The Intersection of Pain and Culture ____________________________________________________________
• Pain is always a personal experience that is influenced to varying degrees by biologic, psychological, and social factors. • Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons. • Through their life experiences, individuals learn the concept of pain. • A person’s report of an experience as pain should be respected. • Although pain usually serves an adaptive role, it may have adverse effects on function and social and psycho- logical well-being. • Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain. Pain can be further categorized as acute (sudden and usually short-lived) or chronic (lasting three months or longer). Acute pain is the most common reason for emergency department visits [7]. High-impact chronic pain is pain that is chronic (i.e., experienced more often than not during the past three months) and that limits work and activities [156]. The temporal label to the term “chronic pain” has resulted in some contro- versy. Some maintain that this definition does not provide a comprehensive picture of the situation and the underlying dynamics, which involve a range of biological, psychological, social, and cultural factors [180]. The term can also lead to tension between providers and patients, with the provider at times assuming the patient is exaggerating or seeking a sick role [180]. It is important to remember that pain is not necessarily pathologic. Pain is the body’s way of alerting that something is wrong and help is needed. When viewed in this way, pain facilitates healing [28]. Unfortunately, chronic pain is a common problem. Globally, it is estimated that 20% of adults experience pain, and every year, 1 in 10 adults are diagnosed with chronic pain [8]. On a worldwide basis, there are 1.9 billion individuals who experi- ence recurrent, tension-based headaches—the most common type of chronic pain [18]. A 2023 study estimated that 21% of adults have chronic pain and 8% have high-impact chronic pain [156]. New cases of chronic pain among U.S. adults occur more often than other common conditions, including diabetes, hypertension, and depression [156]. This finding is consistent with previous findings that an estimated 20.4% of American adults report experiencing chronic pain in the past three months [19]. In the United States, the most common types of chronic pain are back pain (affecting 10.1% of adults), lower extremity pain (4.1%), upper extremity pain (4.1%), and headache (3.5%) [9; 181].
INTRODUCTION Patients’ experiences of pain may be frustrating if they defy biomedical explanation, and the treatment of pain tends to be stigmatized [1]. When culture, race, and ethnicity are taken into consideration, the treatment of pain becomes even more complex. Practitioners should address how patients construct the meaning and experiences of pain rather than simply dealing with a set of medical procedures and routines [1]. Pain is universal. It is not solely a physiological response, and culture influences how patients ascribe meaning to, experience, express, cope with, and seek treatment for pain [2]. Research has found that culture, family beliefs, and religion all affect how patients manage, express, experience, and perceive the sensation of pain [3; 39]. In some cultures, stoicism is highly valued, making patients less likely to verbally or behaviorally express pain, in part because pain is viewed as private [134]. Culture also plays a role in how much pain individuals perceive as tolerable and how they report pain [16]. Consequently, cul- turally competent and sensitive practice is essential for practi- tioners caring for patients who experience pain. It is inevitable that practitioners will work with patients and families who are from different racial and ethnic backgrounds. However, many practitioners are more comfortable taking a traditional biomedical perspective to pain and imposing a mechanistic diagnostic process. The result can cause tension between the patient and the practitioner [4]. This course will provide an overview of how different cultural groups respond to, experience, construct meaning to, and cope with pain. The focus will be on the general concept of pain, although there are many different types of pain and the dynamics for each type may be different. In addition, this course will focus on adults’ (rather than children’s) experiences with pain. Finally, pain disparities and factors that promote these disparities will be explored. This knowledge should assist practitioners to develop and implement culturally competent practice guidelines when working with racially and ethnically diverse patients who experience pain. AN OVERVIEW OF PAIN In ancient times, pain was considered an emotion; Aristotle referred to it as a passion of the soul [5]. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” [6]. In 2020, the IASP expanded this definition with the addition of six key notes for further valuable context [6]:
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