.png)
Tala Allababidi, BS
SUMMARY POINTS
The United States’ extensive opioid consumption has been attributed to pharmaceutical advertising, patient expectations, fear of undertreating pain, and the use of opioids for the treatment of chronic non-cancer pain.
Pain is considered a subjective experience and the expression of it is heavily influenced by one’s culture, social, and psychological factors.
The use of opioids is controversial in some cultural groups, so cultural awareness among health care professionals is needed to manage patients’ pain in a culturally competent manner.
ANALYSIS
According to the CDC, an estimated 20.4% of U.S. adults suffer from chronic pain [1]. Due to its complex nature, management often entails the use of multi-modal pain strategies. Additionally, the United States has been suffering from an opioid epidemic further complicating treatment. Some factors driving the rise in opioid use are pharmaceutical advertisements, patient expectations of pain relief, fear of undertreating pain by prescribers, and the rise in the use of opioids for the treatment of chronic non-cancer pain [2]. There is much concern surrounding the use of opioids to treat chronic non-cancer pain due to the potential for abuse, addiction, and medication diversion. Often overlooked is the influence culture has on individual pain perception and choice of treatment. This makes it challenging for health care professionals practicing in a diverse society to manage their patients’ pain in a culturally competent manner [3] This analysis seeks to discuss the role that culture can play in the expression of pain and the use of opioids for treatment.
Pain is generally considered a private experience that is influenced by one's cultural, social, and psychological factors [4]. Due to its subjective nature, the definition, expression, communication, and beliefs surrounding pain will differ from one patient to another. While difficult to assess by themselves, individual upbringing and cultural beliefs shape behavior. Culture is defined as one's traditions and beliefs as it pertains to their racial, ethnic, religious, and social group [3]. Pain is not exempt from the influence of one’s culture. For example, studies have found that in some Asian cultures, patients are less likely to communicate their pain and are often less direct when discussing their experience of pain with a non-Asian clinician [3]. A study looking at the attitudes of rural Nepalese surrounding low back pain found that individuals were far less likely to seek medical intervention as they attributed their pain to a part of normal aging [3].
According to the anthropologist Mark Zborowski, people’s cultural experiences influence whether they view their pain as a problem that requires clinical treatment [4]. Some cultures consider pain as a sign of healing while others view it as a “test of faith” [4]. Moreover, the use of opioids for pain management is frowned upon in many cultures as it can be viewed as equivalent to euthanasia [5]. This becomes especially challenging during end-of-life care as opioids are considered the primary pharmacological analgesics in palliative care [5]. For example, pain scales can be helpful when treating African American patients as they may avoid pain medication due to fear of addiction. On the other hand, patients from East Asian backgrounds might be more stoic, requiring clinicians to rely more on non-verbal signs [5]. Clinicians should be aware of both verbal and nonverbal cues when interacting with patients to avoid miscommunications regarding pain.
Following discussions at the International Neuroscience Nursing Research Symposium in 2020 on variations in pain assessments and pain management between countries, it was concluded that adequate knowledge of patient backgrounds and preferences is needed to properly manage pain (Table 1) [6].
Table 1. Summary of Cultural Influences and Nursing Implications post International Neuroscience. Nursing Research Symposium in August 2020. SEE ARTICLE Data from Bautista C, Amatangelo MP, Baby P, Cassier-Woidasky A-K, Dycus K, Edoh EI, et al. Cultural perspectives on pain assessment and opioid use: International Neuroscience Nursing Research Symposium Conference Proceedings. Journal of Neuroscience Nursing. 2021;53(3):149-156. doi:10.1097/jnn.0000000000000585.
Religion also plays a major role in individual behaviors regarding pain. Patients’ acceptance of pain and intervention can be heavily influenced by their theology and religious doctrine [7]. According to Catholic teachings, acceptance of suffering is a means of spiritual growth. There is concern about analgesic medications impacting a patient’s level of consciousness. This is especially relevant towards the end of life, when individuals are expected “share in the sufferings of Christ” [7]. While these teachings allow for the use of analgesic medications, including opioids, maintaining some level of awareness is seen as imperative as death is often seen as the “last loving act” [7]. In the Islamic faith, the use of substances that alter mental status is usually prohibited unless medically indicated. While alleviating suffering from pain is seen as a “righteous act”, maintenance of consciousness is encouraged so patients can worship for a longer period [8]. Similarly, in Judaism, according to Immanuel Jakobovits, the father of Jewish medical ethics, it is viewed that “alleviating pain is just as important and noble as treating the actual disease” [9] Though opioid use can be viewed religiously as permissible, some patients might still choose to endure some levels of pain to maintain a higher level of alertness for spiritual gain [8].
Clinicians should be aware of cultural factors influencing individual perceptions of pain when evaluating patients and agreeing on a treatment plan. Clinicians should also emphasize being thorough when explaining a treatment method as patients may have misconceptions about certain medications. The opioid epidemic has resulted in a continued push to investigate alternatives for pain management, which in turn can aid in providing patients with more options for care. Further research is needed to understand patient cultural perspectives driving choices in pain management.
REFERENCES
Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults - United States, 2016. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm?s_cid=mm6736a2_e. Published September 16, 2019. Accessed June 29, 2022.
Penney LS, Ritenbaugh C, DeBar LL, Elder C, Deyo RA. Provider and patient perspectives on opioids and alternative treatments for managing chronic pain: A qualitative study. BMC Family Practice. 2016;17(1). doi:10.1186/s12875-016-0566-0.
Sharma S, Abbott JH, Jensen MP. Why clinicians should consider the role of culture in Chronic pain. Brazilian Journal of Physical Therapy. 2018;22(5):345-346. doi:10.1016/j.bjpt.2018.07.002
Peacock S, Patel S. Cultural influences on pain. Reviews in Pain. 2008;1(2):6-9. doi:10.1177/204946370800100203.
Givler A, Bhatt H, Maani-Fogelman PA. The importance of cultural competence in pain and ... - NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK493154/. Accessed June 29, 2022.
Bautista C, Amatangelo MP, Baby P, Cassier-Woidasky A-K, Dycus K, Edoh EI, et al. Cultural perspectives on pain assessment and opioid use: International Neuroscience Nursing Research Symposium Conference Proceedings. Journal of Neuroscience Nursing. 2021;53(3):149-156. doi:10.1097/jnn.0000000000000585.
O'Rourke RK. Pain relief: The perspective of Catholic tradition. Journal of Pain and Symptom Management. 1992;7(8):485-491. doi:10.1016/0885-3924(92)90135-5.
Al-Shahri MZ. Islamic theology and the principles of palliative care. Palliative and Supportive Care. 2016;14(6):635-640. doi:10.1017/s1478951516000080.
Weiss RR. Pain management at the end of life and the principle of double effect: A Jewish perspective. Cancer Investigation. 2007;25(4):274-277. doi:10.1080/07357900701225380.