Every month the Centers for Disease Control (CDC) addresses a health issue of critical importance. Their July report concerned the alarming increase in overdoses of prescription painkillers such as Oxycontin and Vicodin among women. Between 1999 and 2010 this statistic grew by more than 400 percent. More than 6,600 women die from a prescription painkiller overdose annually (18 women every day). Thomas Frieden, M.D., director of the CDC, explained that the increase in opioid overdose deaths is directly proportional to the increase in prescribing.
These numbers tell several stories, including the prevalence of pain, the ferociously addictive nature of many painkillers, and the deceptive promotion of these agents by pharmaceutical companies. But the story I wish to focus on relates specifically to women and pain.
One of the most striking aspects of this tragic increase in women dying from painkiller overdose is its occurrence in the context of a well-documented history of the under-treatment of women in pain. Numerous studies have revealed that in equivalent clinical situations such as after abdominal surgery (controlling for weight), males receive significantly more narcotic pain medication than females. This pattern extends to pediatric populations. Significantly more codeine has been given to boys than girls for post-operative pain. Girls were more likely to receive Tylenol.
One study revealed that men undergoing coronary artery bypass graft received narcotics more often than women. The female patients were more likely to receive sedative agents, suggesting that they were more often seen as emotional and anxious rather than in pain.
In reviewing the literature that documents the under-treatment of women's pain, it appears as if women's reports of pain are seen by the medical community as less credible than men's.
Chronic pain is a disturbingly common condition plaguing more than 100 million Americans. It is as prevalent as cancer, cardiovascular disease and diabetes combined. Pain is one of the most frequent complaints that bring people to the doctor. While common, it remains poorly understood and too often unsatisfactorily treated. One aspect of pain that complicates its management is measurement.
Currently, there exists no valid and reliable method of objectively quantifying an individual's experience of pain. Therefore, we rely mainly on self-report measures to determine its impact. And here the trouble begins.
Pain is fundamentally resistant to observation. Its subjective nature relegates it to a space in Western medicine where stereotypes, cultural biases and prejudices about women can distort doctors' perception of the female patient in pain.
Surveys indicate that many people believe women can tolerate pain better than men. Childbirth and menstruation are often cited as evidence. Cultural stereotypes also explain a lot. Boys learn from a young age that the expression of weakness, vulnerability, fear or pain is shameful. Women are more comfortable expressing such things, using social supports and seeking medical assistance. Male pain research participants report less pain when tested by a female researcher than a male researcher. The researcher's sex did not affect female subjects responses.
In other words, women have better coping behaviors. Paradoxically, this has played against them when interacting with the medical system.
Questions regarding the differences between men and women may not be politically correct but are essential to our ability to understand and treat any clinical condition that affects both populations. Over the past few decades a growing body of research indicates that men and women experience pain differently. Women have a higher prevalence of chronic pain syndromes and diseases associated with chronic pain. Women are also more sensitive to pain than men.
Why has it taken us so long to learn about this?
Believe it or not, the relative absence of statistically significant numbers of women in research and clinical trials until the 1990s explains why this body of data has only recently been appreciated. This began to change in the '90s with legislation such as the National Institutes of Health Revitalization Act that mandated the inclusion of females and minorities in federally funded research and drug trials. The pressure of advocacy groups like the Society for Women's Health Research also helped create the possibility of funded research that could analyze how men and women differ.
Such investigation is essential. A good illustration of the centrality of this work was the discovery that when having a heart attack, men and women experience different symptoms.
So let's spell it out.
• Women are more sensitive to pain than men
• Women have a higher prevalence of painful conditions than men
• Women seek medical help more often than men
• Women have received less pain medication than men and have had their condition discounted as psychogenic or emotional and therefore not worthy of treatment
Is it possible to view this CDC report on the skyrocketing increase in women dying of painkiller overdose as an unfortunate consequence of a correction in the under-treatment of women in pain?
Is this the price of parity or do women continue to receive inadequate treatment?
Time will tell.
For more by Paul Spector, M.D., click here.
For more on personal health, click here.