The influence of culture on pain management

В то время как влияние культуры на психопатологию широко принимается, воздействию культуры на общемедицинскую практику удалено намного меньше внимания. Примеры медицинских сфер, в которых признается, что культура имеет значимое влияние, включают соматиз-цию, боль, смерть и умирание, комплайенс и деторождение. Традиционно интерес к культуре и боли связан с культурными различиями среди пациентов, и тем, как она действовала на симптомы боли.

While the influence of culture on psychopathology is widely accepted, the influence of culture on general medical practice has received much less attention. Examples of medical areas in which culture has been recognized as having prominent influence include somatization, pain, death and dying, compliance, and childbirth. Traditionally, interest in culture and pain related to cultural differences among patients and how that affected pain symptoms.

In the United States, Canada, and some other countries, a «medical culture» has developed that influences pain management more than the cultural background of the patient. It is called a «medical cul-ture» because it involves specific values and beliefs with regard to pain management. Examples include the belief that pain is commonly undertreated, that only opioids can treat moderate to severe pain, and that opioids remain efficacious over the long term with difficulties rarely arising because of tolerance or addiction. It is also believed that «central sensitization» can occur as an ongoing state, explaining chronic pain in the absence of objective medical findings. These beliefs lead to the assumption that chronic pain should be treated with opioids in response to subjective complaints.

Because of these beliefs, practice trends and research evidence have been moving in opposing directions. In particular, opioid prescriptions for chronic nonmalignant pain have risen exponentially, despite increasing evidence that this approach is neither safe nor effective. Chronic opioid treatment appears to be associated with worsening of painful conditions. Chronic stimulation of the mu opioid receptor causes an upregulation of neuropeptides that enhance pain sensitivity. These include dynorphin, cholecystokinin, and substance P. The newly discovered mechanisms by which chronic opioid intake induces hyperalgesia are multiple and overlapping. The psychology of chronic opioid intake can result in the patient thinking he or she would be worse without the opioid medication, however.

Patients in substance abuse treatment programs are often more likely to be dependent on prescription pain medications than heroin as in the past. Unintentional deaths due to prescription narcotic analgesics have markedly increased. This «culture» of pain management needs to be recognized so that resulting problems with patient care can be minimized.

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