The Influence of Race and Gender on Pain Management: A Systematic Literature Review

Widening Racial Disparities in the U.S. Overdose Epidemic

INTRODUCTION

More Americans died in 2021 from drug overdose than from vehicle accidents and firearms combined. Unlike earlier phases, the current epidemic is marked by its disproportionate impact on communities of color. This report investigates regional and substance-specific variations in racial disparities to generate possible insights into the various forces shaping these trends.

METHODS

This report used data from 1999 to 2022 on opioid-related overdose deaths from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database. Racial disparities at the national, state, and substance levels were compared to describe heterogeneities in disparities trends. Data were analyzed in 2024.

RESULTS

Overall age-adjusted overdose mortality in the U.S. increased from 6.2 to 32.7 deaths per 100,000 between 1999 and 2022. In this same time period, mortality has increased most rapidly in Black, Native, and Hispanic/Latino Americans at 249.3%, 166.3%, and 171.8%, respectively. Disparities with White populations vary regionally. The upper Midwest (i.e., Minnesota, Wisconsin) and Washington state rank highest in excessive Native overdose death; the upper Midwest and Washington, DC rank highest as Black overdose deaths. In terms of substances, deaths from polyuse of methamphetamines and opioids have been highest among Native Americans over time, whereas deaths from cocaine and opioids disproportionately impact Black Americans.

CONCLUSIONS

The opioid epidemic continues to expand, with particularly rapid acceleration in racially minoritized communities. The growing role of stimulants in opioid overdose deaths is a racialized phenomenon disproportionately impacting Black and Native Americans. Wide variation in state-level disparities suggest that structural racism impacts health in regionally specific ways, highlighting the need for regional solutions.

Documenting Race and Gender Biases in Pain Assessment and a Novel Intervention Designed to Reduce Biases

Disparities in pain care are well-documented such that women and people of color have their pain undertreated and underestimated compared to men and White people. One of the contributors of the undertreatment of pain for people of color and women may be the inaccurate assessment of pain. Understanding the pain assessment process is an important step in evaluating the magnitude of and intervening on pain disparities in care. In the current work, we focus on documenting intersectional race and gender biases in pain assessment and present the results of a novel intervention for reducing these biases. Across 3 studies (N = 532) and a mini meta-analysis using real videotaped people in pain as stimuli, we demonstrate that observers disproportionately underestimated women of color's pain compared to all other groups (men of color, White women, and White men). In study 3 (N = 232), we show that a novel intervention focused on behavioral skill building (ie, practice and immediate feedback) significantly reduced observers' pain assessment biases toward marginalized groups compared to all other types of trainings (raising awareness of societal biases, raising awareness of self-biases, and a control condition). While it is an open question as to how long this type of intervention lasts, behavioral skills building around assessing marginalized people's pain more accurately is a promising training tool for health care professionals. PERSPECTIVE: This article demonstrates the underestimation of pain among people of color and women. We also found support that a novel intervention reduced observers' pain assessment biases toward marginalized groups. This could be used in medical education or clinical care to reduce intersectional pain care disparities.

The causal impact of shared decision making on pain outcomes: Gender matters

This national US study determined the causal impact of shared decision making (SDM) on pain outcomes, including any overall pain and the subcategories of any acute pain and any chronic pain. We additionally examined whether the causal impact of SDM on overall pain is moderated by gender, race-ethnicity, clinician-patient racial-ethnic concordance, and clinician-patient gender concordance. We used national US data from the 2003-2017 Medical Expenditure Panel Survey, which were externally valid to the US national non-institutionalized population, employed a standard measure of shared decision making, and applied an internally-valid two-stage least squares approach that used the peer SDM behavior of similar clinicians as an instrument. The instrument was sufficiently strong and statistically uncorrelated with patient characteristics. We found a large impact of SDM on both female and male chronic pain outcomes, where the effect for females was approximately 50% larger than for males, with a 10 percentage point increase in SDM quality resulted fewer females experiencing chronic pain that interfered with everyday activities (-24.8 percentage points; 95% confidence interval [CI]: 43.3, -6.4) than males (-16.5 percentage points; 95% CI: 32.9, -1.0). We estimated that a 10 percentage point national increase in the SDM index would thus result in 10.1 million fewer females and 5.7 million fewer males in the US experiencing chronic pain that interfered with their daily activities. Policy implications include both increasing the quality of SDM for all patients and educating male patients on the value of SDM.

Delay of Gratification, Gender Role Attitudes, and Death Reflections Predict Death Anxiety

Previous work has established that gender, age, and self-control can predict Death Anxiety (DA), the distress that centers around thoughts of one's mortality. However, it has not been determined if DA is associated with Delay of Gratification (DG; a tendency to forgo immediate rewards to receive a more favorable outcome in the future), attitudes toward gender roles (as compared to gender identity itself), and Death Reflections (DR; positive goals that occur when contemplating death). To examine these relations, 131 adults (45% women; aged 23-67 years) completed questionnaires that assess these constructs. We found that greater DG, egalitarian gender role attitudes, and engagement with DR were all associated with reduced DA. Gender identity was not associated with any variable, including DA. Age correlated independently with DA, but not when included in the regression models. These results demonstrate that elements of self-regulation and prosocial attitudes may predict baseline DA.

Dynamic Changes in the Distribution of Hydrocodone and Oxycodone in Florida from 2006 to 2021

BACKGROUND

Florida, which led the country in terms of its number of opioid-prescribing physicians, was unique during the height of the opioid epidemic because of its lax prescribing laws and high number of unregulated pain clinics. Here, we address differences in the distribution rates of oxycodone and hydrocodone across Florida counties during the peak years of the opioid epidemic using an under-utilized database.

METHODS

The Washington Post and the United States Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS) databases provided longitudinal oxycodone and hydrocodone distribution data in grams per county (2006-2014) and state (2006-2021). Grams of oxycodone and hydrocodone were converted into morphine milligram equivalents (MMEs).

RESULTS

There was a steep increase in oxycodone from 2006 to 2010, with a subsequent decline. In 2010, the average MME per person across Florida was 729.4, a 120.6% increase from 2006. The three counties with the highest MMEs per person in 2010 were Hillsborough (2271.3), Hernando (1915.3), and Broward (1726.9), and they were significantly (p < 0.05) elevated relative to the average county.

CONCLUSIONS

The data demonstrated pronounced differences in opioid distribution, particularly oxycodone, between Florida counties during the height of the opioid epidemic. Legislative action taken between 2009 and 2011 aligns with the considerable decline in opioid distribution after 2010.

Comparing Methods for Identifying Post-Market Patient Preferences at the Point of Decision-Making: Insights from Patients with Chronic Pain Considering a Spinal Cord Stimulator Device

Purpose

To compare three methods for identifying patient preferences (MIPPs) at the point of decision-making: analysis of video-recorded patient-clinician encounters, post-encounter interviews, and post-encounter surveys.

Patients and Methods

For the decision of whether to use a spinal cord stimulator device (SCS), a video coding scheme, interview guide, and patient survey were iteratively developed with 30 SCS decision-making encounters in a tertiary academic medical center pain clinic. Burke's grammar of motives was used to classify the attributed source or justification for a potential preference for each preference block. To compare the MIPPs, 13 patients' encounters with their clinician were video recorded and subsequently analyzed by 4 coders using the final video coding scheme. Six of these patients were interviewed, and 7 surveyed, immediately following their encounters.

Results

For videos, an average of 66 (range 33-106) sets of utterances potentially indicating a patient preference (a preference block), surveys 33 (range 32-34), and interviews 25 (range 18-30) were identified. Thirty-eight unique themes (75 subthemes), each a preference topic, were identified from videos, surveys 19 themes (12 subthemes), and interviews 39 themes (54 subthemes). The proportion of preference blocks that were judged as expressing a preference that was clearly important to the patient or affected their decision was highest for interviews (72.8%), surveys (68.0%), and videos (27.0%). Videos mostly attributed preferences to the patient's situation (scene) (65%); interviews, the act of receiving or living with SCS (43%); surveys, the purpose of SCS (40%).

Conclusion

MIPPs vary in the type of preferences identified and the clarity of expressed preferences in their data sets. The choice of which MIPP to use depends on projects' goals and resources, recognizing that the choice of MIPP may affect which preferences are found.

Assessment of pain management among nurses using the knowledge and attitude survey regarding pain tool

BACKGROUND

The prevalence of pain among cancer patients vary in the cancer trajectory and nurses will encounter patients with cancers who may experience pain. Nurses routinely need to assess and manage pain to deliver quality care.

AIM AND METHOD

The study aims to understand the knowledge and attitudes of nurses towards pain management using the self-administered questionnaire-the Knowledge and Attitude Survey Regarding Pain (KASRP).

FINDINGS

Some 80 nurses participated in the study with an average overall KASRP score of 56%. Areas that were poorly answered are related to the knowledge about opioids, assessment of pain and management of pain in different scenarios. Factors like nurse-patient relationships and being unfamiliar with opioids may affect the knowledge and attitude of nurses towards pain management.

CONCLUSION

Curriculum on pain management needs to consider strategies to help nurses translate knowledge to bedside clinical teaching. It needs to include facts of pain management, and topics regarding self-awareness and clarifying misconceptions.

Gender Differences among Nurses in Managing Arterial Puncture-Related Pain: A Multicenter Cross-Sectional Study

There is evidence that healthcare can be executed differentially depending on the gender of patients, researchers, and clinicians. The aim was to analyze the possible existence of nursing gender differences in pain management produced by arterial puncture for blood gas analysis. A cross-sectional, multicenter study designed was conducted in Castilla-la Mancha (Spain). Variables of interest were collected from nurses in the public health system of a European region through a questionnaire. Data were collected for four months; the primary outcome was the use of any intervention to reduce pain and the explanatory variable was the nurse's gender. Bivariate analysis was carried out to assess associations between gender and pain-reducing interventions and a multivariate model was created with those factors that were relevant using logistic regression. A significantly higher proportion of men reported using some form of intervention (45% vs. 30%) and had more specific training (45.9% vs. 32.4%). The adjusted probability of using pain-reducing interventions by men was 71% higher than women. Thus, we found gender differences in the management of pain caused by arterial punctures performed by nurses as the main healthcare providers.

Gender-based differences in assessment and management of acute abdominal pain in the emergency department: A retrospective audit

BACKGROUND

Previous research has identified gender-based differences in acute pain management in the emergency department [ED]. The aim of this study was to compare pharmacological management of acute abdominal pain in the ED by gender.

METHODS

A retrospective chart audit was conducted at one private metropolitan ED including adult patients (18-80 years) who presented with acute abdominal pain in 2019. Exclusion criteria included: pregnancy, repeat presentation within the study period, pain-free at initial medical review or documented refusal of analgesia, and oligo-analgesia. Comparisons by gender included: (1) analgesia type and (2) time to analgesia. Bivariate analysis was undertaken using SPSS.

RESULTS

There were 192 participants: 61 (31.6 %) men and 131 (67.9 %) women. Men were more likely to get combined opioid and non-opioid medication as first line analgesia (men: 26.2 % n = 16; women: 14.5 % n = 19, p = .049). Median time from ED presentation to analgesia was 80 min for men (IQR: 60) versus 94 min for women (IQR: 58), (p = .119). Women (25.2 % n = 33) were more likely to receive their first analgesic after 90 min from ED presentation compared to men versus men (11.5 %, n = 7 p = .029). In addition, women waited longer before receiving second analgesia (women: 94, men: 30 min, p = .032).

CONCLUSION

Findings confirm there are differences in pharmacological management of acute abdominal pain in the ED. Larger studies are required to further explore differences observed in this study.

Race differences in pain and pain-related risk factors among former professional American-style football players

ABSTRACT

The burden of pain is unequal across demographic groups, with broad and persisting race differences in pain-related outcomes in the United States. Members of racial and ethnic minorities frequently report more pervasive and severe pain compared with those in the majority, with at least some disparity attributable to differences in socioeconomic status. Whether race disparities in pain-related health outcomes exist among former professional football players is unknown. We examined the association of race with pain outcomes among 3995 former professional American-style football players who self-identified as either Black or White. Black players reported more intense pain and higher levels of pain interference relative to White players, even after controlling for age, football history, comorbidities, and psychosocial factors. Race moderated associations between several biopsychosocial factors and pain; higher body mass index was associated with more pain among White but not among Black players. Fatigue and psychosocial factors were more strongly related to pain among Black players relative to White players. Collectively, the substantial social and economic advantages of working as a professional athlete did not seem to erase race-related disparities in pain. We highlight an increased burden of pain among elite Black professional football players and identify race-specific patterns of association between pain and biopsychosocial pain risk factors. These findings illuminate potential future targets of interventions that may serve to reduce persistent disparities in the experience and impact of pain.

Physical pain among Indigenous Peoples in Canada: a scoping review

PURPOSE

Pain is a multifaceted experience shaped by various factors including context of pain, previous life events, and ongoing ethnocultural circumstances. Moreover, the definition of pain is inconsistent across cultures. Western medicine views physical pain (e.g., associated with a bone fracture) and nonphysical mental pain (e.g., depression) as two distinct conditions. Indigenous perspectives are often more wholistic, encompassing mental, spiritual, emotional, and physical hurt. The subjective nature of pain invites ample opportunity for discrimination in both its assessment and management. As such, it is important to consider Indigenous perspectives of pain in research and clinical practice. To investigate which aspects of Indigenous pain knowledge are currently considered by Western research, we conducted a scoping review of the literature on pain in Indigenous Peoples of Canada.

SOURCE

In June 2021, we searched nine databases and downloaded 8,220 papers after removal of duplicates. Two independent reviewers screened abstracts and full-text articles.

PRINCIPLE FINDINGS

Seventy-seven papers were included in the analysis. Using grounded theory, five themes emerged: pain measures/scales (n = 7), interventions (n = 13), pharmaceuticals (n = 17), pain expression/experiences (n = 45), and pain conditions (n = 70).

CONCLUSION

This scoping review shows that there is a paucity of research on pain measurement in Indigenous Peoples of Canada. This finding is concerning in light of numerous studies reporting that Indigenous Peoples experience their pain as ignored, minimized, or disbelieved. Furthermore, a clear disconnect emerged between pain expression in Indigenous Peoples and assessment in medical professionals. We hope that this scoping review will serve to translate current knowledge to other non-Indigenous academics and to initiate meaningful collaboration with Indigenous partners. Future research led by Indigenous academics and community partners is critically needed to better address pain needs in Canada.

Assessing the Relationship Between Health Information Technology Use and Self-Rated Health Among Adults with Chronic Low Back Pain in the United States

OBJECTIVE

To assess the use of health information technology (HIT) among adults with chronic low back pain (CLBP) in the United States and to evaluate the relationship between HIT use and self-rated health.

METHODS

The independent variable was the use of the internet to (1) fill prescriptions, (2) communicate with a healthcare provider, (3) look up health information, and (4) schedule a medical appointment. Respondents rated their health in the last 12 months as worse, about the same, or better. A Chi-square analysis was used to assess the use of HIT among those with CLBP; a logistic regression was used to determine predictors of HIT use; and an ordinal logistic regression was used to assess the relationship between HIT and self-rated health.

RESULTS

As compared to those without CLBP, those with CLBP are more likely to use the internet to look up health information (58.9 vs. 53.8%, p-value<.001), refill prescriptions (13.9% vs. 10.5%, p-value<.001), and communicate with a healthcare provider (19.8% vs.15.3%, p-value<.001). Being employed and having a higher level of education were positive predictors of HIT use. As compared to other uses of the internet, using the internet to communicate with a healthcare provider was associated with higher odds of rating health as better compared to worse or about the same within the last 12 months.

CONCLUSION

Among adults with CLBP, a more affluent social status is associated with the use of HIT. Also, HIT is associated with a better health rating as compared to not using it at all. Further studies should assess the longitudinal relationship between HIT use and how adults with CLBP rate their health.

"Be Strong My Sista'": Sentiments of Strength From Black Women With Chronic Pain Living in the Deep South

The experience of chronic pain is influenced by gender, race, and age but is understudied in older Black women. Society and family alike expect Black older women to display superhuman strength and unwavering resilience. This qualitative study examined the narratives of 9 rural- and urban-dwelling Black older women to identify the ways in which they displayed strength while living with chronic osteoarthritis pain. Their "herstories" parallel the 5 characteristics of the Superwoman Schema/Strong Black Woman. Two additional characterizations emerged: spiritual submission for strength and code switching to suffering Black woman; these may be unique to Black Americans with pain.

Chronic Pain and Prescription Opioid Use Among Socially Marginalized Nigerian Women: Exploring Supply Channels and Pathways to Misuse

This study explores pathways to prescription opioid misuse and supply channels based on in-depth interviews with 16 socially marginalized Nigerian women suffering chronic pain. The pathways identified were medical pain treatment, prior substance use and opioid use for recreation and coping with psychological distress. Facing barriers to prescription opioids due to prescribing restrictions and provider stigma, many resorted to unlicensed chemist stores and street drug dealers for opioid analgesics, including fake and potentially harmful products. Patterns of prescription opioid misuse were woven into multiple and overlapping dynamics of marginalization shaping the lives of these women, including homelessness, sex work, substance use and intimate partner violence. Findings show a need to improve access to prescription opioids and other evidence-based approaches, framed within a trauma-informed approach to pain management. Further, integrating substance abuse treatment and pain management could make services responsive to the inter-related problems of chronic pain and prescription opioid misuse.

“When Surviving Jim Crow Is a Preexisting Condition”: The Impact of COVID‐19 on African Americans in Late Adulthood and Their Perceptions of the Medical Field

This article examines how the trauma of historical and structural racism affects one's health and well‐being across the life span, specifically for African Americans identified as descendants of Africans enslaved in the United States (DAEUS). Counselors are provided with antiracist strategies to support the intersection of multiple social identities for DAEUS citizens in late adulthood disproportionately affected by COVID‐19.

The Relationship Between Education and Pain Among Adults Aged 30-49 in the United States

Pain is a major health problem among U.S. adults. Surprisingly little, however, is known about educational disparities in pain, especially among the nonelderly. In this study, we analyze disparities in pain across levels of educational attainment. Using data from the 2010 to 2017 National Health Interview Survey among adults aged 30 to 49 (N = 74,051), we estimate logistic regression models of pain prevalence using a dichotomous summary pain index and its 5 constituent pain sites (low back, joint, neck, headache/migraine, and facial/jaw). We find a significant and steep pain gradient: greater levels of educational attainment are associated with less pain, with 2 important exceptions. First, adults with a high-school equivalency diploma (GED) and those with "some college" have significantly higher pain levels than high school graduates despite having an equivalent or higher attainment, respectively. Second, the education-pain gradient is absent for Hispanic adults. After taking into account important covariates including employment, economic resources, health behaviors, physical health conditions, and psychological wellbeing, educational disparities in pain are no longer statistically significant except for the GED and "some college" categories, which still show significantly higher pain levels than high school graduates. We thus document the overall education-pain gradient in most younger U.S. adult populations, and identify groups where pain is higher than expected (certain educational categories) or lower than expected (eg, less-educated Hispanics). Understanding the causes of these anomalous findings could clarify factors shaping pain prevalence and disparities therein. PERSPECTIVE: Over 50% of U.S. adults age 30 to 49 report pain. Overall, more educated Americans report substantially less pain than the less educated. However, adults with a GED and "some college" report more pain than other groups. Understanding the causes could help illuminate the mechanisms through which social factors influence pain.

Is There a Gender Self-Advocacy Gap? An Empiric Investigation Into the Gender Pain Gap

There are documented differences in the efficacy of medical treatment for pain for men and women. Women are less likely to have their pain controlled and receive less treatment than men. We are investigating one possible explanation for this gender pain gap: that there is a difference in how women and men report their pain to physicians, and so there is a difference in how physicians understand their pain. This paper describes an exploratory study into gendered attitudes towards reporting uncontrolled pain to a physician. This exploratory study provided subjects with a vignette describing a situation in which their pain is not being treated adequately and asked them questions about their attitudes towards self-advocacy and the strategies they would likely use to express themselves. We found that women scored higher than men on measures of patient likelihood to self-advocate. Women also reported intending to use more varied self-advocacy strategies than men. This suggests it is unlikely that patient's communication styles are to blame for the gender pain gap.

Predictors and Characteristics of Opioid Utilization >15 Days Following Total Knee Arthroplasty

BACKGROUND

America is amid an opioid epidemic, best characterized by liberal prescribing practices; widespread opioid misuse, abuse, and diversion; and rising rates of prescription-related opioid overdose. While many contributors to opioid overprescribing exist, orthopedic surgery is identified as a key driver. The purpose of this study is to determine predictors of ongoing opioid use >15 days post-total knee arthroplasty (TKA) and those patients prescribed >1350 morphine milligram equivalents (MMEs) in the 15 days following surgery.

METHODS

A retrospective cohort study was conducted in patients undergoing TKA (January 2016-December 2017) in an integrated healthcare system. Outcomes of interest were patient and clinical characteristics.

RESULTS

A total of 621 patients were included in the study. The majority were female (57.6%), were non-Hispanic/Latino white (92.3%), and from metropolitan areas (64.3%) with fewer than 110,000 population. Mean age was 66.3. Being female (odds ratio [OR] = 1.547, P = .092), having a higher body mass index (OR = 1.043, P = .036), and receipt of more postdischarge prescriptions in the 60-day follow-up period (OR = 8.815, P < .0001) were associated with a greater likelihood of receipt of opioid prescriptions for more than 15 days. Older patients (OR = 0.954, P = .01) and those discharged to home (OR = 0.478, P = .045) were less likely to receive >1350 MME; longer length of stay (OR = 1.447, P = .013) was more likely in those prescribed >1350 MMEs.

CONCLUSION

Several predictors were associated with longer duration and higher doses of opioid prescriptions post-TKA. Further research is needed to ascertain the challenges of opioid prescribing from both the metropolitan surgical team and rural healthcare provider perspective.

Provider Characteristics Associated With Outpatient Opioid Prescribing After Surgery

OBJECTIVE

To characterize differences in postoperative opioid prescribing across surgical, nonsurgical, and advanced practice providers.

BACKGROUND

There is a critical need to identify best practices around perioperative opioid prescribing. To date, differences in postoperative prescribing among providers are poorly understood.

METHODS

This is a retrospective multicenter analysis of commercial insurance claims from a statewide quality collaborative. We identified 15,657 opioid-naïve patients who underwent a range of surgical procedures between January 2012 and October 2015 and filled an opioid prescription within 30 days postoperatively. Our primary outcome was total amount of opioid filled per prescription within 30 days postoperatively [in oral morphine equivalents (OME)]. Hierarchical linear regression was used to determine the association between provider characteristics [specialty, advanced practice providers (nurse practitioners and physician assistants) vs. physician, and gender] and outcome while adjusting for patient factors.

RESULTS

Average postoperative opioid prescription amount was 326 ± 285 OME (equivalent: 65 tablets of 5 mg hydrocodone). Advanced practice providers accounted for 19% of all prescriptions, and amount per prescription was 18% larger in this group compared with physicians (315 vs. 268, P < 0.001). Primary care providers accounted for 13% of all prescriptions and prescribed on average 279 OME per prescription. The amount of opioid prescribed varied by surgical specialty and ranged from 178 OME (urology) to 454 OME (neurosurgery).

CONCLUSIONS

Advanced practice providers account for 1-in-5 postoperative opioid prescriptions and prescribe larger amounts per prescription relative to surgeons. Engaging all providers involved in postoperative care is necessary to understand prescribing practices, identify barriers to reducing prescribing, and tailor interventions accordingly.

Consequences of Chronic Non-Cancer Pain in adulthood. Scoping Review

OBJECTIVE

To examine and map the consequences of chronic pain in adulthood.

METHOD

Documents addressing the impact of chronic pain on the psychological and social spheres of people suffering from chronic pain, published in Spanish and English between 2013 and 2018, were included. Those who addressed pharmacological treatments, chronic pain resulting from surgical interventions or who did not have access to the full text were excluded. Finally, 28 documents from the 485 reviewed were included.

RESULTS

Studies show that pain is related to high rates of limitation in daily activities, sleep disorders and anxiety-depression spectrum disorders. People in pain have more problems to get the workday done and to maintain social relationships. Chronic pain is also associated with worse family functioning.

CONCLUSIONS

This review shows that limitations in the ability to perform activities of daily living, sleep, psychological health, social and work resources and family functioning are lines of interest in published articles. However, knowledge gaps are detected in areas such as the influence of having suffered pain in childhood or adolescence, the consequences of non-fulfillment of working hours and gender inequalities.

Racial differences in presentations and predictors of acute pain after motor vehicle collision

African Americans experience a greater burden of acute pain than non-Hispanic white individuals across of variety of acute medical conditions, but it is unknown whether this is the case after trauma. We evaluated pain, pain-related characteristics (eg, peritraumatic distress), and analgesic treatment in 2 cohorts of individuals (African American [n = 931] and non-Hispanic white [n = 948]) presenting to the emergency department (ED) after a motor vehicle collision. We performed a propensity-matched analysis (n = 796 in each group) to assess racial differences in acute pain in the ED. In multivariable models conducted within the matched sample, race was associated with moderate to severe axial pain (odds ratio [OR] 3.2; 95% confidence interval [CI]: 2.1-5.0, P < 0.001) and higher average numerical rating scale scores (1.3; 95% CI: 1.1-1.6; P < 0.001). After adjustment for pain and other covariates, non-Hispanic white patients were more likely to receive an opioid analgesic in the ED (OR 2.0; 95% CI: 1.4-3.0, P < 0.001) or at discharge (OR 4.9; 95% CI: 3.4-7.1, P < 0.001) and also less likely to receive an NSAID in the ED (OR 0.54; 95% CI: 0.38-0.78; P = 0.001) or at discharge (0.31; 95% CI: 0.43-0.84). Racial differences in the severity of acute posttraumatic pain after a motor vehicle collision are not explained by factors such as socioeconomic status or crash characteristics. Despite a higher burden of acute pain, African Americans were less likely to receive opioid analgesics and more likely to receive NSAIDs. Further work is needed to understand the relationship between pain severity, disparities in analgesic treatment, and longer term outcomes, such as post-motor vehicle collision chronic pain.

Is There Gender Discrimination in Acute Renal Colic Pain Management? A Retrospective Analysis in an Emergency Department Setting

BACKGROUND

Pain is a widespread problem, affecting both men and women; studies have found that women in the emergency department receive analgesic medication and opioids less often compared with men.

AIMS

The aim of this study was to examine the administration and management of analgesics by the medical/paramedical staff in relation to the patients' gender, and thereby to examine the extent of gender discrimination in treating pain.

DESIGN

This is a single-center retrospective cohort study that included 824 patients.

SETTINGS

Emergency department of tertiary hospital in Israel.

PARTICIPANTS/SUBJECTS

The patients stratified by gender to compare pain treatments and waiting times between men and women in renal colic complaint.

METHODS

As an acute pain model, we used renal colic with a nephrolithiasis diagnosis confirmed by imaging. We recorded pain level by Visual Analog Scale (VAS) scores and number of VAS examinations. Time intervals were calculated between admissions to different stations in the emergency department. We recorded the number of analgesic drugs administered, type of drugs prescribed, and drug class (opioids or others).

RESULTS

A total of 824 patients (414 women and 410 men) participated. There were no significant differences in age, ethnicity, and laboratory findings. VAS assessments were higher in men than in women (6.43 versus 5.90, p = .001, respectively). More men than women received analgesics (68.8% versus 62.1%, p = .04, respectively) and opioids were prescribed more often for men than for women (48.3 versus 35.7%, p = .001). The number of drugs prescribed per patient was also higher in men compared with women (1.06 versus 0.93, p = .03). A significant difference was found in waiting time length from admission to medical examination between non-Jewish women and Jewish women.

CONCLUSIONS

We found differences in pain management between genders, which could be interpreted as gender discrimination. Yet these differences could also be attributed to other factors not based on gender discrimination but rather on gender differences.

The Influence of Race, Ethnicity and Genetic Variants on Postoperative Pain Intensity: An Integrative Literature Review

OBJECTIVES

Chronic postsurgical pain is pain that develops and persists for at least 3 months after a surgical procedure. The purpose of this review was to discover what evidence exists regarding the influence of race and ethnicity on postoperative pain intensity and what evidence exists regarding the influence of genetic polymorphisms on postoperative pain intensity.

DESIGN

Integrative literature review.

DATA SOURCES

CINAHL, PsychInfo, SCOPUS, and PubMed/Medline databases were searched for entries within the last 10 years. Sources included primary research investigating the relationship among race, ethnicity, and genetics in postoperative pain outcomes.

REVIEW/ANALYSIS METHODS

Studies adhered to a strict inclusion and exclusion criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to evaluate and assess manuscripts for inclusion.

RESULTS

Twelve manuscripts were included for final review. There are significantly higher preoperative and postoperative pain intensity scores reported between African American and Hispanic individuals compared with non-Hispanic whites. Although some studies identified that non-Hispanic whites consumed more opioids and reported increased pain, there were no significant differences in opioid requirements in Hispanic and non-Hispanic individuals. COMT and OPRM1 were the most identified genetic polymorphisms associated with postoperative pain intensity.

CONCLUSIONS

The literature varies with respect to race, ethnicity, and postoperative pain perception. Perioperative pain intensity has been suggested as a significant predictor of chronic postsurgical pain. COMT and OPRM1 may be associated with higher pain perception after surgical procedures.

Evaluating psychosocial contributions to chronic pain outcomes

The biopsychosocial model of pain dominates the scientific community's understanding of chronic pain. Indeed, the biopsychosocial approach describes pain and disability as a multidimensional, dynamic integration among physiological, psychological, and social factors that reciprocally influence one another. In this article, we review two categories of studies that evaluate the contributions of psychosocial factors to the experience of chronic pain. First, we consider general psychosocial variables including distress, trauma, and interpersonal factors. Additionally, we discuss pain-specific psychosocial variables including catastrophizing, expectations, and pain-related coping. Together, we present a diverse array of psychological, social, and contextual factors and highlight the need to consider their roles in the development, maintenance, and treatment of chronic pain conditions.

Rates of Anovulation in Adolescents and Young Adults with Moderate to Severe Primary Dysmenorrhea and Those without Primary Dysmenorrhea

STUDY OBJECTIVE

To evaluate rates of presumptive anovulation in eumenorrheic adolescents and young adults with moderate to severe primary dysmenorrhea and those without primary dysmenorrhea.

DESIGN

Participants completed luteinizing hormone surge ovulation predictor test kits. Anovulatory cycles were defined by never receiving a positive result before the next menstrual period; participants were grouped as anovulatory if they experienced at least 1 anovulatory cycle during study participation. Participants rated daily level of menstrual pain on a 0-10 numeric rating scale.

SETTING

A university-based clinical research laboratory.

PARTICIPANTS

Thirty-nine adolescents and young adults (ages 16-24) with primary dysmenorrhea and 52 age-matched control girls.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Rates of presumptive anovulation.

RESULTS

One hundred sixty-eight cycles were monitored, 29.8% (N = 50) of which were anovulatory (37.1% [39/105] vs 17.5% [11/63] of cycles in control and dysmenorrhea groups, respectively). During study participation, control girls were significantly more likely to have had at least 1 anovulatory cycle than were girls with primary dysmenorrhea (44.2% [23/52] vs 17.9% [7/39] of participants, respectively; P < .01). Cycle length and number of bleeding days between ovulatory and anovulatory cycles were similar. The primary dysmenorrhea group's maximum menstrual pain ratings did not differ between ovulatory and anovulatory cycles (4.77 and 4.36, respectively; P > .05).

CONCLUSION

Our data support previous findings of increased rates of ovulation in primary dysmenorrhea. However, menstruation after anovulatory cycles can be as painful as menstruation after ovulatory cycles. These data support the idea that regular menses do not necessarily indicate that a normal ovulatory cycle has occurred. Previous implications that ovulation is necessary for the development of substantial menstrual pain are incomplete.

Outcomes and patterns of care in a nationwide cohort of pediatric medulloblastoma: Factors affecting proton therapy utilization

PURPOSE

We examined national outcomes and patterns of care for pediatric patients with medulloblastoma (MB) in a large observational cohort.

METHODS AND MATERIALS

Using the National Cancer Database, we evaluated the clinical features and survival outcomes of patients diagnosed with MB. The association between intervention, covariables, and outcome was assessed in a multivariable Cox analysis and through logistic regression analysis. Survival was estimated using the Kaplan-Meier method.

RESULTS

Among the 4032 patients in the National Cancer Database with pediatric brain tumors, 1300 patients met the inclusion criteria of histologic diagnosis, receipt of chemotherapy and radiation, and age ≤18 years. The median age and follow-up were 8.4 years and 4.5 years, respectively. Five-year survival was 79.0%. In the univariate analysis, inferior outcome (overall survival) was associated with rural residence (hazard ratio [HR], 2.78; 95% confidence interval [CI],1.47-5.29; P < .01) and histology (large cell; HR, 1.78; 95% CI,1.08-2.94; P < .05). In multivariable analysis, both remained significant predictors of survival (large cell: HR, 1.68; P < .05; rural residence: HR, 2.74; P < .01). In 2013, the utilization rate of proton therapy (23% of patients) in the United States surpassed intensity modulate radiation therapy (16%), more frequently for patients with higher income (P < .05) or more favorable insurance status (P < .05).

CONCLUSIONS

As one of the largest data sets on pediatric MB, the observed variations in treatment intervention and survival outcomes may represent a target for further research.

Overview of Pain Management in Older Adults

Epidemiological data suggests that the prevalence of musculoskeletal and neuropathic pain increases with age until at least late mid-life, though the pattern is somewhat unclear beyond this point. And though the prevalence of some types of pain may peak in late midlife, pain is still a substantial and common complaint even in the oldest age groups. This article provides an overview of later-life pain and includes a brief review of its epidemiology, describes commonly encountered barriers to its management, and discusses guidelines and recommended approaches to its assessment and management.

Opioid-induced hyperalgesia: Cellular and molecular mechanisms

Opioids produce strong analgesia but their use is limited by a paradoxical hypersensitivity named opioid-induced hyperalgesia (OIH) that may be associated to analgesic tolerance. In the last decades, a significant number of preclinical studies have investigated the factors that modulate OIH development as well as the cellular and molecular mechanisms underlying OIH. Several factors have been shown to influence OIH including the genetic background and sex differences of experimental animals as well as the opioid regimen. Mu opioid receptor (MOR) variants and interactions of MOR with different proteins were shown important. Furthermore, at the cellular level, both neurons and glia play a major role in OIH development. Several neuronal processes contribute to OIH, like activation of neuroexcitatory mechanisms, long-term potentiation (LTP) and descending pain facilitation. Increased nociception is also mediated by neuroinflammation induced by the activation of microglia and astrocytes. Neurons and glial cells exert synergistic effects, which contribute to OIH. The molecular actors identified include the Toll-like receptor 4 and the anti-opioid systems as well as some other excitatory molecules, receptors, channels, chemokines, pro-inflammatory cytokines or lipids. This review summarizes the intracellular and intercellular pathways involved in OIH and highlights some mechanisms that may be challenged to limit OIH in the future.