Tuesday, September 1, 2015

The Ambiguity of Pain and Its Consequences: Discrimination, Oligoanalgesia, and Addiction

We tend to think of pain as a quantity with a cause that can be identified and a level of intensity that can be characterized.  However, Joanna Bourke, a British historian, tells a different story.  In her book, Story of Pain: From Prayer to Painkillers, she convinces us that pain is a much more elusive entity. 

“….pain describes the way we experience something not what is experienced.  It is a manner of feeling….Crucially, pain is not an intrinsic quality of raw sensation; it is a way of perceiving an experience.”

It is well known that expression of pain is a learned response that varies from one culture to another, from one gender to another, and from one generation to another.  It is also well known that extreme physical injuries can be endured with little or no pain, and that extreme pain can be experienced with no discernible cause.

There is no way of measuring pain directly.  Consequently, a physician must depend on the description of the pain by the patient or draw her own conclusions based on evaluating the signals of pain being expressed by the patient.  Given that high level of uncertainty, it is not surprising that physicians and nurses have treated patients suffering from pain in ways that were affected by biases and baseless assumptions.  Treatment was accorded to patients based on race, ethnicity, gender, and age.  What is surprising is that biases and baseless presumptions have not disappeared as medical knowledge has been accumulated; instead, many have largely persisted in modern times.

Bourke’s study is limited to the English-speaking countries and is thus dominated by Britain and the United States.  Not unexpectedly, when matters of race or ethnicity arose Anglo-Saxons always seemed to be identified as the ideal “race.”  Since pain was to them such a real and compelling sensation they assumed that their superior intellectual development rendered them more sensitive to all stimuli.  People the Anglo-Saxons didn’t respect (everyone else except a few Northern Europeans) were generally assumed to be incapable of experiencing pain at the same level because of inferior physical and mental development.  Jews weren’t well-liked but they couldn’t conveniently be classified as mentally inferior.  It was assumed that Jews were hypersensitive to pain and lacked the ability to control their response to it because they were culturally or racially deprived of the fortitude provided by an Anglo-Saxon heritage.

These beliefs had a great deal of influence on the manner in which people were treated over the centuries.

“….slaves, ‘savages’, and dark-skinned people generally were routinely depicted in Anglo-American texts as possessing a limited capacity to truly feel, a biological ‘fact’ that conveniently diminished any culpability amongst their so-called superiors for acts of abuse inflicted upon them.”

These beliefs about the inferiority of the people the British wished to conquer and colonize were extremely convenient.  In the context of medical treatment, this led to less attention being paid to the pain suffered by certain classes than to others.

Gail Collins provides a startling example of how this presumed insensitivity was put to use by physicians in America's Women: 400 Years of Dolls, Drudges, Helpmates, and Heroines.  There was a horrible tragedy that could befall women in giving birth.  It was referred to as a vesico-vaginal fistula. 

“During childbirth, the wall between their vagina and the bladder or rectum ripped, leaving them unable to control the leakage of urine or feces through the vagina.  The condition had been recognized for centuries, but some historians believe that it increased when doctors began delivering babies [replacing midwives] and inserting their instruments into the womb.”

A surgeon, J. Marion Sims assumed the task of trying to surgically repair this devastating condition in 1845

“J. Marion Sims, an Alabama physician, devised an operation that successfully closed the fistulas and let these tormented women resume their lives.  But the discovery came at a horrifying cost...He experimented with surgical techniques while the [slave] women balanced on their knees and elbows, in order to give them a better view of what he was doing....Four years later he finally succeeded in repairing the fistula of a slave named Anarcha....It was Anarcha’s thirtieth operation, all of them performed without anesthetics.....Sims claimed that the women had begged him to keep trying his experiments and it’s possible that was true....But they were still slaves with no real option to say no, and Sims chose to work on them in part because he believed white women could not endure the kind of pain he was inflicting.”

As Bourke makes clear, this assumption about insensitivity to pain by certain classes of people is not something relegated to the deep, dark past.

“….in the words of a gynaecologist in 1928, forceps were rarely needed when ‘colored women’ were giving birth because ‘their lessened sensitivity to pain makes them slower to demand relief than white women’.”

“From the 1980s onwards, surveys showed that minority patients being treated for pain associated with metastatic cancer were twice as likely as non-minority patients to be given inadequate pain management.  Even after major operations, certain patients, Chinese for example, were likely to be given less pain relief than white patients, in part because of assumptions that they had a higher threshold for tolerating pain.  In a study of people treated for long-bone fractures at the UCLA Emergency Medicine Center in Los Angeles in the 1990s, Hispanics were twice as likely as non-Hispanic whites to receive no medication for pain.”

Women were subject to much analysis on the part of the males who created conventional wisdoms.  While continuing to refer to them as “the weaker sex,” it was generally acknowledged that women were better able to endure pain than men.  Some of the justifications for this assumption were more interesting than others.

“In one particularly pessimistic account in 1910, women’s resilience was simply ascribed to their ‘long practice in suffering the blows of the male’.”

A more politically correct and more compelling view held that since women were provided the unavoidable task of delivering children, nature, or God, must have provided them with the wherewithal to deal with the associated pain.

Women’s reward for actually being the stronger sex (regarding pain) was to be continually provided with less pain relief than men might receive in similar circumstances.  Bourke cites studies that indicate this pattern has persisted into the current century.

Animals and, incredibly, infants suffered due to constantly changing biases and assumptions.  As noted in the beginning, physicians cannot measure pain, they can only guess at it based on claims or actions provided by the patient.  Both animals and newborn infants are unable to provide the appropriate signals that convey what a physician is capable of recognizing as true pain.  Therefore, they were left to the mercy of guesses and assumptions.

“Indeed, one of the main reasons why some scientists regarded it as legitimate to vivisect animals was because they did not behave as if they felt pain to such an extent as the human species’, as one commentator put it in the 1920s.”

Eventually, as animals were used more and more as surrogates for humans in the testing of medicines and medical procedures, it became necessary to learn more about animal pain, and in fact to quantify it.

The history of infants and pain is discussed in Infants, Fetuses, and the Complicated Issue of Pain.  Towards the end of the nineteenth century physicians began to assume that infants felt little if any pain.  Prior to that, they had assumed that infants were extremely sensitive to pain.  The net result was that in a period when anesthetics and analgesics were readily available, infants were not likely to receive much consideration when it came to pain.

“The author of Modern surgical Technique (1938), for instance, claimed that ‘often no anesthetic is required’, when operating on young infants: indeed ‘a sucker consisting of a sponge dipped in some sugar water will often suffice to calm the baby’.”

Around 1980, the consensus changed again and concluded that infants did in fact experience pain.  However, that does not mean that infants were destined to be coddled.

“A study in 1995 revealed that pre-term infants were subjected to an average of sixty-one painful procedures while in the neonatal intensive care unit.  In another study, published in 1987, neonates were subjected to about three invasive procedures an hour.  In addition, neonates were actually less likely to be given analgesia than older children.”

As we have noted, there were classes of people who systematically received less pain care than others: infants, women, minorities, and poor people.  It is important to realize that this discrimination existed within a system whereby inadequate levels of pain relief were being delivered to all.  The medical community has recognized this as a problem and has even created a term to describe the under treatment of pain: oligoanalgesia.

Bourke suggests several reasons why there might be a reluctance to administer sufficient pain treatment.  One explanation was lack of training.  Pain management receives little attention in the education of most doctors and nurses.  Another is the development in the medical community of a culture which declares its goal to be pain reduction, not pain elimination.  If the patient is tolerating pain then what is the problem?  A third explanation rests on a fear of overmedicating patients.  Many pain suppressors are potentially addictive and both patient and physician can suffer if addiction should develop.

This latter issue puts physicians in a difficult situation.  At the same time they are being told to be careful and not under medicate, and be careful and not over medicate.  Dannielle Ofri provided an excellent example of how difficult this could be in practice in a New York Times article: The Pain Medication Conundrum.

It seems that after centuries of medical advancement, doctors and nurses are still reduced to listening to patient complaints, evaluating their expressions of pain, and guessing as to what the level of pain might actually be and how they should respond.


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