“Pain is a highly complex phenomenon that involves biological, psychological and social variables.” (Carterett, 2010, p.1) An increasing cultural diversity in our country means that health care providers must offer culturally relevant treatment and care on a daily basis. Although race, ethnicity and culture or often used interchangeably, they actually represent very different concepts.
- Race as a construct identifies people according to their ancestry, a genetic heritage.
- Ethnicity refers not only to biological and physical characteristics but also include culture and behavior.
- Culture can be defined as a coherent set of values, beliefs and concepts, or a set of learned attitudes or ideals that mold the behavior of a population or particular society.
A person’s culture, is the major influence on the way an individual perceives, experiences, and conveys the pain experience (Peacock and Patel, 2008). In a particular cultural group, it is often their ingrained expectations and acceptance of pain as a normal versus abnormal life experience that determines how they view their clinical situation and how to resolve it. In these same populations, beliefs regarding the nature of pain, resistance to treatment, reluctance to comply to treatment, inability to accept treatment outcomes, and acceptance of disability should not be allowed to become an obstacle to treatment (Campbell and Edwards, 2012).
To add further understanding to pain management in the many varied ethnic and cultural groups in the United States one should explore the concept of acculturation. Acculturation refers to the idea that, over time, a person that migrates from their country of origin, takes on the beliefs, values, culture and lifestyle of the country they are immigrating to. The pain experience of culturally-influenced people can be divides into two groups, Stoic and Emotive. Stoic patients refrain from facial expression, tend to withdraw and emit minimal body language. Emotive patients can be extremely verbal, exhibit facial frowns, are restless, and expect others to respond to their pain as validation. In general, populations arriving to the United States from Northern Europe and those with Asian ancestry are known to be stoic. Those coming from Mediterranean ancestry, the Middle East, and of Hispanic ancestry are more emotive (Carteret, 2010).
Stoicism is seen in the following groups:
- Asian cultures exemplify strong cultural values and perfect self conduct, living life in a dignified manner. Tradition fosters harmony in personal interactions and respect for those of higher education and occupation, older age, and male sex. Suggesting sadness, pain or any negative aspect of self would not occur. A person with higher status, health care professional, would not be questioned or “bothered” with complaints of discomfort. Asian cultures are shown to have perceived higher pain tolerance than their western counterpart. Also, Eastern cultures often have strong beliefs in karma of fate or a higher “spirit”. Acceptance of pain is important to show faith in a higher power, offer this pain to their… God, Spirit, Allah, or in buddhists, acceptance of the pain leads to a spiritual growth. Stoicism is strongly reflected as a mirror of this philosophy as it is often not affected by acculturation (Carteret, 2010).
Emotive reactions to pain include:
- The Hispanic population that has immigrated to the United States, also do not often seek medical treatment for their care but for different reasons. Hispanic populations express a belief that pain should be overcome without medications. They have a “concern” about strong medications and will often use alternative therapies such as herbs, massage, compresses. There is a belief that there needs to be a balance in the four humours (blood, phlegm, black bile, yellow bile) and the use of hot or cold compresses with return to balance. Obstacles to care include language, lack of insurance (36%), feeling of need to uphold social roles (working with pain) and a religious belief that pain is a disharmony that is a punishment from God.
Health care professionals must have a full understanding of the biological, psychological and cultural differences of their patients and the impact of the same on access to health care and proper pain management.
The Opioid crisis in the United States today is a true epidemic. Included in the same is the extent of opioid use, abuse, addiction, and tragic deaths by caused opioid overdose. In 2014, 28,647 deaths were caused by opioid overdose….one every 18 minutes!!. This is 68% of overdose deaths. Opioids enter the patient population in several ways. Patients receive prescriptions for pain relief from their physicians for post-op pain relief, injuries or chronic pain. Other persons obtain opioids for non-medical use. These or persons how have become addicted to the affects of the drug. 50.5% of persons obtained these drugs by diversion from friends and family. Either by stealing them from their home, medicine cabinet, of gifted from that family of friend, 22.1% received them from a physician, and only 4% got them “off the street” (Mira, 2016).
How did we get here?? In 2001, Congress launched a Decade of Pain Control and Research and then The Joint Commission (TJC), introduced its Standards of Pain Management, declaring PAIN as the fifth vital sign. What followed was the largest increase in prescriptions written for opioid pain killers ever. By 2012, 259 million prescriptions were written and between 2006-2015, spending on these drugs increased by 165% (Mira, 2016).
What can we do? As nurses in general, one needs to assess their patients pain, asking careful questions as to intensity, duration, type of pain. Review physician’s orders for appropriate type of medication, dosage and number of pills ordered. Follow up for relief of pain is necessary. Nurses with prescriptive licenses and Advance Practice Nurses have the added responsibility to prescribe according to proper guidelines, using multimodal pain management strategies, lower dose opioids, regional or local infiltration techniques with the concept that pain is a symptom, not a fifth vital sign!! ( Mira, 2016).
From this day forward, members of the heath care team must participate in education, research and advocacy for all patients remembering that pain management for post-operative patients is different than for injury patients than is different for chronic pain patients that is different for cancer patients and that is different for patients with addictive behaviors.
Campbell, C.M., and Edwards, R.R., Ethnic Differences in pain and pain management, Pain Manage, 2012 2(3): 219-230.
Carteret, M., Cultural Aspects of Pain Management, 2010. www.dimensionsofculture.com.
Mira, T., What Anesthesia Providers should know about the Opioid Crisis, 2016. www.anesthesiallc.com.
Peacock, S, and Patel, S., Cultural Influences on Plan. 2008 1(2): 6-9.