americans showed a greater sensitivity to laboratory‐evoked pain compared with
non‐Hispanic White Americans (Rahim‐Williams et al, 2007 Level III‐2). Similarly, African American
women were more sensitive to ischaemic pain than non‐Hispanic white women (Klatzkin et al,
2007 Level III‐2). However, the implications of these results for the clinical setting are unclear.
A systemic review looked at the effect of patient race and ethnicity on pain assessment and
management across a variety of clinical pain settings (Cintron & Morrison, 2006 Level III‐3).
Marked disparities in effective pain treatment were reported; African Americans and Hispanics
were less likely to receive opioid analgesics, and were more likely to have their pain
undertreated compared with white patients.
Differences have been reported in patients of different ethnic groups attending emergency
departments and requiring analgesia. A review of the treatment of pain in United States
CHAPTER 11 the period 1993 to 2005, but that white patients with pain were more likely than black,
emergency departments showed that opioid prescribing for pain‐related visits increased over

Hispanic or Asian patients to receive an opioid, and that these differences did not diminish
over time (Pletcher et al, 2008 Level III‐3). This disparity was reported for all types of pain visits,
was more pronounced with increasing pain intensity, and was unaffected by adjustment for
pain severity.
Prescription of PCA and PCA prescription details also varied with patient ethnicity (Ng et al,
1996 Level III‐3; Salamonson & Everett, 2005 Level III‐3), although the actual self‐administered
doses of opioid were similar (Ng et al, 1996 Level IV). After Caesarean section, significant ethnic
group differences were noted in reported pain and morphine consumption; pain scores and
morphine doses were higher in Indian patients compared with Chinese and Malay patients
even after controlling for age, body mass index, and duration of operation (Tan et al, 2008
Level III‐2).

410 Acute Pain Management: Scientific Evidence