Do gender and race affect decisions about pain management?

OBJECTIVE: To determine if patient gender and race affect decisions about pain management. DESIGN, SETTING, AND PARTICIPANTS: Experimental design using medical vignettes to evaluate treatment decisions. A convenience sample of 111 primary care physicians (61 men, 50 women) in the Northeast was asked to treat 3 hypothetical patients with pain (kidney stone, back pain) or a control condition (sinusitis). Symptom presentation and severity were held constant, but patient gender and race were varied. MEASUREMENTS AND MAIN RESULTS: The maximum permitted doses of narcotic analgesics (hydrocodone) prescribed at initial and return visits were calculated by multiplying mg per pill x number of pills per day x number of days x number of refills. No overall differences with respect to patient gender or race were found in decisions to treat or in the maximum permitted doses. However, for renal colic, male physicians prescribed higher doses of hydrocodone to white patients versus black patients (426 mg vs 238 mg), while female physicians prescribed higher doses to blacks (335 mg vs 161 mg, F1,85 = 9.65, P =.003). This pattern was repeated for persistent kidney stone pain. For persistent back pain, male physicians prescribed higher doses of hydrocodone to males than to females (406 mg vs 201 mg), but female physicians prescribed higher doses to females (327 mg v. 163 mg, F1,28 = 5.50, P =.03). CONCLUSION: When treating pain, gender and racial differences were evident only when the role of physician gender was examined, suggesting that male and female physicians may react differently to gender and/or racial cues.

Psychological influences on pain perception and non-pharmacologic approaches to the treatment of pain.

Pain is a complex process, in part because it is mediated by so many different variables. However, because pain is the primary reason for seeking medical treatment and often a barrier to compliance, therapists treating painful disorders or injuries need to be familiar with those factors that influence pain perception and treatment approaches. How individuals perceive pain, and hence how clinicians treat it, depends upon a wide variety of psychosocial factors, including mood, age, gender, expectations, social support, and perceptions of control. Even the manner with which therapists interact with patients can minimize the pain experience and ultimately impact compliance and recovery rates. This paper overviews the multifaceted nature of pain by outlining how psychologic variables impact pain experiences. In addition, this article reviews a number of nonpharmacologic techniques and approaches (i.e., distraction, imagery, relaxation, biofeedback) that are available for assisting patients in dealing with pain.

Behavioral training and AIDS risk reduction: overcoming barriers to condom use.

To assess the short- and long-term effects of an AIDS-prevention workshop on undergraduates' attitudes about condom use and AIDS, 31 participants and 31 controls were studied immediately after training sessions as well as three months later. The workshop was aimed at reducing embarrassment to purchase condoms, encouraging positive attitudes about condoms, and promoting knowledge about AIDS. To help students overcome their embarrassment over condom purchases, a behavioral intervention was included allowing students to make condom purchases at nearby drug stores. Results revealed that participants reported less embarrassment over condom purchases after training sessions and that this effect became even stronger over time. Knowledge about AIDS and positive attitudes about condoms also increased immediately after the workshop, but these changes did not persist. Results suggest that AIDS prevention workshops may lead to transient changes unless a specific skill (i.e., condom purchasing) is targeted via behavioral training.

PIP: The findings of a case-control study conducted among college students suggest that social learning theory principles can reduce the embarrassment of young adults surrounding condom purchase. Surveyed were 62 male students (mean age, 19.4 years), 31 of whom were randomly assigned to receive the behavioral intervention. The intervention encompassed education on acquired immunodeficiency syndrome (AIDS) prevention, experimentation with proper condom use techniques, and actual condom purchases from off-campus drugstores. Questionnaires concerning sexual practices, knowledge and attitudes about AIDS, and perceptions of condom use were administered to all students both at study entry and three months after study completion. At baseline, 88% of students reported ever-use of condoms and 60% identified condoms as their primary form of contraception; however, only 12.2% were using condoms at every act of intercourse. At the follow-up survey, students exposed to the experimental intervention reported an average of 12.0 condom purchases in the preceding three months compared to 7.8 purchases among controls. Moreover, 66.7% of cases compared to 60% of controls now cited condoms as their contraceptive method of choice. Subjects reported significantly less embarrassment about making condom purchases after the training session, and this effect became stronger with time; controls showed no changes in ratings of embarrassment. Although workshop participants expressed greater intentions to use condoms consistently in the future than controls and a more positive overall attitude toward this method, these changes diminished during the post-intervention period and, by the time of the three-month follow-up, cases and controls were similar on both measures. Similarly, workshop participants were more knowledgeable about AIDS after the intervention, but this change was also subject to erosion. It is concluded that purely educational interventions produce only short-term gains, while behavioral training aimed at imparting a specific skill can result in enduring behavioral change.

Depression and immunocompetence: a review of the literature.

Recent evidence suggests that there is a relationship between depression and immunity. On the basis of these studies, it has been argued that depressed mood may increase susceptibility to disease by means of aberrations occurring within the immune system. Empirical research investigating the relationship between depression and immunity is reviewed here. Studies examining both clinical and nonclinical manifestations of depression are discussed and evaluated. This review reveals that indexes of immunocompetence are lower among people exhibiting depressive symptomology and suggests that immune alterations may be more related to dysphoric mood than to specific situations or events. Alternative hypotheses accounting for links between depressed affect and altered immune states are provided, and suggestions for future research are offered.

Differential effects of controllable and uncontrollable acute stress on lymphocyte proliferation and leukocyte percentages in humans.

This study examined the effects of a 30-min laboratory stressor on aspects of immune function in 24 men and whether behavioral control over the stressor moderates stress effects. The stressor consisted of mild (2.5 mA) electric shock and loud (100 dB) white noise administered in an unpredictable, intermittent fashion. During stress sessions, only half of the subjects were able to control the stressor. Subjects with control were yoked to subjects who could not control the stressor so that both groups were exposed to identical intensity and duration of noise and shock. Immunologic function was assessed across stress and nonstress conditions by measuring changes in lymphocyte proliferation to concanavalin A (Con A) and phytohemagglutinin (PHA) and by measuring changes in percentages of lymphocytes and their subpopulations, granulocytes, and monocytes. Results revealed that exposure to the uncontrollable stressor altered mood but did not affect immune function. In contrast, exposure to controllable stress did not alter mood but did result in lowered lymphocyte proliferation to Con A. Poststress percentages of monocytes were also lower in subjects exposed to the controllable stressor. Results suggest that acute stress can alter aspects of immune function in humans and underscore the importance of stressor controllability in moderating stress effects on human immunity.

Chronic stress, leukocyte subpopulations, and humoral response to latent viruses.

Psychological stress has been shown to affect immune system status and function, but most studies of this relationship have focused on acute stress and/or laboratory situations. The present study compared total numbers of leukocytes and lymphocyte subpopulations (determined by flow cytometry) and antibody titers to latent and nonlatent viruses among a group of chronically stressed individuals living near the damaged Three Mile Island (TMI) nuclear power plant with those of a demographically comparable control group. Urinary catecholamine and cortisol levels were also examined. Residents of the TMI area exhibited greater numbers of neutrophils, which were positively correlated with epinephrine levels. The TMI group also exhibited fewer B lymphocytes, T-suppressor/cytotoxic lymphocytes, and natural killer cells. Antibody titers to herpes simplex were significantly different across groups as well, whereas titers to nonlatent rubella virus as well as IgG and IgM levels were comparable.