Download Pain Presentation from a Cultural Viewpoint

Pain From A Cultural
Viewpoint
Psychological Dynamics of Pain
In Memoriam: John J. Bonica, MD (1917-1994)
Health and Mental Health I
Joint Master of Social Work Program
North Carolina A&T State University
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
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
Pain: Past & Present
Egyptian – Assyrian –
Babylonian
Intruding demons or spirits
escaped by:
Vomiting
Sneezing
Urinating
Sweating
Babylonians – pain in specific
region or area indicated demon
eating away
Pain: Past & Present
Judaism
Hebraic 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
Pain: Past & Present
The Ancient Greeks
Pythagorean School
Conduct 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?
Pain: Past & Present
Middle Ages and Church
Pain 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
Pain: Universal Experience
 Upwards 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
Pain: Universal Experience
 1 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
Pain: Universal Experience
The Quest for Relief
 Oral medications
 Surgery
 Psychotherapy
 Quack remedies
 Counter meds, prescribed or peddled
Pain: Universal Experience
Total Health Care Costs
U.S. bill @ $______ billion
Societal bill @ $______ billion
Work days @ $______ million
Harris poll survey: average full-
time employee loses _____ work
days per year because of pain or
pain related problems
Pain: Universal Experience
Treatment Interventions
Traditional medicines
Injections
Chiropractic
Bee pollen-venom
Acupuncture
Massage
Pain: Universal Experience
Treatment Interventions (cont.)
 DSMO
 Bio-feedback
 Cognitive restructuring
 Relaxation alternatives
 Exercise
 Music, yoga, eastern alternative
 Folk or home remedies
Pain: Universal Experience
Major Culprits
1.
2.
3.
Pain: Universal Experience
Major Culprits
1. Back pain – in its many locations
2. Arthritis – in its presentation
3. Headaches
•
Tension
•
Migraine
•
Cluster
Pain: Universal Experience
Unrelenting 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
Pain: Universal Experience
Why the indifference to pain?
1.
2.
3.
Pain: Universal Experience
Why the indifference to pain?
1. Medical education is limited – average medical student in
medical school @ 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
Pain: Universal Experience
“Study of Pain” is not new

1944 - First sociological studies focusing on
impact of ethnic background and how pain is
perceived undertaken
 Irving Zola – study of presentation of symptoms
to physicians

1966 - Irving Zola provided further research
on how cultural heritage either constrains or
stimulates on how pain is described or
presented
Pain: Universal Experience
Cultural 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”?
Pain: Universal Experience
Perception 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
Pain: Universal Experience
 Cultural 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?
Pain: Universal Experience
 Cultural 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”
Barriers to Communications
Pain and Any Treatment
 Racial 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
Road Blocks and Barriers to
Communication: Patient Issues
Norris, W.M. et al. (2005). Journal of Palliative Medicine, 5, 1016-1024
 Education
 Cognition
 Socioeconomic status
 Languages and dialect
differences*
 Health illiteracy
 Faith expectation
 Resistance to
prognosis*
 Denial
 Stoicism
 Physical or Emotional
Distress
 Psychologically
unprepared
 Mistrust, disbelief
Pain: Universal Experience
Baxter & 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.
Pain: Universal Experience
What questions physicians ask are likely to be
determined by
1.
2.
Pain: Universal Experience
What questions physicians ask are likely to be
determined by
1. Which symptoms have been presented by the
person
2. 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
Pain: Universal Experience
Pain 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
Pain: Universal Experience
Pain 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
Pain: Universal Experience
Pain 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
Pain: Universal Experience
Pain perceptions, culture, communication (cont.)
 Greek Americans
 Turkish Americans
 Armenian Americans
 Asian – Pacific Islander Americans
 Africans – Asians – Latinas – Europeans - Russians Appalachians – Caribbean Islanders
Pain: From Cultural View
Closing Summary
1.
What does “pain” mean to this patient/client?
2.
What impact does it have on body-image, self-esteem, role
functions, role responsibilities, present and future goals?
3.
Is pain thought to signal terminal illness?
4.
How have activities of daily living changed or been influenced
by pain?
5.
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]?
6.
How has the person coped with pain in the past?
7.
Does the patient/client view pain as a means to get well?
8.
Does patient/client desire immediate relief or does he or she
expect to suffer before obtaining relief?
Pain Management
In The Elderly
Where do we go from here?
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
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
Elderly Patients Taking Pain Medications
For Chronic Pain Who Had Seen A Doctor
In The Past Year
 79% 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
Common Causes of Pain
In Elderly Persons
 Osteoarthritis
 back, knee, hip
 Night-time leg cramps
 Claudication
 Neuropathies
 idiopathic, traumatic, diabetic,
herpetic
 Cancer
Misconceptions About Pain
 Myth: Pain is expected with
aging.
 Fact: Pain is not normal with
aging.
Pain Threshold With Aging
Author
Stimulus
Threshold
Shumacher, 1940
Thermal
No Change
Birren, 1950
Thermal
No Change
Sherman, 1964
Electric/Tooth
Higher
Collins, 1968
Electric/Skin
Lower
Harkins, 1977
Electric/Tooth
No Change
Tucker, 1989
Electric/Skin
Higher
Age Related Differences in
Peripheral Nerve Function


Myelinated 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 (1.2-1.6un) not (.4un)
 Substance P, CGRP content decreased
 Neurogenic inflammation reduced
Misconceptions About Pain
 Myth: 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.
Reasons Patients May Not Report
Pain
 Fear 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
The most reliable
indicator of the
existence pain and
its intensity is the
patient’s description.
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
Analgesic Drugs
 Acetaminophen
 NSAID's
 Non-selective COX inhibitors
 Selective COX-2 inhibitors
 Opioids
 Others
 Antidepressants
 Anticonvulsants
 Substance P inhibitors
 NMDA inhibitors
 Others
CAUTION
 Meperidine (Demerol)
 Butorphanol (Stadol)
 Pentazocine (Talwin)
 Propoxiphene (Darvon)
 Methadone (Dolophine)
 Transderm Fentanyl (Duragesic
Patches)****
Do Not Use Placebos!
 Unethical in clinical
practice
 They don’t work
 Not helpful in diagnosis
 Effect is short lived
 Destroys trust
Non-Drug Strategies
 Exercise
 PT, OT, stretching, strengthening
 general conditioning
 Physical methods
 ice, heat, massage
 Cognitive-behavioral therapy
 Chiropractic
 Acupuncture
 TENS
 Alternative therapies
relaxation, imagery
herbals
Patient And Caregiver Education
 Diagnosis, prognosis, natural
history of underlying disease
 Communication and assessment of
pain
 Explanation of drug strategies
 Management of potential sideeffects
 Explanation of non-drug strategies
Remember Again!
1.
What does “pain” mean to this patient/client?
2.
What impact does it have on body-image, self-esteem, role
functions, role responsibilities, present and future goals?
3.
Is pain thought to signal terminal illness?
4.
How have activities of daily living changed or been influenced
by pain?
5.
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]?
6.
How has the person coped with pain in the past?
7.
Does the patient/client view pain as a means to get well?
8.
Does patient/client desire immediate relief or does he or she
expect to suffer before obtaining relief?