Saturday, August 7, 2010

“John Henryism” & Pain-Relief Deficits in Women

Briefly Noted Despite an increasing prevalence of chronic pain and the many therapeutic modalities to manage it, new research shows inadequate pain assessment and treatment in primary care settings, particularly when it comes to female patients but also among African Americans. Along with that, women exhibit less effective skills for coping with their pain, measured in this study as “John Henryism.”

According to prior literature, women and racial/ethnic minorities are particularly vulnerable to suboptimal assessments of their pain (whether acute, chronic, or cancer pain) and their complaints of pain receive less attention from healthcare providers leading to undertreatment. To further examine these issues, researchers at the University of Michigan Medical School, Ann Arbor, MI, enrolled a convenience sample of 128 patients younger than age 50 referred to their tertiary-care center for the assessment and treatment of chronic pain lasting about 5 years [Green and Hart-Johnson 2010]. Subjects, all of whom completed a battery of assessment instruments about their prior treatment, were 47% African American and 60% female. Here are highlights of the study results reported in the August 2010 issue of The Journal of Pain:
  • Proportionately fewer women had previously adequate management of their chronic pain than men (approximately 42% vs 62%, respectively).

  • Blacks were prescribed significantly fewer pain medications than whites (p=.03).

  • Women were generally taking fewer pain medications than men (p=.09) and significantly fewer women were prescribed medications with adequate analgesic strength (p=.04).

  • Younger males had experienced better pain management than females but this difference declined as the men approached age 50 (age groups older than this were not considered in the research).

  • When barriers to effective treatment were examined, blacks more frequently endorsed items such as, “It is easier to put up with pain than the side effects of medication,” and “Pain medicine should be saved in case the pain gets worse.” The latter phrase also was endorsed more often by women than by men.

  • Interestingly, blacks and female chronic pain sufferers were less likely to be married or have a significant other when compared with whites (p<.001) and men overall (p=.01), which may reflect greater social consequences of chronic pain in these groups.
Overall, the researchers note that the study population at the time of referral had experienced chronic pain for a number of years, with high pain severity and clinically significant depression, high disability, decreased quality of life, and insufficient analgesic therapy. In particular, women had less adequate pain management in the past, which is of great concern, and their coping styles — defined as “John Henryism” (and described below) — were less effective in helping them to deal with their pain.

The researchers express concern that an important obstacle to quality pain management in the primary care arena is the minimal pain education physicians and other healthcare professionals receive. This is surprising, they concede, since pain is such a frequent cause of healthcare utilization and disability. They state, “Most people living with chronic pain (especially minorities) believe they should have been seen in a pain clinic sooner while reporting frequent utilization of emergency care facilities for managing chronic pain. There is also important variability in how physicians make decisions for any types of pain, with minorities and women generally receiving lesser quality care.”

COMMENTARY: It should be acknowledged that this was a small convenience sample of patients seen upon referral to an academic medical center and may not be representative of all chronic pain populations; for example, it did not include any patients older than 50 years of age. An interesting, albeit not new, measure used in this study was “John Henryism.” Introduced in 1983 by epidemiologist Sherman James and colleagues, the John Henryism Active Coping Scale assesses a person’s predispositions to actively cope with psychosocial stressors in the environment. Named after the African American folk hero John Henry, who worked vigorously to successfully compete with a steam-powered machine, the Coping Scale measures mental and physical vigor, tenacity, and a strong sense of personal efficacy in the face of adversity.

As a coping style, the researchers found that John Henryism was significantly less common among women than men (p<.05). However, there were surprisingly no differences between blacks and whites, even though African American patients experienced significantly greater self-perceived suffering due to their pain (p=.02). The researchers contend that chronic pain may stress an individual’s coping abilities and women, in particular, may be at a disadvantage. Further research in larger and more diverse populations would help to help facilitate successful primary care interventions, improve the quality of pain management, and eliminate disparities.

REFERENCE: Green CR, Hart-Johnson T. The Adequacy of Chronic Pain Management Prior to Presenting at a Tertiary Care Pain Center: The Role of Patient Socio-Demographic Characteristics. J Pain. 2010(Aug);11(8):746-754 [abstract here].