2/12/97
Contact: Mike Goodkind, (415) 725-5376 or 723-6911.
Comment: Dr. Eugene Carragee may be contacted at (415) 723-7797.
Editors, reporters please note: Black-and-white photos and color transparencies are available showing Dr. Carragee with patients in Vietnam.
STANFORD -- 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.
U.S. patients with fractures of the femoral shaft (thighbone) were much less satisfied with the narcotic pain relief 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 (orthopaedic 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 will present the new findings Thursday, Feb. 13, in San Francisco at the annual meeting of the American Academy of Orthopaedic Surgeons.
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 in the bone to stabilize the fracture and promote healing.
All patients in the study received morphine or equivalent drugs, known as 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 in the study.
On average, the 25 Vietnamese patients in the study (at two hospitals in Hanoi and one in Ho Chi Minh City) received doses equivalent to 0.9 milligrams of morphine per kilogram of body weight per day. Doses for the 25 U.S. 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/day. 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 percent of the Vietnamese group -- compared with 80 percent of the U.S. group -- said they felt their pain control had been inadequate, Carragee said.
Although the study didn't 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 U.S. 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 percent of the U.S. group -- compared with 76 percent 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 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 said he originally thought of doing this study after noticing the markedly smaller -- but apparently effective -- doses of morphine commonly given surgery patients in Southeast Asia. Some colleagues were skeptical of the value of such a comparison because they thought Vietnamese patients might fear retaliation for appearing to complain or undervalue their care. "But the Vietnamese patients we talked with seemed vociferous and outspoken when complaining about other aspects of their situation, such as missing work or having difficulties with transportation to the hospital," said Carragee.
In 1992 Carragee worked with the United Nations peacekeeping forces in Batambang and Phnom Penh, Cambodia, caring for Vietnamese refugees of the Cambodian civil war. That same year, he served with the nonprofit organization Orthopaedic Overseas. In 1994 he worked in Vietnam as a physician on a project of the U.S. Agency for International Development.
His colleagues on the pain study included Dr. David Burton, clinical professor of functional restoration (orthopaedic surgery) at Stanford and head of orthopaedic surgery at Santa Clara Valley Medical Center; Thao P. Truong, a pre-dental student at the University of California, Santa Cruz; and Stanford medical student Daniel Vittum.
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