Beyond the Nociceptor--Addressing Social Determinants of Pain in Anesthesia Care

Despite advances in regional anesthesia and multimodal analgesia, pain disparities in perioperative and chronic pain populations persist, particularly among marginalized groups who experience higher postoperative pain and poorer recovery. Social determinants of pain (SDOP) link social adversity to nociceptive processing through biological pathways. Chronic stress and allostatic load induce epigenetic changes that accelerate aging and affect pain biology. Most clinicians lack understanding of how to apply this knowledge in daily practice. This review examines links between SDOP, allostatic load, and pain vulnerability, with implications for perioperative pain management. Racialized minorities and socioeconomic disadvantages predict greater stress and worse pain outcomes. Allostatic load, reflecting cumulative physiological wear from chronic stress, is associated with greater pain severity, epigenetic modification of genes in pathways that regulate stress and aging, leading to accelerated biological aging and pain vulnerability. For instance, individuals with chronic low back pain show accelerated biological aging compared to healthy controls, and the pace of biological aging mediates the relationship between chronic pain stigma and pain outcomes. Understanding these biological pathways enables CRNAs to adopt evidence-based strategies, including routine social screening, equitable access to regional techniques, and targeted care for high-risk groups. More studies are needed to inform equity-centered pain management.