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Chapter: Medical Surgical Nursing: Pain Management

Factors Influencing the Pain Response

A person’s pain experience is influenced by a number of factors, including past experiences with pain, anxiety, culture, age, gen-der, and expectations about pain relief.


A person’s pain experience is influenced by a number of factors, including past experiences with pain, anxiety, culture, age, gen-der, and expectations about pain relief. These factors may in-crease or decrease the person’s perception of pain, increase or decrease tolerance for pain, and affect the responses to pain.

Past Experience


It is tempting to expect that a person who has had multiple or prolonged experiences with pain would be less anxious and more tolerant of pain than one who has had little pain. For most peo-ple, however, this is not true. Often, the more experience a per-son has had with pain, the more frightened he or she is about subsequent painful events. This person may be less able to toler-ate pain; that is, he or she wants relief from pain sooner and be-fore it becomes severe. This reaction is more likely to occur if the person has received inadequate pain relief in the past. A person with repeated pain experiences may have learned to fear the esca-lation of pain and its inadequate treatment. Once a person expe-riences severe pain, that person knows just how severe it can be. Conversely, someone who has never had severe pain may have no fear of such pain.


The way a person responds to pain is a result of many separate painful events during a lifetime. For some, past pain may have been constant and unrelenting, as in prolonged or chronic and persistent pain. The individual who has pain for months or years may become irritable, withdrawn, and depressed.


The undesirable effects that may result from previous experi-ence point to the need for the nurse to be aware of the patient’s past experiences with pain. If pain is relieved promptly and ade-quately, the person may be less fearful of future pain and better able to tolerate it.

Anxiety and Depression

Although it is commonly believed that anxiety will increase pain, this is not necessarily true. Research has demonstrated no consis-tent relationship between anxiety and pain, nor has research shown that preoperative stress reduction training reduces post-operative pain (Keogh, Ellery, Hunt et al., 2001; Rhudy & Meagher, 2000). Postoperative anxiety is most related to pre-operative anxiety and postoperative complications. However, anxiety that is relevant or related to the pain may increase the pa-tient’s perception of pain. For example, a patient who was treated 2 years ago for breast cancer and now has hip pain may fear that the pain indicates metastasis. In this case, the anxiety may result in increased pain. Anxiety that is unrelated to the pain may dis-tract the patient and may actually decrease the perception of pain. For example, a mother who is hospitalized with complications from abdominal surgery and is anxious about her children may perceive less pain as her anxiety about her children increases.


The routine use of antianxiety medications to treat anxiety in someone with pain may prevent the person from reporting pain because of sedation and may impair the patient’s ability to take deep breaths, get out of bed, and cooperate with the treatment plan. The most effective way to relieve pain is by directing the treatment at the pain rather than at the anxiety.


Just as anxiety is associated with pain because of concerns and fears about the underlying disease, depression is associated with chronic pain and unrelieved cancer pain. In chronic pain situa-tions, depression is associated with major life changes due to the limiting effects of the pain, specifically unemployment. Longer durations of pain are associated with an increased incidence of depression (Wall, 1999). Unrelieved cancer pain drastically interferes with the patient’s quality of life, and relieving the pain may go a long way toward treating the depression.


Beliefs about pain and how to respond to it differ from one cul-ture to the next. Early in childhood, individuals learn from those around them what responses to pain are acceptable or unaccept-able. For example, a child may learn that a sports injury is not ex-pected to hurt as much as a comparable injury caused by a motor vehicle crash. The child also learns what stimuli are expected to be painful and what behavioral responses are acceptable. These beliefs vary from one culture to another; therefore, people from different cultures who experience the same intensity of pain may not report it or respond to it in the same ways.


Cultural factors must be taken into account to effectively manage pain. Many studies have examined the cultural aspects of pain. Inconsistent results, methodologic weaknesses or flaws (Lasch, 2000), and failure of many researchers to carefully dis-tinguish ethnicity, culture, and race make it difficult to interpret the findings of many of these studies. Factors that help to explain differences in a cultural group include age, gender, education level, and income. In addition, the degree to which a patient identifies with a culture influences the degree to which he or she will adopt new health behaviors or cling to traditional health be-liefs and practices. Other factors that affect a patient’s response to pain include his or her interaction with the health care system and provider factors (Lasch, Wilkes, Montuori et al., 2000).


The nurse’s cultural values may differ from those of other cul-tures. The nurse’s cultural expectations and values may include avoiding exaggerated expressions of pain, such as excessive crying and moaning, seeking immediate relief from pain, and giving complete descriptions of the pain. 

A patient’s cultural expecta-tions may be to moan and complain about pain, to refuse pain re-lief measures that do not cure the cause of the pain, or to use adjectives such as “unbearable” in describing the pain. A patient from another cultural background may behave in a quiet, stoic manner rather than express the pain loudly. The nurse must react to the person’s pain perception and not to the pain behavior be-cause the behavior is different from his or her own culture.


Recognizing the values of one’s own culture and learning how these values differ from those of other cultures help to avoid eval-uating the patient’s behavior on the basis of one’s own cultural expectations and values. A nurse who recognizes cultural differ-ences will have a greater understanding of the patient’s pain and will be more accurate in assessing pain and behavioral responses to pain, as well as more effective in relieving the pain.


The main issues to consider when caring for patients of a dif-ferent culture are:


          What does the illness mean to the patient?


          Are there culturally based stigmas related to this illness or pain?


          What is the role of the family in health care decisions?


          Are traditional pain-relief remedies used?


          What is the role of stoicism in that culture?


          Are there culturally determined ways of expressing and communicating pain?


          Does the patient have any fears about the pain?


          Has the patient seen or does the patient want to see a tradi-tional healer?


Regardless of the patient’s culture, nurses need to learn about that particular culture and be aware of power and communica-tion issues that will affect care outcomes. Nurses need to avoid stereotyping patients by culture and provide individualized care rather than assuming that a patient of a specific culture will ex-hibit more or less pain. In addition to avoiding stereotyping, health care providers need to individualize the amount of med-ications or therapy according to the information provided by the patient. Nurses need to recognize that stereotypes exist and be-come sensitive to how stereotypes negatively affect care. Patients in turn must be instructed about how and what to communicate about their pain.


Age has long been the focus of research on pain perception and pain tolerance, and again the results have been inconsistent. For example, although some researchers have found that older adults require a higher intensity of noxious stimuli than do younger adults before they report pain (Washington, Gibson & Helme, 2000), others have found no differences in responses of younger and older adults (Edwards & Filligim, 2000). Other researchers have found that elderly patients (older than 65 years of age) re-ported significantly less pain than younger patients (Li, Green-wald, Gennis et al., 2001). Experts in the field of pain management have concluded that if pain perception is dimin-ished in the elderly person, it is most likely secondary to a dis-ease process (eg, diabetes) rather than to aging (American Geriatrics Society, 1998). More research is needed in the area of aging and its effects on pain perception to understand what the elderly are experiencing.


Although many elderly people seek health care because of pain, others are reluctant to seek help even when in severe painbecause they consider pain to be part of normal aging. Assessment of pain in older adults may be difficult because of the physiologic, psychosocial, and cognitive changes that often accompany aging. In one study, as many as 93% of nursing home residents reported being in pain daily for the past 6 months (Weiner, Peterson, Ladd et al., 1999). Unrelieved pain contributes to the problems of de-pression, sleep disturbances, delayed rehabilitation, malnutrition, and cognitive dysfunction (Miaskowski, 2000).


The way an older person responds to pain may differ from the way a younger person responds. Because elderly people have a slower metabolism and a greater ratio of body fat to muscle mass than younger people, small doses of analgesic agents may be suf-ficient to relieve pain, and these doses may be effective longer (Buffum & Buffum, 2000). Elderly patients deal with pain ac-cording to their lifestyle, personality, and cultural background, as do younger adults. Many elderly people are fearful of addic-tion and, as a result, will not report that they are in pain or ask for pain medication. Others fail to seek care because they fear that the pain may indicate serious illness or they fear loss of independence.


Elderly patients must receive adequate pain relief after surgery or trauma. When an elderly person becomes confused after sur-gery or trauma, the confusion is often attributed to medications, which are then discontinued. However, confusion in the elderly may be a result of untreated and unrelieved pain. In some cases post-operative confusion clears once the pain is relieved. Judgments about pain and the adequacy of treatment should be based on the patient’s report of pain and pain relief rather than on age.




Researchers have studied gender differences in pain levels and in responses to pain. Once again, the results have been inconsistent. In one study, women tended to report higher levels of pain than men and reported their highest intensity of pain during the day, while men reported the highest intensity at night (Morin, Lund, Villarroel et al., 2000). Kelly (1998) reported no gender differ-ences in pain.


Riley, Robinson, Wade et al. (2001) compared pain intensity, pain unpleasantness, and pain-related emotions (depression, anx-iety, frustration, fear, and anger) in men and women who were asked to rate their experiences with chronic pain. Women had higher pain intensity, pain unpleasantness, frustration, and fear compared to men. Robinson, Riley, Meyers et al. (2001) reported that men and women are socialized to respond differently and differ in their expectations relative to pain perception. In a study of responses of men and women to chronic pain and anxiety, Edwards, Auguston and Fillingim (2000) noted no difference be-tween genders regarding pain and depression. There was, however, a difference in anxiety and gender, with men being more anxious about their pain.

The pharmacokinetics and pharmacodynamics of opioids dif-fer in men and women and have been attributed to hepatic me-tabolism, where the microsomal enzyme activity differs (Vallerand Polomano, 2000). Genetic factors play a role in the varied re-sponses to nonsteroidal anti-inflammatory drugs (NSAIDs) seen in men and women (Buffum & Buffum, 2000).

Placebo Effect

A placebo effect occurs when a person responds to the medica-tion or other treatment because of an expectation that the treat-ment will work rather than because it actually does so. Simply receiving a medication or treatment may produce positive effects. The placebo effect results from the natural (endogenous) pro-duction of endorphins in the descending control system. It is a true physiologic response that can be reversed by naloxone, an opioid antagonist (Wall, 1999).


A patient’s positive expectations about treatment may increase the effectiveness of a medication or other intervention. Often the more cues the patient receives about the intervention’s effective-ness, the more effective it will be. A person who is informed that a medication is expected to relieve pain is more likely to experi-ence pain relief than one who is told that a medication is unlikely to have any effect.


Researchers have shown that different verbal instructions given to patients about therapies affect patient behavior and significantly reduce opioid intake. Pollo, Amanzio, Arslanina et al. (2001) studied the effect of information and expectations in patients who had undergone thoracotomy. Patients in three groups were given an intravenous infusion of normal saline solution and could re-ceive a dose of buprenorphine (Buprenex) on request. One group was given no information about the analgesic effect of the regimen; one group was informed that the infusion received could be an analgesic or a placebo; the third was told that the infusion was a powerful analgesic. Although the three groups did not differ in reported level of pain, the group told that the infusion was a pow-erful analgesic used less opioid than the other two groups.


A meta-analysis of 114 published research studies comparing placebo with no treatment showed similar results (Hrobjartsson Gotzsche, 2001). The studies analyzed investigated many clin-ical conditions; 27 of the 114 trials involved the treatment of pain. Other clinical conditions in the studies included obesity, asthma, hypertension, insomnia, and anxiety. Pain was the only condition in which a placebo effect was demonstrated.


The American Society of Pain Management Nurses (1996) holds the position that placebos (tablets or injections with no ac-tive ingredients) should not be used to assess or manage pain in any patient regardless of age or diagnosis. Furthermore, the group recommends that all health care institutions have policies in place prohibiting the use of placebos for this purpose. Educational pro-grams should be conducted to educate providers about effective pain management, and ethics committees should assist in for-mulating these policies (Chart 13-2).


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