1 Pain From A Cultural ViewpointPsychological Dynamics of Pain In Memoriam: John J. Bonica, MD ( ) Health and Mental Health I Joint Master of Social Work Program North Carolina A&T State University

2 Pain: Past & Present Role and cause of pain is a central theme in history Pain number one reason patients visit medical provider Explosion of pain centers and treatment today Fear of prosecution by many medical providers

3 Pain: Past & Present In early civilizations pain was result of intrusion of body by Magical fluids Demons Objects – spears, darts, arrows Magical elements produced pain Role of shaman, sorcerer, priest, soothsayer was to remove, cast out, remove or reduce pain

4 Pain: Past & Present Egyptian – Assyrian – BabylonianIntruding demons or spirits escaped by: Vomiting Sneezing Urinating Sweating Babylonians – pain in specific region or area indicated demon eating away

5 Pain: Past & Present JudaismHebraic teaching – if one were to continue to appease false gods for healing – one could incur punishment from the one true G-d Book of Job, “They that plow iniquity, and sow wickedness, reap the same. By the blast of G-d they perish and by the breath of his nostrils are they consumed.” Shift – sin equated with punishment

6 Pain: Past & Present The Ancient Greeks Pythagorean SchoolConduct determines the soul’s fate By choosing the soul either returns to the gods or receives punishment by returning to earth Pain and suffering are necessary for developing “self-control” and discipline Achievement of nobility and courage What myth told the story how pain and suffering were introduced into the world?

7 Pain: Past & Present Middle Ages and ChurchPain and sin fundamental in Christian thought Latin – poena – punishment Life was “spiritual journey” Penance tempers punishment Pain or physical suffering must be lived To alleviate physical suffering is to transgress against G-d’s eternal order

8 Pain: Universal ExperienceUpwards of 50 million Americans suffer pain Almost 15 million suffer chronic and intractable pain, severe enough to be disabling 76.5 million Americans report with pain of any sort that persists for more than 24 hours Estimated 75% cancer pain patients do not receive adequate pain relief More than ½ hospitalized patients experience pain in their last days of life Estimated 20% or 42 million adults report pain interrupts their sleep a few nights a week Costs – healthcare expenses, lost income, lost productivity – estimated $100 billion

9 Pain: Universal Experience1 out of 1,400 doctors get prosecuted or reviewed – pain specialists nightmare Back pain estimated 26 million Americans Estimated 46 million Americans have been told by doctor they have arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia In 2003 knee replacements cost $11.9 billion; hip replacement $12.2 billion Migraine, jaw and lower facial pain account for over 25 million pain suffers

10 Pain: Universal ExperienceThe Quest for Relief Oral medications Surgery Psychotherapy Quack remedies Counter meds, prescribed or peddled

11 Pain: Universal ExperienceTotal Health Care Costs U.S. $______ billion Societal $______ billion Work $______ million Harris poll survey: average full- time employee loses _____ work days per year because of pain or pain related problems

12 Pain: Universal ExperienceTreatment Interventions Traditional medicines Injections Chiropractic Bee pollen-venom Acupuncture Massage

13 Pain: Universal ExperienceTreatment Interventions (cont.) DSMO Bio-feedback Cognitive restructuring Relaxation alternatives Exercise Music, yoga, eastern alternative Folk or home remedies

14 Pain: Universal ExperienceMajor Culprits 1. 2. 3.

15 Pain: Universal ExperienceMajor Culprits Back pain – in its many locations Arthritis – in its presentation Headaches Tension Migraine Cluster

16 Pain: Universal ExperienceUnrelenting Pain Cycle Dr. John Bonica, University of Washington, Seattle Pain is chronically mismanaged by medical community Chronic pain sufferers – vicious cycle Excessive medication Loss of sleep Fear physical activity Patient becomes frustrated and frustrates medical providers Depression

17 Pain: Universal ExperienceWhy the indifference to pain?

18 Pain: Universal ExperienceWhy the indifference to pain? 1. Medical education is limited – average medical student in medical 3 to 4 hours focused on formal study – where do future medical practitioners learn about pain? 2. Reservation or hesitancy of the medical provider that pain is severe or creates “intense discomfort” to the level patient describes 3. Medical providers filter information based upon their knowledge, medical experience, practice experience, or personal experience Ethnocentric concept – we analyze/interpret from own perspective

19 Pain: Universal Experience“Study of Pain” is not new First sociological studies focusing on impact of ethnic background and how pain is perceived undertaken Irving Zola – study of presentation of symptoms to physicians Irving Zola provided further research on how cultural heritage either constrains or stimulates on how pain is described or presented

20 Pain: Universal ExperienceCultural background affects our Reactions to symptoms How we respond to symptoms How we report these to physicians When we report these to family, friends, and medical providers Examples: How about your family’s “approach”?

21 Pain: Universal ExperiencePerception of health is relative to one’s culture Overweight American – 10+ pounds, suggests ill, health risk, eat too much, unhealthy behavior Samoa – Big women, big ankles, good sex Japan – Sumo wrestlers, a condition to be obtained and sustained, rewarded

22 Pain: Universal ExperienceCultural differences and communications What is communicated may not be what we understand Example: An elderly African-American patient who was born and raised in South Carolina islands [Gullah] was asked by her physician how she was feeling regarding the pain in her lower back, she told the doctor that “The pain done gone” What do you think the doctor thought about her pain? What do you think the health providers heard? What would you think of her statement? What do you think she meant?

23 Pain: Universal ExperienceCultural differences and communications: “The pain done gone” When asked again, the patient said: “The pain done been gone.” From this statement it may be assumed pain is over, done, extinguished! Fortunately the patient’s daughter explained – based upon the dialect/culture – her 74-year-old grandmother was saying the pain had temporary left but it still was returning in both intensity and duration during days and nights interrupting her daily living routine, sleeping, eating, social life According to the daughter – Gullah language uses the statement “Gone, gone” or if her mother said, “The pain is gone, gone” Could it be assumed the pain is actually gone!

24 Barriers to Communications Pain and Any TreatmentRacial bias Cultural bias (implicit and explicit) Discussions in certain areas [death, dying] difficult - fear of taking hope away Refusal to accept therapeutic offering is failure Ethical conflicts may erode communication Family structures may be matriarchal – who does patient/client depend or look to for final decision making Preferences for life-sustaining therapies Historical inequities and ongoing disparities may induce fear and mistrust

25 Road Blocks and Barriers to Communication: Patient Issues Norris, W. MRoad Blocks and Barriers to Communication: Patient Issues Norris, W.M. et al. (2005). Journal of Palliative Medicine, 5, Resistance to prognosis* Denial Stoicism Physical or Emotional Distress Psychologically unprepared Mistrust, disbelief Education Cognition Socioeconomic status Languages and dialect differences* Health illiteracy Faith expectation

26 Pain: Universal ExperienceBaxter & Cyster (1980) A Scottish doctor advised his male patient who was experiencing pain due to probable cirrhosis of the liver to not drink more than 2 glasses of sherry a day. He smiled as the doctor told him this. He would gladly give up the thought of drinking sherry since he only drank whiskey and not sherry anyway.

27 Pain: Universal ExperienceWhat questions physicians ask are likely to be determined by 1. 2.

28 Pain: Universal ExperienceWhat questions physicians ask are likely to be determined by Which symptoms have been presented by the person Socio-economic-cultural characteristics or cues reflective of the person If all of us in this class individually saw our physician for low back pain problem – would we all get the same evaluation, questions, diagnostic work-up? Physical and mental health providers consider signs (physical) and communications (verbal) to identify a sign of illness or disease

29 Pain: Universal ExperiencePain has various interpretations Pain as ritual admission Pain as social status – past or present Pain as reflective of the strength of person or “curse” to endure

30 Pain: Universal ExperiencePain has various interpretations: Pain as ritual admission Secret societies, primitive tribes, college fraternity or sorority initiation Pain as social status – past or present Walking cane, eye patch may be related to decorated war injury or stroke etc. Scar, skin scarification may reflect social status in gang or group membership, fraternity, former prison inmate Pain as reflective of the strength of person or “curse” to endure Person has a “cross to bear” due to infraction of law, mores, behavior and must endure discomfort as a form or penance

31 Pain: Universal ExperiencePain perceptions, culture, communication What did you discover about various groups from your diversity course when focusing on health issues or relationships with health and mental health providers? African Americans European Americans Jewish Americans Puerto Rican – Hispanic Americans Native indigenous peoples Italian Americans

32 Pain: Universal ExperiencePain perceptions, culture, communication (cont.) Greek Americans Turkish Americans Armenian Americans Asian – Pacific Islander Americans Africans – Asians – Latinas – Europeans - Russians - Appalachians – Caribbean Islanders

33 Pain: From Cultural View Closing SummaryWhat does “pain” mean to this patient/client? What impact does it have on body-image, self-esteem, role functions, role responsibilities, present and future goals? Is pain thought to signal terminal illness? How have activities of daily living changed or been influenced by pain? Does he or she want to be left alone due to the “pain” or does it provide a forum for interactions with others, medical staff, immediate family, or others [family/friends]? How has the person coped with pain in the past? Does the patient/client view pain as a means to get well? Does patient/client desire immediate relief or does he or she expect to suffer before obtaining relief?

34 Pain Management In The ElderlyWhere do we go from here?

35 Physicians and Health Providers Have a Moral Obligation to Provide Comfort and Pain Management Especially for those near the end of life! Pain is the most feared complication of illness Pain is the second leading complaint in physicians’ offices Often under-diagnosed and under-treated Effects on mood, functional status, and quality of life Associated with increased health service use

36 18% of Elderly Persons Take Analgesic Medications Regularly (daily or more than 3 times a week)71% take prescription analgesics 63% for more than 6 months 72% take OTC analgesics Median duration more than 5 years 26% report side-effects 10% were hospitalized 41% take medications for side-effects

37 Elderly Patients Taking Pain Medications For Chronic Pain Who Had Seen A Doctor In The Past Year79% had seen a primary care physician 17% had seen a orthopedist 9% had seen a rheumatologist 6% had seen a neurologist 5% had seen a pain specialist 5% had seen a chiropractor 20% had seen more than 5 doctors

38 Common Causes of Pain In Elderly PersonsOsteoarthritis back, knee, hip Night-time leg cramps Claudication Neuropathies idiopathic, traumatic, diabetic, herpetic Cancer

39 Misconceptions About PainMyth: Pain is expected with aging. Fact: Pain is not normal with aging.

40 Pain Threshold With Aging

41 Age Related Differences in Peripheral Nerve FunctionMyelinated nerves Reduction in density (all sizes including small) Increase in abnormal/degenerating fibres Decrease in action potential/slower conduction velocity Unmyelinated nerves Reduction in number ( un) not (.4un) Substance P, CGRP content decreased Neurogenic inflammation reduced

42 Misconceptions About PainMyth: If they don’t complain, they don’t have pain Fact: There are many reasons patients may be reluctant to complain, despite pain that significantly effects their functional status and mood.

43 Reasons Patients May Not Report PainFear of diagnostic tests Fear of medications Fear meaning of pain Cultural cues misread by patient and/or providers Communications and misinterpretations Cannot adequate describe “pain” or discomfort Perceive physicians, nurses, health providers too busy Complaining may effect quality of care Believe nothing can or will be done

44 The most reliable indicator of the existence pain and its intensity is the patient’s description.

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46 There is a lot we can do to relieve pain!Analgesic drugs Non-drug strategies Specialized pain treatment centers Patient and caregiver education and support

47 Analgesic Drugs Acetaminophen NSAID's Opioids OthersNon-selective COX inhibitors Selective COX-2 inhibitors Opioids Others Antidepressants Anticonvulsants Substance P inhibitors NMDA inhibitors

48 CAUTION Meperidine (Demerol) Butorphanol (Stadol) Pentazocine (Talwin)Propoxiphene (Darvon) Methadone (Dolophine) Transderm Fentanyl (Duragesic Patches)****

49 Do Not Use Placebos! Unethical in clinical practice They don’t workNot helpful in diagnosis Effect is short lived Destroys trust

50 Non-Drug Strategies Exercise PT, OT, stretching, strengtheninggeneral conditioning Physical methods ice, heat, massage Cognitive-behavioral therapy Chiropractic Acupuncture TENS Alternative therapies relaxation, imagery herbals

51 Patient And Caregiver EducationDiagnosis, prognosis, natural history of underlying disease Communication and assessment of pain Explanation of drug strategies Management of potential side- effects Explanation of non-drug strategies

52 Remember Again! What does “pain” mean to this patient/client?What impact does it have on body-image, self-esteem, role functions, role responsibilities, present and future goals? Is pain thought to signal terminal illness? How have activities of daily living changed or been influenced by pain? Does he or she want to be left alone due to the “pain” or does it provide a forum for interactions with others, medical staff, immediate family, or others [family/friends]? How has the person coped with pain in the past? Does the patient/client view pain as a means to get well? Does patient/client desire immediate relief or does he or she expect to suffer before obtaining relief?