I Don’t Feel Your Pain
It’s also clear that not everyone’s pain receives equal attention. A robust and growing body of evidence suggests that the groups who suffer the most also receive less effective treatment for that suffering. Pain is “a huge public health problem,” said Carmen Green, a pain specialist at the University of Michigan who has researched disparities in care. But because a disproportionate number of its victims belong to traditionally disempowered groups, “it’s been a silent epidemic.”
Pain, it appears, is distributed with a kind of inequality distinct from the other inequalities in American health care—one with its own contours, its own logic, and its own disturbing history. And because chronic pain, in particular, often lacks a discrete location in the body, it leaves both diagnosis and treatment almost completely up to a doctor’s own judgment, which brings in a range of subtle prejudices that psychologists and other scholars are only beginning to understand. “Chronic pain greatly exacerbates already existing inequality within society,” said Joanna Bourke, an historian at Birkbeck College in London, whose new book, “The Story of Pain: From Prayer to Painkillers,” makes the intriguing argument that both experiences of and responses to pain have evolved since the 18th century.
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It sounds like the kind of paternalism that would be easy for modern doctors to shed, but the evidence shows that such inequalities persist. “I don’t think things have changed as much as we tell ourselves,” said Bourke. Women still receive less effective pain treatments, even though they are significantly likelier than men to experience pain. A 2007 study of heart-surgery patients found that men were likelier to be given pain medication, and women were likelier to be given sedatives. An earlier study found women with metastatic breast cancer were less likely to receive “optimal” pain treatment than men with prostate cancer. With chronic pain in particular, convincing doctors to take pain seriously can be difficult. “With childbirth, we don’t say to the woman, ‘Oh, you’re making up the pain, stop being such a wuss,’” said Judy Foreman, a former health reporter for the Globe and the author of the recent book “A Nation in Pain: Healing Our Biggest Health Problem.” “With chronic pain, the pain can be way worse than childbirth, and you don’t know if it’s going to go away, and people don’t believe you.”
The evidence for undertreatment of pain in minority patients is even more striking. Black pain patients are less likely than white patients to receive pain medication; when they do receive it, they receive less. Studies of post-operative care have repeatedly found white patients receiving higher doses of opioids than minorities. The same is true for chronic pain. A 2005 study found that minorities are also less likely to be able to get their prescriptions for analgesics filled at their local pharmacies. A more recent study even found that Hispanic children received 30 percent less opioid analgesic than white children for their tonsillectomies.
Potential explanations for these disparities include conscious and unconscious bias, and doctors’ assumptions about minorities’ ability to pay for medication. But a separate strain of research suggests that doctors may not even recognize the full extent of that pain in the first place. In experiments published in a 2012 study, Sophie Trawalter, an associate professor of public policy and psychology at the University of Virginia, asked participants to think about how much pain they would experience in certain scenarios, and then showed them pictures of either a black person or a white person and asked how much pain they would expect that person to feel.
Bourke’s book, and the emerging research on pain, suggest that pain mirrors existing prejudices in society in ways that medicine is only beginning to grapple with. There’s no quick route to solving the problem of pain care, and its thorniness suggests that doctors must first face the steep challenge of understanding both the history and psychology of a problem that medicine, often, would rather not talk about.
http://www.bostonglobe.com/ideas/2014/06/14/don-feel-your-pain/cIrKD5czM0pgZQv7PgCmxI/story.html
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