Culture appears to influence people's perceptions of narcotic pain relief after surgery, say researchers who have surveyed fracture patients in Northern California and in Vietnam.
US patients with fractures of the femoral shaft were much less satisfied with the narcotic pain relief that their doctors provided, even at doses more than 30 times greater than those received by a matched group of Vietnamese patients, said Dr. Eugene Carragee, associate professor of functional restoration (orthopedic surgery) at Stanford University School of Medicine.
"Many studies have demonstrated that pain can be subjective and influenced by experience, but we were impressed at how large a role culture appears to play in actually managing patients," said Carragee.
"This information is extremely useful because either too much or too little painkiller can cause side effects and complications, and the rough guidelines we employ aren't always particularly useful. We need further research to determine better pain management standards," he said. Carragee presented the new findings in February at the annual meeting of the American Academy of Orthopedic Surgeons in San Francisco.
Femoral fractures are a particularly painful form of injury, and the surgery to correct them is also associated with serious discomfort. The procedure involves placing a rod into the bone to stabilize the fracture and promote healing.
Study Results
All patients in the study received morphine(Drug information on morphine) or opioid analgesics to relieve their pain. To assess pain relief, independent examiners, not the patients' caregivers, conducted standardized interviews with each patient between 12 and 16 days after surgery. Pain relief during surgery and in the recovery room was not evaluated.
On average, the 25 Vietnamese patients in the study, at two hospitals in Hanoi and one hospital in Ho Chi Minh City, received daily doses equivalent to 0.9 mg/kg of morphine. Doses for the 25 US patients, at Stanford University Hospital and Santa Clara Valley Medical Center in San Jose, averaged more than 30 times higher, at 30.2 mg/kg/d. On average, the Vietnamese patients weighed significantly less than the Americans, and dosage comparisons were adjusted to account for this.
Despite the large difference in weight-adjusted dosage, only 8% of the Vietnamese group, compared with 80% of the US group, said they felt their pain control had been inadequate, Carragee said.
Possible Explanations for Differing Perceptions
Although the study did not attempt to identify the reasons for this, Carragee does offer some speculation. "A strong history of privation due to war, and a pervasive Buddhist tradition, whose first tenet is 'All life is suffering,' may have colored the expectation of the Vietnamese patients," said Carragee, who has worked as a physician on several projects in Southeast Asia in recent years. In addition, "Vietnamese people traditionally have great confidence in their doctors, and this faith could explain a feeling of well-being, hence lack of pain, that came from believing they were following the proper path," he said.
A surprising number of the US patients "believed there was some factor or agent at work making their situation worse, be that a problem with the bed or a suspected problem with the surgery," Carragee noted.
Preconceptions about how much a broken thighbone would hurt also varied dramatically between the two groups, he said. Only 4% of the US group, compared with 76% of the Vietnamese group, said the pain was about as strong as they would have expected for such an injury. Almost all of the Americans said that the pain was much worse than expected.
Some of the apparent differences in pain perception and pain mitigation might reflect cultural differences in patient care practices, Carragee noted. For example, Vietnamese patients routinely received heat treatments, foot rubs, and hand rubs, as well as herbal medications, traditional teas, and dietary guidelines thought to augment healing.
Carragee's colleagues on the pain study included Dr. David Burton, clinical professor of functional restoration (orthopedic surgery) at Stanford and head of orthopedic surgery at Santa Clara Valley Medical Center; Thao P. Truong, a predental student at the University of California, Santa Cruz; and Stanford medical student Daniel Vttum.
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