Thursday, August 25, 2011

Disparities of Pain and Its Treatment in Women

Gender Disparities Many chronic noncancer pain conditions afflict women more often than men, and the pain in women also can to be more severe and complex. A multifaceted cycle of pain-distress-pain is common in women and, while they are prescribed opioid analgesics more often than their male counterparts, this does not mean that their pain management needs are being met. A woman’s ability to cope with pain along with other life stresses can be critical factors.

According to Beth D. Darnall, PhD, writing in the publication MDNG Pain Management [PDF here], women are not only more likely than men to acquire a chronic pain condition in their lifetime but women’s pain occurs more frequently, is more intense, and lasts for a longer duration of time. Women are more likely than men to seek medical attention for their pain conditions, but this does not always translate into better or appropriate care.

Darnall — who is an assistant professor at Oregon Health & Science University and is a pain psychologist and researcher — observes that a number of chronic pain conditions are women-specific, including dysmenorrhea, vulvodynia, dyspareunia, and certain other forms of pelvic pain. Additional conditions — fibromyalgia, irritable bowel disorder, migraine, arthritis, complex regional pain syndrome, and some inflammatory disorders — are much more prevalent in women.

In general, women are prescribed opioids analgesics more often than men for their chronic pain and at higher doses. However, Darnall suggests this is unrelated to the intensity of pain; rather, women’s behaviors during office visits appear to be more influential. For example, negative affect, psychological distress, and pain behaviors (eg, grimacing or bracing) predict receipt of an opioid prescription, and more so for women than for men.

Additionally, she observes, anxiety, depression, and pain-related dysfunction in women have been shown to influence greater opioid prescribing. She suggests that the logic of the prescriber may be a well-intended assumption that pain relief with opioids will lead to reduced psychological distress and improved function; although, this is unsupported by research evidence, she adds.

Rather, Darnall emphasizes the importance of proper assessment and treatment of psychological comorbidities and distress in women. The stresses of chronic pain are multifold — interpersonal, family, social, work, financial — so the patient must deal with the experience of her pain as well as the life impact of the pain. As stress increases and coping abilities diminish, psychological stressors and comorbidities are more likely to emerge.

Under these conditions, physical pain also will increase, thus completing a dreadful cycle of pain-distress-pain. “It’s unsurprising that stress/distress and pain are so closely related,” Darnall states. “Indeed, cognitive, emotional, and behavioral factors powerfully influence the experience of pain, our level of distress regarding pain, the trajectory of pain, and response to pain treatments. This may be more true for women, given that women’s brains are wired to be more attuned to the emotional aspects of situations.”

“Perhaps the most important thing physicians and other pain care providers can do for their female chronic pain patients is to properly assess their ability to cope with their pain and other life stresses,” she continues. Referral to a pain psychologist is recommended, if there are such resources available.

The psychologist will assess coping patterns and develop a plan to help the patient self-manage her stress responses. Addressing the cognitive, emotional, and behavioral responses to pain can empower the patient with the understanding, skill set, and support to make concrete changes that lead to improved quality of life and a reduced need for pain medication.

According to Darnall, there is evidence that women are more influenced by their thoughts and expectations related to pain than are men. For instance, “women who expect pain relief from a placebo pill tend to experience greater pain relief than men.” Additionally, women who are stressed by thinking negatively about their pain may be more likely to express proinflammatory cytokines in their blood, she asserts.

Opioid analgesia can have unique consequences for women, Darnall cautions. For instance, long-term opioid use is associated with dysregulation of the endocrine system, including disruption of testosterone, estradiol, and dehydroepiandrosterone sulfate (DHEAS) levels in women. “Because the endocrine system influences the experience of pain, it is possible that opioid-induced endocrinopathy is a primary pathway by which pain worsens over time,” she writes.

One study found that women of reproductive age who took opioids long term experienced opioid-induced amenhorrhea, which may incur risks of compromised bone health and infertility. Conversely, a subset of reproductive age women on opioids maintains fertility and providers should monitor these patients for pregnancy planning.

Darnall advises that female patients also should be informed that opioids carry teratogenic risks, including “low birth weight, premature birth, hypoxic-ischemic brain injury, prolonged QT syndrome, neonatal withdrawal syndrome, and neonatal death.” When possible, women should be weaned off opioids prior to pregnancy.

Providers are advised to consider ordering a baseline hormone panel as a reference point for women prior to initiating opioid therapy and then monitor those levels during treatment. The endocrine system is known to impact mood, cognition, insulin secretion, cardiovascular events, sexual function, and bone loss and fracture risk (particularly in older women). Referral to an endocrinologist may be advisable for patients with detected hormonal irregularities.

Lastly, women should be informed of potential treatment risks before it is initiated. “Taking time to review the medication risks may provide the clinician with an opportunity to highlight some alternate evidence-based non-pharmacological treatment options, such as pain psychology and cognitive behavioral pain care, meditation, physical therapy, and gentle yoga,” Darnall concludes.

COMMENTARY: Much of the information in Dr. Darnall’s article may not be new to readers, whether practitioners or patients. Yet, there are good reminders of the need for considering gender differences in the complex world of pain management. And, the article — which is obviously written from the perspective of a pain psychologist — serves to reinforce the potential value of a multimodal approach to the woman with chronic pain.

However, some of the alternate therapies noted by Darnall may work best if at least modest pain relief is first attained, and this may require pharmacotherapy or other medical interventions. Along with that, the quality and quantity of scientific evidence supporting specific complementary or alternative therapies, including psychological approaches, for particular pain conditions requires careful consideration.

For more information on possible hormonal imbalances (in both women and men) associated with long-term opioid therapy, see the Pain-Topics Special Report, “Opioid-Induced Sexual Dysfunction: Causes, Diagnosis, & Treatment,” by Stephen Colameco, MD, MEd [details and access here].