Chronic Pain (cont.)
What is the role of age and gender in pain?
Gender and Pain
It is now widely
believed that pain affects men and women differently. While the sex hormones
estrogen and testosterone certainly play a role
in this phenomenon, psychology and culture, too, may account at least in part for differences in how men and
women receive pain signals. For example, young children may learn to respond to
pain based on how they are treated when they experience pain. Some children may
be cuddled and comforted, while others may be encouraged to tough it out and to
dismiss their pain.
Many investigators are turning their attention to the study of gender
differences and pain. Women, many experts now agree, recover more quickly from
pain, seek help more quickly for their pain, and are less likely to allow pain
to control their lives. They also are more likely to marshal a variety of
resources-coping skills, support, and distraction-with which to deal with their
pain.
Research in this area is yielding fascinating results.
For example, male experimental animals injected with estrogen, a female sex
hormone, appear to
have a lower tolerance for pain-that is, the addition of estrogen appears to
lower the pain threshold. Similarly, the presence of testosterone, a male
hormone, appears to elevate tolerance for pain in female mice: the animals are
simply able to withstand pain better. Female mice deprived of estrogen during
experiments react to stress similarly to male animals. Estrogen, therefore, may
act as a sort of pain switch, turning on the ability to recognize pain.
Investigators know that males and females both have
strong natural pain-killing systems, but these systems operate differently. For
example, a class of painkillers called kappa-opioids is named after one of
several opioid receptors to which they bind, the kappa-opioid receptor, and they include the
compounds nalbuphine (Nubain) and butorphanol (Stadol). Research suggests
that kappa-opioids provide better pain relief in women.
Though not prescribed widely, kappa-opioids are
currently used for relief of labor pain and in general work best for short-term pain. Investigators are not
certain why kappa-opioids work better in women than men. Is it because a woman's
estrogen makes them work, or because a man's testosterone prevents them from
working? Or is there another explanation, such as differences between men and
women in their perception of pain? Continued research may result in a better
understanding of how pain affects women differently from men, enabling new and
better pain medications to be designed with gender in mind.
Pain in aging and pediatric populations: special needs and concerns
Pain is the number one complaint of older Americans, and
one in five older Americans takes a painkiller regularly. In 1998, the American
Geriatrics Society (AGS)
issued guidelines (Journal of the American Geriatrics Society (1998; 46:635-651) for the management of pain in older people. The AGS panel
addressed the incorporation of several non-drug approaches in patients'
treatment plans, including exercise. AGS panel members recommend that, whenever
possible, patients use alternatives to aspirin, ibuprofen, and other NSAIDs
because of the drugs' side effects, including stomach irritation and
gastrointestinal bleeding. For older adults, acetaminophen is the first-line
treatment for mild-to-moderate pain, according to the guidelines. More serious
chronic pain conditions may require opioid drugs (narcotics), including codeine
or morphine, for relief of pain.
Pain in younger patients also requires special attention, particularly
because young children are not always able to describe the degree of pain they
are experiencing. Although treating pain in pediatric patients poses a special
challenge to physicians and parents alike, pediatric patients should never be
undertreated. Recently, special tools for measuring pain in children have been
developed that, when combined with cues used by parents, help physicians select
the most effective treatments.
Nonsteroidal agents, and especially acetaminophen, are most often prescribed
for control of pain in children. In the case of severe pain or pain following
surgery, acetaminophen may be combined with codeine.
* Journal of the American Geriatrics Society (1998; 46:635-651).
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