Christine Miaskowski chats about pain management

(CNN) -- The medical community is turning greater attention to alleviating pain. Christine Miaskowski is president-elect of the American Pain Society. Currently professor and chair of the department of physiological nursing, University of California-San Francisco, she has been involved with the APS and the journal Pain Forum in various capacities throughout the 1990s.

CNN Moderator: What prompted you to investigate the differences in the way men and women perceive pain?

Miaskowski: We actually have not done differences between how men and women perceive pain, but we've done men and women's responses to analgesics. That report, in the literature, showed that men and women did have differences in perceptions of pain, and we thought it would be interesting to see the different responses to pain medication.

CNN Moderator: What can you tell us about your findings?

Miaskowski: We have done a series of studies now that do show that men and women respond differently to pain medications. The drugs we've looked at are drugs that work on a certain receptor called the kappa receptor. It's been shown from our studies that women respond much better to these types of analgesics.

Question from the chat room: Pain is subjective. Does part of it depend on the person's willingness to verbalize how he/she feels?

Miaskowski: Yes, pain is subjective. The only way to get an accurate assessment of an individual's pain is to ask the patient, or the person experiencing the pain. In the general epidemiological literature, women report more symptoms than men. No one has looked specifically at whether there are differences in self-reported pain from men and women, but culturally, little boys are taught to behave differently when they have pain than girls. So maybe there are some sociocultural things that allow one gender to report pain differently. But that hasn't been studied specifically.

Question from the chat room: What type of medications did you use in this study?

Miaskowski: We used three pain medications that are available that work at the kappa receptor -- pentazocine, nalbuphine, and butorphanol. Those are believed to act more at the kappa receptor, unlike something like morphine, which acts at the mu receptor.

Question from the chat room: Why would men and women respond differently to different analgesics? Does this suggest a hormonal effect on the nervous system?

Miaskowski: It may, very well. There may be a hormonal effect. There has been some work done with mice, looking at differences in genes that male and female rats have. There seems to be some differences in the genes that affect our responses to analgesics. Some may be hormonal -- some may be genetic. I should emphasize that this is a relatively new area of research, so we have more questions than answers right now.

CNN Moderator: In your research, what type of pain was being studied?

Miaskowski: We've looked at a classic model to study analgesics -- dental pain. It's relatively young men and women who are having wisdom teeth extracted, and it's a pretty classic way to study analgesics. It's a nice model, because it's well controlled, in terms of the person performing the surgical procedure. It's a fairly severe, acute pain problem.

Question from the chat room: It seems that alcohol affects women more then men. Is this due to body size? If so, were the analgesics you administered the same dosages for both genders?

Miaskowski: In terms of the analgesics we administered, we statistically controlled for weights in our experiments. So, we took care of the weight factor. You're right, you do have to account for that.

Question from the chat room: Headaches, migraines, arthritis and wounds are different types of pain. Which involve kappa receptors?

Miaskowski: Kappa receptors are not involved in pain, they're involved in the way that opioids work to relieve pain. However, certain painful problems are more common in men than women. For example, women have a higher prevalence of arthritis, migraine and TMJ, where men have a higher incidence of chronic headache, not migraine. Back pain is probably equal in both genders. There is some speculation that the pain problems that are more common in women may be hormonally related.

CNN Moderator: Are there pain medications that work well for one gender but not the other?

Miaskowski: Those were the kappa drugs that worked better for women than for men.

Question from the chat room: What about our aging population and chronic pain?

Miaskowski: As people age, the number of pain problems increase. So, as our population ages, we'll see an increase in the prevalence of chronic pain problems, for instance arthritis, degenerative joint disease.

Question from the chat room: Should men ask for other types of pain medications then?

Miaskowski: Men should not ask for the three drugs I mentioned, pentazocine, nalbuphine and butorphanol. Those drugs are not used that frequently in clinical practice. Probably the more common one is butorphanol, which is Stadol. It's sometimes used to treat migraine headache, but I haven't seen any documentation that men who would take this drug for migraine respond less well. I don't know if that's been looked at.

CNN Moderator: Is there follow up research being planned?

Miaskowski: One of the issues is the hormonal mediation, which we're trying to evaluate. Another question -- is the effect in a dental pain model maintained with more than one dose of the drug? We've only done single dose studies, so we want to look at that. And then, what about differences in patients with chronic kinds of pain, for example, cancer pain. Do men and women respond differently?

Question from the chat room: Is there an evolutionary advantage to having gender differences in pain perception?

Miaskowski: There might be. If you think about, you know, back with the saber-toothed tiger, and men needing to potentially be able to withstand more pain during battle, there might be an advantage.

Question from the chat room: Congratulations on becoming president of the American Pain Society for 2002. As a nurse, will you be doing pain studies in places such as CCU or trauma units to see if gender differences are evident there?

Miaskowski: I don't study that area. My area is generally cancer-related pain and I have a colleague that works with dental-related pain. I hope others will. That's a good question.

Question from the chat room: Have there been any combination drug studies on pain and would that be more effective?

Miaskowski: There haven't been any combinations studies that I'm aware of that look at the gender differences. There is one study looking at gender differences in nonsteroidal anti-inflammatory drugs that showed that they had a gender preference for males, interestingly enough.

CNN Moderator: New guidelines for hospitals to treat pain were adopted in December and were supposed to go into effect in January. Is there any indication yet how those guidelines are working?

Miaskowski: These are guidelines published by the Joint Commission for the Accreditation of Health Care Organizations (JACHO) that require health care organizations to assess pain and treat it appropriately. It covers all facilities that are accredited by JACHO, both inpatient and outpatient. Health care organizations are developing processes to implement these standards. In my own opinion, I think it's having a major effect on the field of pain management. In most organizations, the focus has been on developing methods to assess pain, and then educating clinicians who care for patients, physicians, nurses, ancillary staff, in how to assess and manage pain. Another part of these guidelines is that organizations need to incorporate pain management into their quality improvement program. So, over the next year, I think we'll start to see progress in effectively managing pain in health care organizations.

Question from the chat room: In my hospital when we started treating pain more subjectively, and didn't hold back as much, there was quicker healing and overall less pain. This was reported to the nurses by our pain management nurse.

Miaskowski: There has been work looking at -- if you treat pain more aggressively will you improve outcome? The answer is yes. Studies have shown that, in patients that get aggressive pain management in the post-operative period, it decreased post-operative complications, such as pneumonia, improved wound healing and shortened length of stay. So aggressive management is important for all types of pain.

CNN Moderator: Do you have any final thoughts for us today?

Miaskowski: Pain assessment is extremely important, and it's important to educate patients as well as family care givers in how to effectively manage pain at home. About 75% of surgeries today are performed in an outpatient setting, and the majority of pain problems are managed by the family at home.

CNN Moderator: Thank you for joining us today, Christine Miaskowski.

Miaskowski: Thank you!

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Guidelines released for cancer pain treatment
April 4, 2001

American Pain Society
University of California-San Francisco

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