Cultural Differences in the Treatment of Pain

Due to the rapid increase in prescription drug abuse, the Centers for Disease Control and Prevention has declared prescription drug abuse an epidemic. The latest National Survey on Drug Use and Health indicates that over 70 percent of people who abused prescription pain medications obtained them from friends or relatives, while approximately 5 percent got them from a drug dealer or over the Internet.

Fighting prescription pain medication abuse is an uphill battle with no easy solution. It requires a comprehensive approach to address the problem at clinician, patient, and manufacturer levels. The Food and Drug Administration requires the manufacturers of long-acting and extended-release opioid medications to submit a risk evaluation and mitigation strategy (REMS) that focuses on educating the prescribers of safe use of these medications. The effectiveness of the opioid REMS is yet to be seen. Some pharmaceutical companies have developed new opioid drug formulations to deter drug abuse. What else can be done to mitigate prescription pain medication misuse?

Logically, if we decrease the prescription of opioids, we can decrease the abuse of opioids. Opioids, some of them the most powerful painkillers available, can be life-saving medications for cancer patients and some patients with chronic, severe, noncancer pain. However, are these medications overprescribed? In other words, can some pain be treated with an alternative with less or no abuse potential? In China, opioid use is less common due to cultural differences in pain perception and management. In Chinese culture, pain itself is not generally considered a disease that needs treatment. One is expected to try to “tough it out.” Even patients with severe acute pain might not take painkillers, some for fear of the addiction potential, some holding it off for worse pain to come. Chinese clinicians generally reserve opioids for cancer patients. For acute short-term pain such as postoperative pain, opioids might be used in a hospital setting, but patients are not discharged home with prescriptions for opioid medications. Opioid is also generally not the choice for chronic, noncancer pain, which is treated in China with physical therapy, massage therapy (in a clinic or self-administered), herbal medicine (oral or topical), and acupuncture. Non-opioid pain medications are used in some patients on an as-needed, short-term basis.

Is it feasible to replace opioid medications with these alternative measures in America? For some patients, the answer may be “yes,” but for others, no. Let’s look at postoperative pain for instance. In China, postoperative patients are usually bedbound for some time and taken care of by family members. According to tradition, a woman is to stay home for a month after giving birth, and grandparents usually pitch in to care for the newborn. Therefore, there is less need for powerful painkillers. American patients on the other hand, pride themselves as independent and request a quick return to normal life. After caesarean sections, women need to be ambulatory to care for their babies. This cannot be achieved without medications that provide quick pain relief. Patients who do not respond to nonsteroidal anti-inflammatory drugs require opioids. As for chronic, noncancer pain, the alternative measures, such as herbal medicine and acupuncture, may be too novel to be accepted by the majority of the general population. In addition, herbal medicine may not provide quick onset action, which hinders its use in patients needing immediate pain relief.

Despite the obstacles, these alternative pain management remedies can at least complement the mainstream biomedicine and thereby decrease the reliance on opioid medications. The increased recognition of osteopathic medicine and integrative medicine in this country will help to introduce more patients to alternative pain treatment.

By the American standard, pain is undertreated in China. With economic growth, medical care in China will eventually focus more on improving patients’ quality of life, and not just treating and controlling the diseases. Easier access to pain medications may bring with it the problem of prescription drug misuse. Nonetheless, the fear of drug misuse should not be a reason to deny patients effective treatment options. In any country, the medical community and the regulators should seek to keep the fine balance between access to opioid medications by patients who really need them, and steps taken to control the risk of potential misuse of these medications.

All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions.


Dear Hua,

Thank you very much for your insightful article, I really enjoyed it because it shows wisdom and compassion, a rare balance when discussing the benefits/drawbacks of traditional versus alternative medicine. What is interesting is that in the case of China and other ancient cultures, the once "traditional" approach is now called "alternative" and vice-versa.

Kind regards,

Dear Carmen,

Thanks very much for taking time to comment. You pointed out nicely how much the world has changed. Some Chinese pharmaceutical companies are trying to obtain approval in the US and EU to market certain herbal medicines to treat heart disease, high cholesterol, etc. If they can prove efficacy and safety by western standards, it will provide a nice bridge between "traditional" and "alternative" medicine.

Dear Dr. Carroll,

I applaud your interest in cultural differences in the management and perception of pain. In America we have come to understand chronic (not acute) pain as a disease unto itself. This approach recognizes that chronic pain causes many physiological and psychological changes in the sufferer and needs to be treated. From a practical perspective it is similar to cancer treatment and palliative care. When the cause of pain is known (cancer or say non-cancer nerve damage) but treatment of the cause (a cure) is beyond the scope of current medical science, the the pain itself becomes the focus of treatment. While the treatment of pain is humanitarian it is also no different than the treatment of any other disease in that good disease management improves quality of life, sense of well being, function and may prolong life. As with any disease, treatment is not without risk. Treatment of Rheumatoid Arthritis with the newer "biologics" runs the risk of the patient developing a cancer or overwhelming infection resulting in death. The risks with opioids are well known but it is not the risks to the patient (although some patients will develop addiction) that is different with opioids, it is the abuse of these drugs by persons who are not patients (or by patients who develop addiction) that sets these drugs apart from most other medications (not all other medications as benzodiazepines, stimulant drugs and a few others share in this). Patients and non-patients do not seek out arthritis drugs for abuse but they do seek out opioids for abuse. This unique aspect of opioids leads the medical management of pain to intersect with judicial attempts to control drug abuse. This is the key difference between Pain Medicine and all other branches of medicine.

As a Pain Medicine and Addiction Medicine physician, I think the solution to this problem lies in physician education. Much of the problem in the U.S. has occurred because U.S. physicians have little or no training in pain management or addiction medicine. This is not a major problem when opioids are used only for brief periods, for a few days after surgery for example, but it has caused a major problem with the long term use of opioids for chronic pain. If other countries are going to utilize opioids for chronic non-cancer pain management they would do well to look at the U.S. and learn from our mistakes. In my opinion the key to minimizing problems associated with the long term use of these drugs lies in physician education. Utilizing alternative medicine approaches will suffice for some patients and can be tried early on in most patients but clearly these techniques will not suffice for many patients with severs chronic pain. For the foreseeable future opioids will remain the mainstay for this latter group.

Best Regards,
Don Taylor, MD
Pain Medicine
Addiction Medicine
Clinical Research

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