NY TIMES, Articles on Women's Pain - 6/23/02

[Guest guest]

thanks for passing those articles on

i found them very interesting.

stacey

[Guest guest]

NEW YORK TIMES SPECIAL SECTION ON WOMEN'S HEALTH

Contained the following four articles on pain.

June 23, 2002

Hurting More, Helped Less?

By NANCY WARTIK

DR. CHRISTINE MIASKOWSKI still remembers the patient, a woman in her 50's, who

visited the pain management service at the Albert Einstein College of Medicine

in the Bronx, where Dr. Miaskowski worked in the 1980's. The woman was suffering

from a burning, prickling pain - punctuated by shooting spasms - of a kind that

tends to strike after breast cancer surgery, when the incision has healed and

patients look outwardly fine.

" This woman literally had a frozen shoulder because of the pain; she couldn't

move her arm, " Dr. Miaskowski says. " Her surgeon kept telling her, `It will get

better, it will get better.'

" It got worse. She went from physician to physician, and no one believed her

pain, or offered her any painkillers. She'd saved the medications she'd gotten,

mostly anti-anxiety drugs like Valium and she'd decided if we could not help

her, she was going to commit suicide. "

Pain relievers, including morphine, and physical therapy brought the woman

relief, but her story lingered with Dr. Miaskowski, who is the chairwoman of the

physiological nursing department at the University of California, San Francisco,

and president of the American Pain Society. She is currently applying for a

grant from the National Institutes of Health to study, among other things, this

form of pain. But even 20 years later, Dr. Miaskowski says: " The majority of

breast cancer surgeons will tell you this syndrome doesn't exist, doesn't occur.

One surgeon I asked told me, `You can study it in my patients but it's not

actually a problem.' "

For Dr. Miaskowski, as for some of her colleagues, such remarks reflect a

well-entrenched, little-recognized inequity in the world of pain management.

Those who work in this world have long known - and studies solidly back them up

- that health care providers in general do a poor job of treating pain of all

kinds: the throbbing ache that follows surgery; the persistent pain of chronic

disorders like backache or migraine; the bone-deep torment that attends

life-threatening diseases like cancer.

But more recently, a small group in the medical community has begun to ask if

women, even more so than men, are at risk of having their pain ignored. Last

fall, a report in The Journal of Law, Medicine and Ethics titled " The Girl Who

Cried Pain: A Bias Against Women in the Treatment of Pain, " concluded that

" women's pain reports are taken less seriously than men's, and women receive

less aggressive treatment than men for their pain. " It added that women were

" more likely to have their pain reports discounted as 'emotional' or

'psychogenic' and, therefore, 'not real.' "

The conclusions take on extra weight because they dovetail with other data

gathered in recent years, suggesting that when it comes to pain, women don't

start on a level playing field. A wide range of studies has shown that women, on

average, tend to feel pain (in particular, acute pain, the sort caused by direct

injury) more intensely than men do, while they are also more vulnerable to a

variety of painful conditions that include migraines, arthritis, the muscle

disorder known as fibromyalgia, temporomandibular disorders (a type of jaw

problem), pelvic pain and abdominal pain of various kinds. (Back pain, from

which men and women suffer at equal rates, seems to be one of the few exceptions

to the rule.)

" Women are at higher risk than men for experiencing almost every type of pain

that's been studied, " says Dr. LeResche, an epidemiologist at the

University of Washington in Seattle. " They're more likely to have multiple pain

conditions. They're more likely to be disabled by the pain than men are. One

possible interpretation for why we're seeing this is simply because it's more

culturally acceptable for women to talk about pain. But there's lab work and

animal work that leads me to believe that's not the only thing going on. "

Exactly what is going on is a subject of growing interest in pain medicine; in

the last decade or so, sex differences have become a prime topic in the field.

Some of the more clear-cut data comes from laboratory experiments of how much

pain women, versus men, can tolerate. " So many studies have been done now and

the story stays the same, " says Roger B. Fillingim, a psychologist at the

University of Florida. " Women in general have a lower threshold and lower pain

tolerance than men. It's a moderate difference but a real effect. " Other work,

with both animals and humans, is pinpointing genetic, hormonal, biochemical and

anatomical factors that contribute to sex differences in pain.

But even as they explore the nuts and bolts of the nervous system, many

researchers emphasize that pain is also a highly subjective, psychologically

influenced experience. " Pain is a perception, it's a product of the brain, " says

Dr. Allan I. Basbaum, chairman of the department of anatomy at the University of

California, San Francisco. " It's generated by transmission of an injury message

but also by what that message means, how it's interpreted. Once the message gets

to the brain, it may or may not lead to pain perception. If you imagine looking

at a Mondrian, there are a few bars and stripes, yellow, black, a little red.

But it can bring tears to some peoples' eyes, for others it does nothing. Same

stimulus, different experience. That's how pain is processed. "

THIS perspective, some researchers think, helps explain why the sexes hurt

differently -- and perhaps why women hurt more.

" The overriding thing in someone who ends up in chronic pain are the individual

differences, " says Dr. J. Berkley, a neuroscientist at Florida State

University. " Someone's past history, how they've come to be in the situation

they're in, the environment they live in. Insofar as men and women bring

different backgrounds and experiences to pain, that's a big part of where sex

differences are going to play out. "

Women are more prone to notice when others are in pain, Dr. Berkley says.

" They're raised with a lot of attention given to nurturing, empathy, social

interactions, " she says. " They're more attuned to what's harmful than men are.

They're better pain experts. And so they end up having more pain than men. " That

doesn't mean, Dr. Berkley and other specialists in the field stress, that women

are to blame for their own pain, or that chronic pain with no obvious physical

cause is " all in someone's head. " Rather, it suggests the pain process may be

initiated in ways scientists still don't understand, by things less palpable

than losing a filling or stubbing a toe.

Given women's greater susceptibility, it makes sense to treat their pain as

aggressively as men's -- if not more so. But that is not necessarily what

happens when women turn to the health care system, according to the authors of

the report in The Journal of Law, Medicine and Ethics, Diane Hoffman, the

director of the law and health care program at the University of land School

of Law, and Dr. Anita Tarzian, a research associate in that program. A 1994

study at the University of Connecticut that looked at medical records of

appendectomy patients in three hospitals showed that women received

significantly lower doses of painkillers immediately after surgery than men did.

A 1996 study of more than 350 patients with AIDS-related pain, done at the

Memorial Sloan-Kettering Cancer Center in New York, found that being female

doubled the risk of being undermedicated, though women's pain levels were

slightly higher than men's. " Gender turned out to be the most powerful predictor

of undertreatment and that wasn't what you'd think, " says Dr. S.

Breitbart, chief of psychiatry at Sloan-Kettering. " With IV drug users in the

study, you'd think that would be the most powerful factor preventing someone

from giving a patient opioid analgesics. "

Findings are similar with cancer patients. Women had 1.5 times the risk men did

of getting inadequate doses of painkillers, according to a 1994 study in The New

England Journal of Medicine, which compared treatment of more than 1,300 male

and female cancer outpatients in 54 medical centers. Just last year, a

still-unpublished study at the University of California, San Francisco, looked

at painkillers prescribed to male and female bone cancer patients. Precise

figures from the study are not available yet, but a version posted on the

Internet shows there are still sharp inequities in how men and women are

medicated for equal levels of discomfort.

None of these studies looked at why women got short shrift. But clues come from

other research into how health care providers think about and interact with

female patients. Women, for example, tend to be more expressive and emotional

than men in describing their symptoms, and that may work against them. " The

stereotype is that women exaggerate their pain complaints, " Dr. Breitbart says.

" That they're quote, unquote hysterical. When they say their pain is an eight,

it's really a six. " And yet, he suggests, women, if anything, may try harder

than men to cooperate in their own care. Results from one study he did, Dr.

Breitbart says, showed " women are much more sensitive to being perceived as

problematic patients. " It's a finding, he says, " that would seem to suggest

they're not exaggerating their pain complaints, they're doing the opposite. "

But confronted with the same symptoms in a man and a woman, doctors lean toward

attributing a man's problems to physical illness or pain, a woman's to

psychological issues.

" I've been in the exam room with quite a few physicians and patients, " says Dr.

Judith Paice, a pain specialist who holds a nursing Ph.D. and is in the division

of hematology and oncology at Northwestern Memorial Hospital in Chicago. " I

often end up serving as a coach for patients. I've observed so many times that a

woman will feel stressed and start to cry. I can just see and feel the

physician's response. They'll articulate afterward, 'Oh, this is a patient with

emotional issues, it's probably not pain.' It's easy to disallow the physical

pain, once someone starts crying. "

One patient with facial pain that is disrupting her life starts to sob as soon

as she comes in to see the doctor, Dr. Paice says. " I coach her so that when she

sees the physician, she uses every resource she can muster not to cry, " she

said.

Women may also be badly served by conventional wisdom that says they handle

discomfort better than men. " It's tied a lot to their bearing children, " Ms.

Hoffmann says. " There's this notion men could never go through that. People will

say, 'If men had to bear children, we'd have far fewer children.' " And that

sometimes translates to a belief that women are better able to cope with pain,

she said.

Not everyone in pain medicine accepts the idea that women are more undertreated

for pain. They cite studies that have not found evidence of such bias and argue

that the definitive research remains to be done. " My own interest in this area

came out of children's pain, " says Dr. Anita Unruh, an occupational therapist at

Dalhousie University in Halifax, Nova Scotia, who has looked extensively at

treatment bias. " We had to do numerous surveys to prove pain in children was

undertreated. You can't just take a couple of studies and say, 'Therefore this

is true.' "

THAT'S not to say, Dr. Unruh stresses, that women in pain aren't underserved.

" There's potential for a big problem, " she says, but now, " we need to show in a

number of different settings if this is pervasive. "

But medical providers, Dr. Unruh says, need not sit back and wait for the data

to come in: " If you're in health care you should be asking yourself, 'What

biases do I hold personally about how men and women respond to pain? Does it

influence my judgment?' " When providers become aware of stereotypes they hold

about women, Dr. Unruh adds, men benefit, too: " If women are more likely to get

psychological explanations for their pain, one might think that's primarily a

problem for women, " she says. " But all pain is a psychological experience. With

women we pay attention to the emotional component. With men, we may respond to

that not nearly as well, if at all. "

Whatever future research may show about undertreatment of women in pain,

everyone in the field agrees it's part of a larger problem that the medical

community desperately needs to address.

" Everyone is undertreated, " says Dr. Breitbart of Sloan-Kettering.

" Patients with more severe pain -- I think it's hard for clinicians to identify

with. Most clinicians haven't had, and can't imagine, pain of 9 or 10 on a scale

of 10, that keeps on being a 9 or 10. "

Dr. Miaskowski, the president of the American Pain Association, agrees.

" Undertreatment of pain is the meta problem, " she says. " All kinds of pain are

just not well treated. " And, she adds, " the gender bias adds insult to injury. "

June 23, 2002

Calling In the Pain Team, Specialists in Suffering

By SANDEEP JAUHAR, M.D.

ONE winter morning when I was a second-year medical resident, a nurse paged me

during rounds. A patient with leukemia that had transformed into what was called

blast crisis, was in her room, screaming. She had been on a morphine drip to

control the severe pain in her bones - her bone marrow was churning out leukemia

cells at a prodigious rate - but her IV had fallen out. Could I come quickly and

put in another one?

When I got there she was writhing, oblivious to my presence. A bag of morphine

liquid hung uselessly from a metal pole near her bed. She said her legs felt as

if they were going to explode. As a resident, I had been taught the importance

of treating cancer pain aggressively, but until then it had just been a concept.

I told the nurse to give the patient an intramuscular morphine injection, but

she said she already had, twice, with no effect. I grabbed an IV and jabbed it

into the woman's arm, but because it was so swollen from cancer and

chemotherapy, I couldn't find a vein. I tried repeatedly, in her arms and feet,

desperately trying to draw back a red blush, but with no luck. Her shrieks were

becoming more piercing as the morphine was running out in her body.

" Page the pain team, " I told the nurse.

The team arrived and immediately gave the patient a shot of a very potent

narcotic, which calmed her down. Then they put in an IV and started a morphine

drip that she could adjust for her own comfort. When I visited her a few hours

later, she was sitting up in bed, watching television.

Of all symptoms, pain is probably the most terrifying, to patients and to

doctors, but few doctors are trained to deal with it. We tend to view pain as

something to be palliated on the way to a greater goal - fix the hip, treat the

leukemia - not an end in itself, which undermines our effectiveness in treating

it. Not so pain specialists, a special breed of doctors, usually

anesthesiologists, who see pain not as incidental to disease, but as a disease

in its own right.

At Bellevue Hospital Center in New York, where I now work, the pain management

program began in late 1997 with two anesthesiologists, a pain management fellow,

a clinical psychologist and a nurse specialist. Dr. Bruce Levin, a current

fellow, said the reason for forming the team was simple: to make sure that

people in pain were not forgotten. " The medical establishment really was not

meeting the minimal requirements of people with pain, " he said, expressing a

view shared by the Joint Commission on the Accreditation of Health Care

Organizations, a federal agency studying the problem. Today, most major

hospitals have a pain management team.

One morning not long ago, I went to the pain management clinic to watch these

doctors at work. The clinic takes place in several rooms along a remote corridor

lined with blue chairs and bright yellow doors. Patients were sitting quietly in

the hallway, waiting to be seen. I met with Dr. Levin, who took me in to see his

first patient.

Her name was Ragin, and she was in a wheelchair, wearing jeans, a

matching jacket and a black bandanna on her head. " How are you doing? " Dr. Levin

asked her cheerfully. Ms. Ragin smiled weakly. " I'm still having pain all the

time, " she replied.

She was born 23 years ago with a congenital disease that causes webs of blood

vessels, or arteriovenous malformations, to form in her left leg. When she stood

up, I noticed it was three times the size of her right leg. She frequently

develops blood clots in the leg - a mesh filter had been placed in a large vein

in her abdomen to catch them before they lodged in her lungs - and infections

that cause chronic, severe pain for which she has been hospitalized more than 30

times.

Dr. Levin asked her to describe the pain. It was constant and throbbing and

localized to her left ankle, calf, thigh and buttock. It started when she was a

child. Almost any kind of pressure, including sitting, set it off, and nothing,

not even four-times-daily doses of Percocet and OxyContin, relieved it. " On a

scale from 1 to 10, " she volunteered, with a sophistication accrued from a

lifetime of talking with doctors, " it's a 10. "

She had tried nearly every pain medication - Tylenol, Motrin, Naprosyn,

Celebrex, morphine, fentanyl, Neurontin, codeine (which gave her welts), Elavil

- without relief. She had experimented with various alternative treatments,

including massage therapy, with little success.

Dr. Levin told her the first step to a pain-free state was to stop taking pain

medications that did not work. " People like taking pills, " he said, " but taking

pills several times a day for chronic pain doesn't make much sense. " He wanted

to put her on a drug that she would have to take only once or twice a day.

He decided on methadone, a long-acting narcotic with effects similar to

OxyContin. Though more commonly used for treating heroin withdrawal, methadone

is also a very effective analgesic. Dr. Levin said it was particularly effective

for neuropathic pain, in which nerves that constantly transmit pain become

entrained, through cellular changes, to transmit pain. This, he suspected, was a

large part of Ms. Ragin's problem.

IT would take a week for the methadone to reach its peak effect, he told her;

she shouldn't become discouraged or stop taking the drug if it didn't work

immediately. But methadone, he said, was only part of the solution. The primary

goal was to treat the causes of her pain through blood thinning to prevent

clots, antibiotics for infections and physical rehabilitation to prevent blood

pooling and improve conditioning. The pain management team, which currently

includes several anesthesiologists, a pain management fellow, nurse specialist,

social worker and clinical psychologist, also receives recommendations from

physiatrists, neurologists, orthopedists, neurosurgeons and internists.

After Ms. Ragin left, Dr. Levin said that, unlike acute pain, which has a

purpose, as when you touch a stove, " chronic pain is not adaptive. " Ninety

percent of its victims, he added, suffer from psychological problems, including

personality disorders and major depression.

" We can't take away pain altogether, but we can modulate it, " he said. " We want

to restore patients to a life where they can feel productive. We kind of see

ourselves as the last barrier between the patient and a life of agony. "

June 23, 2002

Stroked, Poked and Hypnotized in the Search for Relief

By DONNA WILKINSON

NOT long ago, the idea of treating pain with acupuncture or hypnosis would have

raised many an eyebrow within the medical mainstream. But now a growing number

of hospitals are offering patients alternative or complementary therapies,

combined with traditional medicine.

A big reason for the trend is consumer demand. A 1997 Harvard study reported

that Americans made 629 million visits to alternative practitioners compared

with 386 million visits to primary care doctors, spending $27 billion (a good

part of it out of pocket) on alternative treatments.

Attitudes are also changing. Though nontraditional medicine has many skeptics,

some techniques have gained credence among pain specialists. Dr. Handel,

a clinician at the Pain and Palliative Medicine Service at the National

Institutes of Health in Bethesda, Md., uses biofeedback, hypnosis, acupuncture

and other techniques to aid patients on drug protocols.

" If what you do shows efficacy - even at a place like the N.I.H., which everyone

would think would be conservative - doctors will embrace it, " Dr. Handel said.

Pain specialists emphasize that treatments are used as complements to, not

substitutes for, traditional medicine. In fact, they prefer to call them just

that: " complementary " or " integrative, " rather than " alternative. " " Alternative

therapies, particularly in cancer, are offered as alternatives to mainstream

care, and complementary therapies are used along with mainstream care, " said Dr.

Barrie Cassileth, the chief of the Integrative Medicine Service at Memorial

Sloan-Kettering Cancer Center in Manhattan, which offers acupuncture and guided

imagery, among other therapies.

Proponents say complementary techniques, particularly mind-body therapies, offer

many benefits: they are not invasive and have no side-effects. And they tap into

the healing power of the mind.

" We know from a significant body of research going back many years that we can

use our minds to control pain, " said Dr. S. Gordon, the chief of the White

House Commission on Complementary and Alternative Medicine Policy, which did a

study on nontraditional medicine.

Complementary experts say some therapies promote relaxation, which can be

beneficial in healing. " The kinds of pain management techniques we offer

frequently reduce the amount of pain medication that patients need to take, " Dr.

Cassileth said.

The fact that patients can use many techniques on their own can give them a

sense of control. " One of the problems of pain is that you feel helpless and

dependent on doctors and medication, " Dr. Gordon said. " When people understand

that they can do something to make a difference, it's the beginning of making a

difference. "

Here are some complementary techniques being offered in hospitals:

HYPNOSIS A mind-body technique in which the patient becomes deeply relaxed; in

this state the power of suggestion is used to ease symptoms of pain.

Applications: acute and chronic pain, cancer pain, nausea, asthma, irritable

bowel syndrome. " The key component in hypnosis seems to be the ability to focus

and separate from your environment and self, " Dr. Handel said. " In that state,

you can attain significant psycho-physiologic changes. "

BIOFEEDBACK A mind-body technique that uses sensors to measure physiological

functions like muscle tension or gastrointestinal activity; as patients watch

the " feedback " on a monitor, they become aware of how their bodies respond and

learn how to control that response. Applications: headaches, chronic pain,

irritable bowel syndrome. " You learn how to make a change even when you're not

in front of the machine, " Dr. Handel said.

ACUPUNCTURE According to this ancient Chinese technique, each person has an

energy force called Qi (pronounced chee), which travels through channels in the

body. Pain or illness results when channels become blocked. To restore flow,

fine needles are inserted at specific points on the skin's surface.

Applications: postoperative and chemotherapy nausea, dental pain, headaches,

myofascial pain, osteoarthritis, back pain, carpal tunnel syndrome. A 1997

N.I.H. study suggests that acupuncture releases pain-relieving endorphins.

MASSAGE THERAPY Complementary care uses variations of touch, from gentle

stroking to deep tissue manipulation. The most common technique is Swedish

massage, in which the muscles are stroked or kneaded with varying amounts of

pressure. Applications: muscle pain, acute and chronic pain. " Massage in general

creates a state of relaxation, which may help to relieve many types of pain, "

Dr. Gordon said.

RELAXATION THERAPY Complementary techniques include guided imagery, a form of

self-hypnosis in which the patient visualizes positive images to ease pain;

progressive muscle relaxation, in which the patient tenses, holds and then

releases muscle groups; and meditation, in which the patient tries to clear the

mind by focusing on a word or sound. Applications: chronic pain, cancer-related

pain and nausea. " You can use your mind to affect your experience of pain in a

very significant way, " Dr. Gordon said.

June 23, 2002

Using More Than Medicine

Dr. Michel Y. Dubois, Anesthesiologist and director of the New York University

Pain Management Center and professor of clinical anesthesiology at New York

University School of Medicine.

Q. What are the questions you hear most often from women?

A. There are major questions that any pain patient will ask before you initiate

treatment. Doctor, you are treating my pain, but what about the disease that

creates the pain? Is it going to conceal the disease, which is going to

progress, and is it therefore a bad thing to do?

Then you have to tell them that pain by itself is a disease when it lasts too

long and has adverse reactions on the body. It has to be treated like anything

else.

If you're in pain, you don't feel well, you cannot function physically very

well. That's going to have a significant impact eventually on your mental

functioning. Very quickly you become anxious. You are going to avoid what you

think is creating the pain, and anybody put into this ordeal is going to feel

low.

Typically, acute pain is good. When you burn yourself, a defense mechanism makes

you remove your hand from the hot pot. However, chronic pain may exist without

any evidence of anything that may create the pain.

At the same time, it creates more symptoms, which handicap the patient. Stress

creates headaches, but the headache itself is going to create stress. It's a

vicious circle.

Women are more sensitive to pain on an experiential basis, but also can express

much better than men what they are feeling. The way they describe pain usually

is more detailed and factual. They classically admit they endure pain less than

men. Men have as a rule a more macho attitude, trying to conceal their symptoms

and endure pain without treatment. Women don't have this silly attitude.

[Guest guest]

Meg,

Thanks for the great articles.

Take care,

Matija