Culture May Influence Patients' Perception of Painkiller Effectiveness

Culture appears to influence people's perceptions of narcotic pain reliefafter surgery, say researchers who have surveyed fracture patients in NorthernCalifornia and in Vietnam.

US patients with fractures of the femoral shaft were much less satisfiedwith the narcotic pain relief that their doctors provided, even at dosesmore than 30 times greater than those received by a matched group of Vietnamesepatients, said Dr. Eugene Carragee, associate professor of functional restoration(orthopedic surgery) at Stanford University School of Medicine.

"Many studies have demonstrated that pain can be subjective andinfluenced by experience, but we were impressed at how large a role cultureappears to play in actually managing patients," said Carragee.

"This information is extremely useful because either too much ortoo little painkiller can cause side effects and complications, and therough guidelines we employ aren't always particularly useful. We need furtherresearch to determine better pain management standards," he said.Carragee presented the new findings in February at the annual meeting ofthe American Academy of Orthopedic Surgeons in San Francisco.

Femoral fractures are a particularly painful form of injury, and thesurgery to correct them is also associated with serious discomfort. Theprocedure involves placing a rod into the bone to stabilize the fractureand promote healing.

Study Results

All patients in the study received morphine or opioid analgesics torelieve their pain. To assess pain relief, independent examiners, not thepatients' caregivers, conducted standardized interviews with each patientbetween 12 and 16 days after surgery. Pain relief during surgery and inthe recovery room was not evaluated.

On average, the 25 Vietnamese patients in the study, at two hospitalsin Hanoi and one hospital in Ho Chi Minh City, received daily doses equivalentto 0.9 mg/kg of morphine. Doses for the 25 US patients, at Stanford UniversityHospital and Santa Clara Valley Medical Center in San Jose, averaged morethan 30 times higher, at 30.2 mg/kg/d. On average, the Vietnamese patientsweighed significantly less than the Americans, and dosage comparisons wereadjusted to account for this.

Despite the large difference in weight-adjusted dosage, only 8% of theVietnamese group, compared with 80% of the US group, said they felt theirpain control had been inadequate, Carragee said.

Possible Explanations for Differing Perceptions

Although the study did not attempt to identify the reasons for this,Carragee does offer some speculation. "A strong history of privationdue to war, and a pervasive Buddhist tradition, whose first tenet is 'Alllife is suffering,' may have colored the expectation of the Vietnamesepatients," said Carragee, who has worked as a physician on severalprojects in Southeast Asia in recent years. In addition, "Vietnamesepeople traditionally have great confidence in their doctors, and this faithcould explain a feeling of well-being, hence lack of pain, that came frombelieving they were following the proper path," he said.

A surprising number of the US patients "believed there was somefactor or agent at work making their situation worse, be that a problemwith the bed or a suspected problem with the surgery," Carragee noted.

Preconceptions about how much a broken thighbone would hurt also varieddramatically between the two groups, he said. Only 4% of the US group,compared with 76% of the Vietnamese group, said the pain was about as strongas they would have expected for such an injury. Almost all of the Americanssaid that the pain was much worse than expected.

Some of the apparent differences in pain perception and pain mitigationmight reflect cultural differences in patient care practices, Carrageenoted. For example, Vietnamese patients routinely received heat treatments,foot rubs, and hand rubs, as well as herbal medications, traditional teas,and dietary guidelines thought to augment healing.

Carragee's colleagues on the pain study included Dr. David Burton, clinicalprofessor of functional restoration (orthopedic surgery) at Stanford andhead of orthopedic surgery at Santa Clara Valley Medical Center; Thao P.Truong, a predental student at the University of California, Santa Cruz;and Stanford medical student Daniel Vttum.