Quarantined people have to go out to get their prescriptions and can’t get a backup supply.
by Maia Szalavitz
Mar 24 2020, 6:00am
Quarantined people have to go out to get their prescriptions and can’t get a backup supply.
by Maia Szalavitz
Mar 24 2020, 6:00am
As you may know or have read in our President’s Column, Dr. John Satterthwaite has stepped down from his long-standing role as SPS Treasurer and will remain on the board as a non-voting member. We are grateful for his 34 years at the financial helm of the organization and appreciate his wisdom, historical perspective and recommendations that have kept SPS healthy, financially sound and robust.
As such, we are pleased to announce the appointment of Randy Roig, MD as the Southern Pain Society’s new Treasurer. Dr. Roig has been on the SPS board as at-large director for the past year. Due to his extensive finance and non-profit experience, coupled with his leadership interest in our organization, Dr. Roig has stepped into his new role effective January 1, 2020. We are delighted to have his expertise. Dr. Roig will be on the 2020 SPS ballot as a nominee for formal election.
Dr. Randy Roig is a resident of New Orleans and is a summa cum laude graduate of the Tulane School of Engineering and the LSU School of Medicine in New Orleans. He completed his physical medicine and rehabilitation (PM&R) residency in 1996, serving as chief resident. He is holds American Board of Medical Specialties (ABMS) certifications in PM&R, spinal cord injury medicine, and pain medicine. He is presently practicing at the Southeast Louisiana Veterans Health Care System, where he is the Associate Chief of Staff for Education and Designated Education Officer, Assistant Chief of the PM&R Service, and Chief of the Pain Medicine Section. He is on the faculty of both LSU in New Orleans and Tulane University, as well as Emory University in Atlanta, Georgia. He serves as the program director for the pain medicine fellowship training program and clinician co-director of the course in musculoskeletal medicine and dermatology at LSU. He is volunteer Executive Editor of Rehab in Review, a monthly journal for the field of physiatry published by Emory University.
Dr. Roig has served on numerous nonprofit boards and committees within the medical community, including the Association of American Medical Colleges and the American Academy of Physical Medicine and Rehabilitation (AAPM&R). He also serves as co-chair of the Medical/Legal Interprofessional Committee of the Louisiana State Medical Society (LSMS) and the Louisiana State Bar Association.
Dr. Roig’s new role includes the financial stewardship of SPS and from our by-laws: “The Treasurer will be responsible for the custody of the Society’s funds and securities and for maintaining a full and accurate record of receipts and disbursements. He shall act within the confines of good business practices and under the supervision of the board of directors.”
Gepants are small molecule calcitonin gene-related peptide (CGRP) receptor antagonists. The preventive CGRP monoclonal antibodies(Aimovig, Emgality, Ajovy) are large molecules, delivered once per month as a SQ injection. Seven gepants have been developed since 2004. (1) Telcagepant was extensively studied, but withdrawn due to hepatotoxicity concerns. CGRP has many effects throughout the body. CGRP triggers a cascade of inflammatory mediators that feed into the trigeminovascular system. By blocking CGRP, the gepants stop the process prior to inflammation.
Regarding migraine, CGRP is an inflammatory compound. They will initially be utilized as migraine abortives, but eventually they will also be used to prevent migraine. The gepants may be helpful for 3 groups of migraineurs. They will be prescribed for a number of patients who found triptans (sumatriptan, rizatriptan, zolmitriptan, etc.) to be ineffective. In addition, gepants will be used for certain patients who cannot tolerate triptans. Finally, for those patients with significant cardiac or cerebrovascular risk factors, the gepants may be relatively safe, since they do not constrict cardiac or cranial arteries. While efficacy is modest, these are well tolerated medications.
The first gepant to come to market will be ubrogepant. Almost 2,700 patients participated in the ubrogepant ACHIEVE studies. (2,3) The doses have ranged from 25mg to 100mg. The t-max is 0.7 to 1.5 hours. Approximately 20% of patients who used the 50mg dose were pain free after 2 hours. While 25mg and 100mg tablets of ubrogepant were evaluated, it is likely that 50mg will be the primary dose. Ubrogepant was well tolerated, with 2% to 5% of patients reporting nausea, somnolence, dry mouth, dizziness, or upper respiratory tract infections. No serious adverse events were reported. The safety and tolerability were also explored in a 52 week extension study. Few adverse events, and no hepatotoxicity was reported. The effect of ubrogepant on the patient’s most bothersome migraine symptom was evaluated 2 hours post-dose. 39% of those treated with ubrogepant reported that their worst migraine symptom was resolved. The therapeutic gain for ubrogegepant (active drug vs. placebo) is relatively low, 6.4%-9.4%. In comparison, the therapeutic gain for sumatriptan is 16%-21%.
Rimegepant is another gepant, in development for abortive and preventive use. The dose is 75mg, with a t-max of 2 hours. In the 2 main trials, 19.4% of patients achieved pain freedom at 2 hours. (4) 37% of patients reported freedom from their most bothersome symptom. As with ubrogepant, no significant liver toxicity was reported. Adverse events were low, with nausea being reported by 1.4% of patients. The therapeutic gain for rimegepant is 5% to 7.6%.
A third gepant, atogepant, is currently being studied.
The gepants will be a useful alternative to triptans. Many patients find triptans to be ineffective. Some migraineurs cannot tolerate the adverse effects of the triptans. For certain patients with cardiovascular risk factors, triptans may not be completely safe. Gepants will be considered in these clinical settings. The initial (2 hour) efficacy rates are fairly low, but it appears that gepants may become more effective over 2 to 8 hours. During the trials, these were fairly well tolerated medications. It will take at least several years before we are able to accurately assess the true adverse effect profile of the gepants.
1. Olesen J, Diener H-C, Husstedt IW et al Calcitonin gene-related peptide receptor antagonist BIBN 4096 BS for the acute treatment of migraine. 2004. N Eng J Med 350:1104-1110.
2. Allergan Announces Positive Top Line Phase 3 Clinical Trial for Ubrogepant- an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine. Available at http://www.allergan.com/news/news/thomson-reuters/allergan-announces-positive-phase-3-resul.
3. Allergan Announces Second Positive Phase 3 Clinical Trial for Ubrogepant- an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine. Available at http://www.allergan.com/News/News/Thomson-Reuters/Allergan-Announces-Second-Positive-Phase-3-Clinica.
4. Biohaven Announces Successful Achievement of Both Co-Primary regulatory Endpoints in Two Pivotal Phase 3 Trials of Rimegepant an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine Available at https://biohavenpharma.com/wp-content/uploads/2018/03/CONFIDENTIAL-BIOHAVEN-PRESS-RELEASE-FINAL-v2.pdf.
Lisa Edgerton, PharmD, BCPS, CPP, Olivia Herndon, MA, and Joseph Pino, MD, MHA
Wilmington is a community in southeastern North Carolina known for its beautiful beaches, historic river-walk district, and the largest domestic television and movie production facility outside of California. In April of 2016, this city also became recognized for something else.
In 2016, Castlight Health released a report titled “The Opioid Crisis in America’s Workforce.” The study noted those who abused opioids are more likely to live in the rural south with 22 of the top 25 cities in Southern states. Furthermore, it named Wilmington, NC as the city with the highest abuse rate in the United States. In response, our medical community mobilized and recruited partners from disciplines outside of healthcare to reduce harm from opioids in our region.
Through a “call to action” where more than 100 regional stakeholders and leaders, the Community Partners Coalition (CPC) was born. This CPC aims to improve collaboration and coordination between those who provide care to individuals seeking access to mental health and substance use services by aligning efforts in the region. A primary focus of the CPC was to improve safe medication disposal options in our region by expanding medication take-back events and permanent drop boxes.
The first medication take-back event was held at New Hanover Regional Medical Center (NHRMC) in March 2009. This event was held at one location on our hospital’s main campus in New Hanover county. NHRMC partnered with the Wilmington Sheriffs office and collected 140 pounds of medication at that event. This solo event continued biannually however, dates were chosen based upon availability of volunteer coordinators and coinciding community events. NHRMC continued to host this single site medication take-back event biannually through the Spring of 2017.
Through the support of the CPC, in the Fall of 2017, this event was expanded to 9 locations within 4 counties and collected 3,680 pounds of medication and 29,675 needles or sharps. This biannual medication take-back event has continued to grow now hosting 19 locations spanning 6 counties in our region.
In October 2019, we collected almost 6,000 pounds of medication, 43,000 needles or sharps and 178 medications, valued at $55,000, that were donated to a local clinic serving those without resources for re-dispensing. Expanding our medication take-back event to 19 locations did present some challenges along the way.
To expand our reach, leaders of the takeback event needed to engage in detailed planning and consider logistical challenges. We aligned our event dates to the Drug Enforcement Administrations (DEA) National Prescription Drug Take Back Day. Aligning with the DEA allowed us to plan for future events as these dates are standardized on the last Saturdays in April and October. Alignment also enabled law enforcement to register event locations in their national website. This site is searchable and provides a map of locations nearest to search area. Alignment with the DEA also connected us to our regional State Bureau of Investigation (SBI). This partnership enabled us to receive support including standard boxes used to collect medications at each take-back location. The SBI supplied NHRMC with 250 evidence boxes that were distributed to site leaders at each take-back location.
When planning to staff each of our sites, federal rules indicate that law enforcement must be present at each medication take-back location. When planning for our Fall 2017 expansion, we discovered that our hospital law enforcement officers could staff all NHRMC and affiliate locations. At the Fall 2017 event, we were able to utilize NHRMC police for 5 of the 9 locations. This allowed us to extend our partnership with local sheriff’s offices and expand to additional sites. We continue to collaborate with our regional county sheriff departments who provide an additional 1-2 law enforcement officers for each location.
NHRMC company police have been instrumental in not only staffing these events but also coordinating with regional law enforcement agencies. They collect and store the medication until the “burn day”. This often occurs 2-3 days after the takeback event. Our event has become so large that NHRMC law enforcement transports over 100 boxes of medication. As a result of our success, we have outgrown the transport capacity of our standard vehicles. We now either have to rent commercial trucks or borrow large box trucks from another department in our hospital.
In addition to organizing law enforcement to be present at each site, we decided we would accept needles or sharps at each of the 19 drop off locations. This became an issue for sites that were not affiliated with a health system because they did not have sharps containers at their locations. Prior to each event, NHRMC now donates sharps containers to each of these sites. Following the event, we now also coordinate with either law enforcement or a volunteer at the site to collect the sharps bins.
To raise awareness of this multi-county, multi-site drug takeback event, we approached our hospital’s marketing department to help us by advertising this event. They created a universal flyer listing each drop off location by county. This flyer is printed in a variety of sizes and is posted across our health system and to each of our drop-off location partners. We also advertise in advance of this event on social media, radio stations and local newspapers as well as media outlets on the day of the event. We also created a NHRMC webpage dedicated to medication disposal where we post our upcoming flyer and list locations of all area permanent drop boxes. Through this effort, we also learned that funeral homes, hospice care centers, veterinarian offices and churches are effective locations to advertise these events and added these sites to our marketing locations for future events. We also realized that we needed to create a Spanish-version of our flyer to appeal to other segments of our community and plan to do so for our next event.
We also discovered that we needed to develop a standard process to enable us to repurpose unused medication. Medication take-back locations staffed with NHRMC volunteers may collect any unused medications and can donate them to a charitable clinic. These medications must meet North Carolina repository rules and regulations to qualify for donation. Following the event, each unused medication collected is visually inspected by a pharmacist to ensure it meets all applicable federal guidelines for donated medications. By following this process, we could donate $ 55,000 of medication to one of our local, charitable clinics.
During our medication take-back expansion in 2017, NHRMC also installed three permanent medication drop boxes across several sites within our health system. Medication drop boxes were installed on the main campus within our Outpatient Pharmacy, at our free-standing emergency department located off campus, and at our critical access hospital located in a neighboring county. It was anticipated that the drop boxes would need to be emptied once a month. When first installed, the permanent drop box in our main hospital, which holds roughly 55 pounds of medication, needed to be emptied every 9-10 days. This was not anticipated. We now collect 1,600 pounds of medication in our 3 permanent medication boxes annually.
Like other communities across the country, Wilmington and our surrounding area have been significantly impacted by the opioid crisis. Through the development of the CPC and the leadership of NHRMC, we expanded our drug takeback events to multiple sites in multiple counties in our region. As a consequence of our success, we also discovered we needed to coordinate law enforcement at each location, establish safe storage, rent large trucks to transport thousands of pounds of medication collected at each event, develop a process to reclaim medication and manage high volume disposal of medication in permanently installed drop boxes across our health system. We are fortunate to have such an engaged community to collectively work to reduce harm from medication. Hopefully, these lessons learned will help you do the same.
Ann Quinlan-Colwell, PhD, APN
Developing this president column is no small task. It is written to pay tribute to our friend and mentor Dr. John Satterthwaite who recently stepped down from serving as the treasurer of the Southern Pain Society during the last 34 years. John nurtured and guided SPS while significantly impacting many SPS members in ways that can never be repaid. As Dr. Mordi Potash said so well: “it is an absolute truism that there would not be a Southern Pain Society in existence in 2020 if not for John Satterthwaite.” This was echoed by Lori Postal who recently wrote John Satterthwaite has served the Southern Pain Society as a “trusted mentor, historian, voice of reason and steward of our finances.” Not only is John a man of many talents who has contributed greatly to the world of pain management but he has paradoxical qualities as well. Although he is often a wise sage when on the stage, he is equally comfortable and meaningful being the guide on the side. He is often a man of few words yet a great storyteller. John has always reminded Dr. Geralyn Datz of “a firm but fair patriarch, if you are under his wing, he is protective and compassionate.” Several people make the analogy of John steering and guiding the SPS ship. Dr. Harry Gould appreciated John’s welcoming spirit and guidance for the “kids in the candy shop” (the SPS Board of Directors) “to get the most with what we had” (financially). John’s devotion and perspective on the history and the mission of SPS have been priceless. As I recount these observations and impressions I am nodding my head in agreement. John is an expert physician, teacher, patriarch, sage, guide, shepherd, steward, mentor, storyteller, navigator, voice of reason, friend and so much more.
Dr. Eric Pearson particularly loves John’s “wisdom and amazing dry sense of humor” which was reflected in preparing for this column. After sending John some questions about his life, he sent me the “answers to the essay test.” He was the son of a Station Manager for Capital Airlines born in Clarksburg, W.V. but moving frequently during his childhood and teens. He had several early occupational goals including being “a trash collector because you could ride on the outside of the truck,” an Air Force pilot and “several other questionable thoughts.” His focus changed while working summers as an orderly and surgical tech in the OR in Georgia, where the anesthesiologists encouraged him to consider anesthesiology instead of surgery which as a fan of the TV show Ben Casey, he found interesting. In fact, he initially “thought of going into Thoracic Surgery, but the residency was too long, and “ultimately chose anesthesiology because you work in a climate-controlled area and can wear pajamas all day (ha-ha)… It is immediate treatment response medicine and sleeping patients don’t complain.”
John noted that his “involvement with pain was accidental.” After practicing for 2-3 years, a neurosurgeon from Memphis, TN moved to the area and asked John to do epidural steroid injections. As a result, other ortho and neuro doctors followed with similar request, and he became the first person in Greenville, S.C. to be “practicing pain.” Subsequently other surgeons asked if there were injections that could administered for “patients with an unusual pain with discoloration and extremity swelling.” John’s interest was sparked in what was then RSD (reflex sympathetic dystrophy) which he began treating. He was told by a local orthopedist that “we never had RSD in Greenville until you came to town.”
John joined SPS in March of 1987 which qualified him as a Charter Member. He clarifies: “at least that is what my certificate says.” His intertest in RSD led him to attend his first SPS meeting in 1989 because they had a day long program on “RSD” at the SPS regional section meeting, held in conjunction with APS. Wearing his historian hat, John wrote: “attendance at the regional meetings tended to be greater than the APS meetings and we were subsequently uninvited to hold our meetings with APS. The first independent SPS meeting was in 1991 in Chattanooga, TN. I have been to each meeting since then except one.”
“In 1989, the President of SPS Dan Hamaty, whom I knew because of his involvement with Pain Therapy Centers (PTC), asked me to become Treasurer which I accepted.” Because of the involve tax and registration paperwork necessary to transfer the office, John continued to act in that capacity until 12/31/2019. “If not for my current health issues, I would continue as I get to interact with some of the giants in the field and it is fun. I was asked to run for SPS President by Renee Rosomoff 1996, but declined because of this” (responsibility to the role of treasurer).
Because of his interest in pain, John developed a relationship with Dr. C. David Tollison who was a Clinical Psychologist specializing in pain. Dr. Tollison set up a multidisciplinary pain treatment program in hospital system where John was located. This was the start of PTC of which John became Medical Director with Dave as Program Director. “Due to the financial success of PTC, other hospitals in the region became interested. We started a program in Charlotte with Dr. Hamaty as Medical Director, and at one time there were several programs in four states. Unfortunately, with changing reimbursement, these programs ultimately died out.”
John noted that he has “been surrounded by some of the greats in the field of pain, but the person who has had the greatest influence was Dave Tollison. We have practiced together for 30 years. We have edited several books and spoken at many events. One of my prized possessions is a copy of the 3rd edition of our “Practical Pain Management” which was translated into Chinese. This was the third bestselling pain text behind Bonica and Raj.” “Others especially Hu and Renee Rosomoff had a tremendous influence on my life in pain management as well.”
John felt fortunate to meet or work with Hu and Renee Rosomoff, Marty Grabois, Bert Ray, Stan Chapman, Peter Staats, Jeannie Koestler, Ben Johnson, Dan Doleys, Todd Sitzmann, and many other leaders and pioneers in the field of pain management during the last 30 years. He has many SPS related reminiscences. His most “memorable SPS event was at a Board of Directors meeting in Charlotte in 1996. President Renee Rosomoff was notorious for micromanaging and long meetings, but this one started at 11:00 am and was finally over at about 1:30 the next morning when someone (not one of us although I wish it had been) set off the fire alarm at the hotel. Although we were still not finished, nobody went back to the meeting room following the “all clear”. Even Renee’s husband Hu, who came to all Board meetings because of his love for the organization, had left much earlier. (FYI, Hu Rosomoff was founding President of SPS, and subsequently served as APS President, AAPM President, and was a giant in the field of pain. I was privileged to call him a friend.)” Another favorite memory was that Hu and Renee “attended every Annual Meeting together. They sat on the front row, in front of the speaker, so you knew they were listening. After every speaker Hu would stand and provide commentary. All of it useful, but sometimes critical. I presented a talk on “Epidural and other steroid injections” at one of our meetings. I knew Hu was a multidisciplinary treatment advocate. Despite his being a neurosurgeon, he was very critical of procedures or medications for pain treatment. His clinic in Miami was one of the leading multidisciplinary pain treatment facilities in the world. When he stood up, I held my breath until he said my presentation was the most objective and comprehensive discussion on injections he had ever heard. Quite a relief.”
A memory lane of pain management for John reflects significant change. It also reflects the “honesty, genuineness, firm opinions rooted in his experience and desire for others to succeed” that Dr. Geralyn Datz described. He relays that today “it has become almost impossible to treat patients appropriately. In the early years, we treated patients based on our understanding of the pain mechanisms and pathophysiology. We experimented with injections, infusions, anticonvulsants, antidepressants, calcium channel blockers, anti-inflammatory, and other medications. This laid the groundwork for much of what we use now or try to. Now every pharmacist, insurer, lawyer, and government/insurance bean counter are practicing medicine and preventing, or impeding, treatment of patients. Malpractice suits and regulatory agency threats are constant threats. Cost effective has become the mantra instead of patient effective. I agree with evidence-based medicine, but we had no evidence in the early years. In fact, many of the studies now quoted began with a ‘what if we try this?’ That was our work. It’s hard to formulate a treatment program with a bureaucrat or insurer standing in the way. Yes, PT, complementary treatments, behavior modification are excellent alternatives to opioids, but no insurer will cover them. Private practice is handcuffed by payors.”
When asked about the current opioid abuse/misuse crisis, John replied: “I think back to Russell Portenoy who basically asked, ‘what is the difference in pain from a vertebral fracture from metastatic cancer and from osteoporosis?’ Answer, there is none except the cancer patient will probably die sooner than the osteoporosis patient. This was the beginning of the use of opioids for non-malignant pain. Unfortunately, practitioners were unable or unwilling to appropriately screen and evaluate patients and prescribing went out of control. It has become extremely difficult in this day of volume practice to appropriately evaluate who is a candidate for opioid use and who is not. Evaluating who is and is not a candidate for chronic opioid use is not easy and is quite time consuming, and you must be able to say no. Opioids are also being inappropriately prescribed for acute pain. A postop hernia repair does not need 30 mg of Oxycontin for pain management. Back strain does not require initial treatment with opioids when other modalities have not been tried. It is just quicker and easier to write a script than do a more complete evaluation and get other treatments declined. Finally, there are people who misuse or abuse opioids, and many practitioners do not take the time to weed them out. Unfortunately, there is not a lab test for pain, and a history and physical have become relics of the past while lab studies, computers, and x-ray have taken over.”
If John could wave a magic wand to achieve a program/practice of perfect pain management, he would have two wishes. “First, patients would be honest and not lie or manipulate, but this will never happen. Second, there would be complete coverage for interdisciplinary treatment to include behavior modification, psychological evaluation, physical therapy, aquatic and other therapy, medications as indicated, injections as indicated, necessary evaluations and procedures, rehab and work hardening, and last but not least, any opioid prescriptions for longer than two weeks needs to be approved by a specialist. In fact, as many clinics do, no one should be placed on opioid therapy without a psychological evaluation from a qualified pain psychologist and undergo ongoing eval and treatment.”
In conclusion to reflect the wonderful Satterthwaite wisdom that Eric Pearson noted, John offered a few pearls and words of wisdom for pain management clinicians. He stressed that “the key word is clinician. Remember you are a professional. If you are a one trick pony, one trick is all you have. If the only thing you have is a hammer, you will be useless for anything but a nail.” “Pain has been defined by the IASP as An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. The proposed new 2019 definition is: An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury. In those definitions notice three factors: actual or potential tissue injury, sensory experience, emotional experience. Each of these aspects needs to be addressed. Injections, pills, or counselling only deal with one issue. Pain is a complex issue so there is no simple answer or treatment. So, stop trying to hammer that bolt through the steel plate with your hammer.”
Ann Colwell-Quinlan, PhD, APN
The 2019 Southern Pain Society (SPS) conference was held September 13 through 15 in New Orleans. We enjoyed reconnecting with those who attended previous conferences and meeting a number of first-time attendees. It was great to have a new attendee share that “this is great – so much better than I ever expected.”
This was definitely a conference during which it would be difficult to find someone who didn’t learn at least a few new things and/or wasn’t encouraged to think about things in a new way. A slate of well-informed speakers shared their knowledge with the attendees.
The speakers enlightened us about the various new perspectives and options of integrated pain care. The conference commenced on Friday afternoon with Dr. Blake Fagin providing education on prescribing controlled substances as well as how to appropriately treat patients with Substance use disorder. Using numerous examples, he made the Louisiana mandated three hour Controlled Dangerous Substance education enjoyable while meeting the state requirements for content. Dr. Steven Stanos opened the Saturday program by escorting us through the history of how pain professionals arrived at a new crossroads of pain management. He then led us to comprehensively provide safe pain care. Appreciation for and aspects of comprehensive pain management were discussed from a psychological aspect by Dr. Jennifer Murphy. Then Dr. Jeffrey Sibrack explored the role of the endogenous opioid system with pain management.
We learned about some innovative options on the horizon. Dr. Ashley Mullens updated the group on the Therapeutic Cannabis Program at the LSU AgCenter including some very interesting research studies using cannabis with zebra fish and rodents. A very timely evidence based presentation about using stem cells for pain management was given by Dr. Amadeus Mason. Then Dr. Forest Tennant explored the role of hormones in pain control. Monique Serpas, PT, DPT shared the various analgesic techniques used by physical therapists. She and Dr. Stanos both discussed the importance of function in pain control. In a sense Dr. Dan Doleys brought us full circle by updating on screening for opioid use disorder prior to starting opioids. We concluded with Dr. Charles Figley educating us about and encouraging us to pursue commitments to self-care personally and to support other members of SPS in pursuing the same for themselves. We also were fortunate to view several excellent posters.
For me our annual business meeting was an amazing event. First, I had the pleasure to present the President’s Award for Distinguished Service to the SPS to Dr. Thomas Davis who has served as secretary of SPS for many years as well as co-chair of this amazing 2019 conference. During that time Dr. Davis has always had a calm, even, well-balanced approach to any issue that arose. Then, Dr. John Satterwaite presented the 2019 Hubert L. and Renee S. Rosomoff Award for Excellence in Pain. I can only remember having an intense emotional response when I heard him say my name. To say that I was speechless is an underestimation. I doubt there is any greater honor than to be recognized for excellence by professional peers and partners. Now that I have regained cognition, I am extremely honored and appreciative to have been selected to receive this prestigious award. I also am very appreciative for all of the wonderful teachers, mentors, peers and especially patients who have taught me so much about working with people who live with pain. It certainly is incentive to continue to work with SPS to pursue our mission “to serve people with pain by advancing research and treatment and to increase the knowledge and skill of the regional professional community.”
My appreciation also goes to our planning committee led by Drs. Geralyn Datz and Thomas Davis; the SPS board, our Executive Director Lori Postal, the amazing presenters, Lisa and Wilma from MAHEC; and Chris Hall who did his magic with the audio visuals for all of their efforts in making the 2019 SPS conference a fantastic experience.
Jennifer L. DelVentura, Ph.D., ABPP
Jennifer L. Steiner, Ph.D., ABPP
In a post in a previous issue of this newsletter, titled “Gender disparities in Pain and Pain Care,” we explored the evidence that women are not only at higher risk for pain and pain conditions but that their pain appears to be underestimated and, in some cases, undertreated compared with men’s pain. Similar patterns are evident in diagnosis and treatment of pain in racial/ethnic/SES minority patients, ranging from differences in prevalence and severity of pain in these groups to differential access to resources and pain care.
While there are many factors operating at different levels (community, institutional/systemic, familial/social, individual) contributing to these disparities, the impact of provider biases on pain care is of particular interest for us, as clinicians. Biases are ubiquitous, often unconscious, and a normal part of human cognition, but they are not innocuous. They may even be inconsistent with conscious beliefs—e.g., one may deny having negative beliefs about minority groups, but still evidence presence of unconscious biases in decision-making. But importantly, with awareness and effort biases are malleable. It is our task as ethical, caring providers to strive to minimize the impact of harmful biases on patient care.
Using measurement tools normed for minority populations
One approach to reducing impact of biases involves using pain assessment tools normed for minority patient populations. Even seemingly unbiased tools may be interpreted and rated differently by minority groups. Take for example the widely-used numerical pain rating scale with verbal anchors (e.g., “moderate,” “severe” or “worst pain imaginable”) to describe pain intensity. While these scales appear bias-free, their use rests on the assumption that we all interpret pain descriptors in the same way. Yet this may not be true, as is demonstrated in a study by Campbell and colleagues, comparing pain ratings to thermal stimuli in men vs. women and white vs. black participants. Findings indicated that when using a generic numerical pain rating scale, women and black participants rated the stimuli as significantly more painful than their counterparts. However, when participants were allowed to individualize the rating scale by moving the verbal anchors to reflect their subjective interpretation of pain, group differences in pain ratings were no longer significant suggesting group differences in how these anchors were interpreted, perhaps attributable to culture, socialization, or other factors.
The Campbell et al  study points to the need for measures modified for or normed to different populations. Indeed, a few measures with such norms do exist. For example, for psychologists, the MMPI-II-RF and Millon Behavioral Medicine Diagnostic , offer a multitude of specific patient group norms divided by gender (but not ethnicity). Additionally, several behavioral measures of functioning that are commonly used by physical therapists now have more extensive norms for different populations. The unipedal stance (UPST) now has norms for age and gender  and several other common tests such as the timed up-and-go test and single limb stance test have established significant differences based on age [4-6]. However, most measures lack norms specific to race/ethnicity, and thus this remains an important area of development for the field of pain management. Because such minority group norms are not widely available, it is crucial to be aware of the inherent limitations of our commonly used measures.
Provider-level strategies for managing bias
But what else can providers do to reduce impact of bias on patient care? Social psychology research offers valuable insights into strategies for addressing biases in our work. Based on this research, Burgess and colleagues  put forth a multi-step, evidence-based framework for addressing biases in healthcare, parts of which we will briefly summarize here.
First, fostering providers’ internal motivation for change is foundational to this model and involves bringing awareness to the presence of biases in our work. This can be done using techniques like the implicit association test (IAT, [8, 9], a measure of response latency that evaluates the strength of an association between pairs of contrasting concepts and is believed to tap into implicit connections between concepts in the brain. The IAT takes advantage of the brain’s inherent tendency to pair concepts together in service of faster processing, the more closely two concepts are linked together for an individual, the faster the person should be able to respond when one component of the pair is activated in the brain. It is a computer-administered task that has been used to highlight unconscious biases or preferences for people that belong to particular social groups (race, gender, religion., etc.), however, it is important to note that there is some debate as to what the IAT actually measures, and whether implicit bias is correlated with explicit bias and/or explicit behavior [10, 11]. Nevertheless, completing an IAT for a number of variables, i.e. gender, race, size, etc. (at projectimplicit.net) may offer some insight into our own associations and may inform self-reflection.
To give an example of what such an exercise might look like we invite you to consider the following sentences (adapted from the group exercise described in Holm et al., 2017) and count how many are true for you:
Consider what you notice here. How many feel true for you? And how might this reflect privilege (or lack thereof) in a healthcare environment? The intention here is not to blame or shame individuals who carry privilege, but rather to consider how this privilege might impact our experience and the quality of care we receive [7, 12].
Now, we invite you to bring to mind a patient or acquaintance with minority group affiliations (race, gender, age, SES). Then with this patient in mind, read through and consider these sentences again from this person’s perspective. How many of these might feel true to this person? And in turn, how might this impact actual or perceived care? The answers and experience might be rather different in this case, and may be uncomfortable for us to consider. Indeed, it is common for exercises like the above to elicit some negative emotions and internal discomfort (e.g., cognitive dissonance). However, when elicited in a safe, nonjudging environment, these negative emotions can serve to motivate behavior change.
Other strategies and considerations for providers
Other steps in the Burgess et al  model include increasing contact and comfort with minority groups, and facilitating perspective-taking and empathy for minority group patients—e.g., imagining situations from the patient’s perspective. However, empathy can suffer due to stress, burnout, and time (e.g., over the course of one’s career). Even when great strides have been made in reducing the impact of biases and increasing awareness of one’s biases, as creatures of habit we tend to regress back into old patterns if not careful. Thus, self-care and becoming attuned to our own needs is vital to reducing bias in our work. It is important that providers practice recognizing signs of burn-out within themselves and routinely re-assess for potential biases. At a systems level, this perhaps highlights the need for greater resources, i.e. advocating for lighter patient caseloads, more time with patients, more time for education (such as seminars or experiential trainings) of this nature both during graduate-level training and at the post-licensure level, and more.
All considered, it is important to note that perfection is neither expected nor realistic in efforts to reduce negative impacts of biases. Rather, we should strive to reduce biases through practice of empathy, perspective-taking, awareness, and seeing patients as individuals rather than through the lens of group membership.
 Projectimplicit.net is run by a non-profit organization and collects the data for scientific purposes.
 The Cultural and Linguistic Competence Health Practitioner Assessment (CLCHPA) through the Georgetown University National Center for Cultural Competence can be found at https://nccc.georgetown.edu/assessments/. Please note that the assessment and website are temporarily out of service for revisions
Joseph Tramontana, Ph.D.
As a member of the Board of Directors of the Southern Pain Society, I want to share with the membership a recent workshop I presented to the Canadian Federation of Clinical Hypnosis in Banff, Canada. The workshop was titled “Hypnotically Enhanced Addictions Treatment: Drug Abuse, Alcoholism and Alcohol Abuse, Gambling Addiction, Smoking Cessation, and Obesity, with a Focus on Drug Dependence during this Opioid Crisis.”
The 2-day workshop was presented by invitation to a group of 19 advanced hypnosis practitioners, including MDs, Psychologists, Licensed Clinical Social Workers, and Licensed Counselors.
While the title was lengthy, a number of problem behaviors were addressed. Dealing with pain patients, was a major focus. For example, if a patient came in experiencing pain at a “7,” (on a 10-point scale) and after the first hypnosis session he/she reported it was down to a “3,” the change was not only significant, but interpreted to them as “probably as much relief as you get from a pain pill, but it’s natural.” More importantly, the patient is taught self-hypnotic techniques to use at home as a coping skill. The goal is to use hypnotic relaxation when hurting instead of instinctively reaching for the pill bottle.
Another technique is having the patient, while in trance, imagine the sensation of pain medication, but replicating the relief without the actual medicine.
These techniques fit well with psychoeducation interpretations to patients about the “Mind-body connection.”
Jennifer L. DelVentura, PhD ABPP
Jennifer L. Steiner, PhD ABPP
“I just want my life back, I want to feel like me again”. This is a common refrain in our work as pain psychologists. Too often individuals with chronic pain feel as though their lives have fundamentally changed from ones defined by activity and engagement in a meaningful life to ones full of limitations, isolation, and feelings of loss. Many feel unable to move forward in their lives without elimination of the pain and find themselves stuck in an endless search for a cure, spending enormous amounts of energy, money, and time searching for the next best treatment or the “right” doctor. For these patients, life becomes about escaping the pain and no longer about living. But escape from pain is short-lived, and often comes at a price–from medications that offer temporary relief while also reducing functioning due to drowsiness, to self-medication with alcohol, drugs, or food which offer short bursts of pleasure or distraction, but serve to worsen pain, depression, and isolation over time. Of course, patients want the pain to be eliminated, but often what is most distressing about a life with pain is the loss of the sense of self, meaning, and purpose.
Indeed, research has demonstrated that individuals with chronic pain experience a change in self-concept after the onset of chronic pain (Harris, Morley, & Barton, 2003; Hellstrom, 2001; Leventhal, Idler, & Leventhal, 1999). For example, patients may feel that they are no longer the person they were prior to pain and may go through a period of mourning the loss or death of the “past self”. Others go through feelings of loss for the future “possible self,” “what could have been,” and plans that they envisioned for themselves that they fear will never come to fruition due to their pain condition. Some individuals may fluctuate between both of these experiences. It is perhaps not surprising then that depression is highly comorbid with chronic pain, and for some individuals much (though not all) of this can be attributed to the changes in quality of life and sense of self observed with pain.
Acceptance of Pain
Traditional treatment approaches often focus on symptom reduction and “fixing” the problem of pain, leaving patients feeling frustrated, discouraged, and depressed when the pain is not sufficiently alleviated. But what if the pain did not have to be “fixed” in order to improve functioning and quality of life?
Acceptance of chronic pain and illness has been a growing area of interest over the past 20+ years and has been defined as “acknowledging that one has pain, giving up unproductive attempts to control pain, acting as if pain does not necessarily imply disability, and being able to commit one’s efforts toward living a satisfying life” (McCracken, 1998, p. 22). It does not mean that one “gives in” to the pain and succumbs to an unsatisfactory life; but rather, that one makes a conscious decision to fully live with the chronic pain or illness while still being aware that the condition may not improve. One of the foundational theoretical underpinnings of acceptance-based approaches is that it is actually the lack of engagement in meaningful life experiences and activities, not the pain itself, that leads to suffering. Through acceptance it is believed that individuals change their relationship with their pain and how pain impacts their quality of life. Indeed, greater pain acceptance has been shown to be associated with better mental health outcomes physical functioning, quality of life, etc. (McCracken, 1998; Viane et al, 2003).
Acceptance and Commitment Therapy (ACT, pronounced like the verb “act”) for pain is an evidence-based psychological intervention aimed at increasing pain acceptance. ACT helps patients to realize that many of the things they do to try to control pain (e.g., avoidance or self-medication) may actually cause further damage to health, emotional state, and quality of life in the long-run. For example, many of the patients with whom I [JLS] work have said that they spend most of the day resting or “waiting for the pain to subside” before they will do anything (play with children, get dressed, complete small chores around the house, etc.). As a result, patients often end up waiting all day, and sometimes weeks, before anything gets done. In ACT, the therapist helps the patient realize that waiting for pain to go away is futile and unproductive as the pain is always present (indeed, it is “chronic”!). This is done in part through helping the patient explore what matters to them (personal values) and helping them find a way to pursue those actions even in the presence of pain. Through a combination of ACT techniques that include collaborative evaluation of the utility of pain reduction and avoidance strategies, exploration of personal values, values-based goal setting, and mindfulness, patients regain a sense of control over their lives so that they are dictating their actions rather than allowing pain to control all of their life choices. This makes for happier patients and more successful encounters for providers. The key is helping patients see that they don’t have to completely give up on what matters to them, but to flexibly find ways to pursue their dreams even if it looks differently than what they originally had in mind.
Take for example a patient I [JLS] worked with who was a former college athlete and had lifelong dreams of teaching his sons to play soccer. However, chronic lower back issues had made it impossible for him to play with them. Together we devised a way for him to engage in teaching his sons the game, even if he could not physically participate. He now helps coach his sons’ soccer team, watches game tapes with them, and attends all of their games. His pain is still present and he has continued to experience some physical limitations; however, he has said that he is less focused on his pain. As a result of being able to do more with his children, he reported decreases in depression and increased quality of life.
ACT for chronic pain is considered to have strong empirical support based on guidelines outlined by the American Psychological Association (APA). Meta-analytic work examining ACT for Chronic pain has demonstrated that ACT is associated with positive effects on depression, disability, and quality of life, as well as modest effects on anxiety and pain interference (Veehof, Oskam, Schreurs, & Bohlmeijir, 2011; Veehof, Trompetter, Bohlmeijir, & Schreurs, 2016). These studies suggest that effects from ACT are comparable to effects from CBT, though some studies that have directly compared the two common interventions have found greater patient satisfaction associated with ACT (Wetherell, 2011). Unlike cognitive behavioral therapy (CBT; long known as the “gold standard” of psychological treatments for chronic pain), which often places emphasis on symptom reduction and changing maladaptive thoughts about pain, ACT emphasizes increasing quality of life through values-based behavior and letting go of attempts to control or avoid the pain that have ultimately proven to be unproductive. ACT (compared with TAU) is also associated with reduced absence from work and utilization of medical resources due to pain with some of these changes maintained at follow-up (Dahl et al, 2004).
A note about what ACT is NOT.
There is a common misconception that ACT for chronic pain is akin to telling patients to “suck it up and do it anyway”. That is not what we are suggesting. Rather, from an ACT perspective to improve patient quality of life we must find a way to help the individual pursue values in different ways and stop waiting for pain to go away, as that day may never come. Similarly, ACT does not propose that patients give up any and all pain management strategies, but to consider the effectiveness or workability of these strategies and give up the ones that interfere with values or quality of life.
FINDING AN ACT THERAPIST
Finding a therapist trained in ACT is not always easy. We encourage referring providers to be aware that not all pain psychologists are trained in ACT, and not all ACT therapists have experience with chronic pain. A good place to start is the Provider Directory through SPS and outreaching these psychologists directly to ask about their expertise or recommendations for other providers in your area. Most states also have State Psychological Associations with member directories that often list providers’ areas of expertise as well.
You can also search for providers in your area through the Association for Contextual Behavior Science (ACBS) website at this link:*
Most of us may agree helping patients with chronic pain can be challenging, and we may not always be able to “cure” or even reduce the pain. However, through interventions like ACT and focus on finding new ways to pursue a meaningful life, we may be able to reduce suffering. Isn’t that really the point?
*Please be aware that providers listed on this website are self-identified as ACT providers, and expertise in chronic pain is not guaranteed.
Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior therapy, 35(4), 785-801.
Harris, S., Morley, S., & Barton, S. B. (2003). Role loss and emotional adjustment in chronic pain. Pain, 105(1-2), 363-370.
Hellström, C. (2001). Temporal dimensions of the self-concept: Entrapped and possible selves in chronic pain. Psychology and Health, 16(1), 111-124.
Leventhal, H., Idler, E. L., & Leventhal, E. A. (1999). The impact of chronic illness on the self system. Rutgers series on self and social identity, 2, 185-208.
McCracken, L. M. (1998). Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain, 74(1), 21-27.
Veehof, M. M., Oskam, M. J., Schreurs, K. M., & Bohlmeijer, E. T. (2011). Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis. PAIN, 152(3), 533-542.
Veehof, M. M., Trompetter, H. R., Bohlmeijer, E. T., & Schreurs, K. M. G. (2016). Acceptance-and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cognitive behaviour therapy, 45(1), 5-31.
Viane, I., Crombez, G., Eccleston, C., Poppe, C., Devulder, J., Van Houdenhove, B., & De Corte, W. (2003). Acceptance of pain is an independent predictor of mental well-being in patients with chronic pain: empirical evidence and reappraisal. Pain, 106(1-2), 65-72.
Wetherell, J. L., Afari, N., Rutledge, T., Sorrell, J. T., Stoddard, J. A., Petkus, A. J., Solomon, A.J., Lehman, D.H., Liu, L., Lamg, A.J., & Atkinson, J. H. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain, 152(9), 2098-2107.
Jennifer L. DelVentura, Ph.D., ABPP
Jennifer L. Steiner, Ph.D., ABPP
In a widely-shared article published in the Atlantic in 2015, titled “How Doctors Take Women’s Pain Less Seriously,” author Joe Fassler tells of his wife Rachel’s visit to the ER after she is suddenly stricken with excruciating abdominal pain, later revealed to be a life-threatening ovarian torsion . The article tells of their agonizing 14-hour wait in the ER for evaluation and treatment while Rachel’s pain is dismissed (“You’re just feeling a little pain honey”), undertreated, and summarily misdiagnosed as kidney stones without full examination. While Rachel survives the experience, she describes being left with “the trauma of not being seen,” and suffers physical and emotional scars in the aftermath. This story is notable not because of the long wait in the ER, which is often routine, but because it points to a more insidious problem in how we view and respond to women’s pain in healthcare.
Ample research indicates that gender biases impact our treatment of patients with pain, including how we interpret the nature and severity of that pain. Take for example a study examining how clinicians perceive patient reports (verbal and nonverbal) of pain severity . In the study, clinicians viewed video of male and female patients, all with shoulder pain and all undergoing painful manipulation procedures. Despite similar conditions and presentation, female patients were judged to be in significantly less pain than their male counterparts and were seen as significantly more likely to exaggerate their pain. Indeed, the more a female patient was perceived to be exaggerating her pain the lower the clinicians judged her actual pain to be, while the same relationship did not hold true for male patients (e.g., perceived exaggeration did not significantly impact judgments of pain severity) .
In a similar study in children, Yale researchers showed clinicians video of a child crying in pain during a fingerstick blood test and asked the clinicians to judge the pain the child experienced . The child, whose observable gender characteristics were ambiguous, was referred to by either a male or female name. The authors found that the “boy” child was judged to be experiencing significantly more pain than the “girl” despite identical circumstances (in fact, the same child). Perhaps more unexpectedly, it was largely the women clinicians’ ratings that drove the observed biases in pain ratings, making clear that women are not immune to gender biases.
Extending this further, research demonstrates that gender can play an influential role in how clinicians diagnose and treat pain. A few studies have tested this by asking providers to evaluate case vignettes of patients that vary only in gender (and in some cases race) of the fictional patient. When the patient is identified as female, providers are more likely to reference psychosocial factors in the case history , more likely to offer nonspecific diagnoses (e.g., “myalgia”) , more likely to recommend antidepressants or mental health referrals [5, 6], and less likely to prescribe higher doses of pain medications (compared to when the patient is identified as male; ). Here too, women providers often demonstrated as much, if not greater, influence of gender bias in decision-making [4, 5].
This apparent underestimation and under-treatment of women’s pain occurs in the context of decades of research demonstrating that women are disproportionately burdened with pain. Globally, women are diagnosed with chronic pain conditions at higher rates than men  and often report greater severity of pain on average compared with men with those same chronic pain conditions . Even in healthy (chronic pain free) individuals, women appear to be more pain-sensitive (have lower pain thresholds/tolerances) across a range of stimulus types (pressure, thermal, electrocutaneous [9, 10]) compared with men. 1
The factors underlying these differences are manifold, including biological, psychological, and sociocultural influences. And some of these factors may also function to disadvantage men suffering with pain. For example, evidence suggests women are viewed as more willing to express pain compared with men  and doing so is less inconsistent with traditional gender roles , and hence more acceptable. Likewise, women are known to access healthcare at higher rates than men , perhaps contributing to underrepresentation of men seeking medical care for pain. Thus, one could postulate that men suffer similarly from pain but are more reluctant to endorse or seek care for it, due to fear of stigma.
While the above is hardly an exhaustive review of the evidence, it is clear that observed gender differences in pain experience and pain care are consistent, concerning, and complex. Lack of acknowledgement and attention to these differences risks invalidating women’s pain experience, as well as underdiagnosing and undertreating their pain symptoms. And yet, this should not be interpreted as an attempt to place blame or suggest harmful intent on the part of providers. Indeed, such biases are often wholly unconscious. This was illustrated in a study of race and gender influences on treatment-planning in medical trainees, in which not only did race and gender factors significantly influence decision-making for at least 30% of the trainees, but at least 50% of them were unaware their biases . As human beings, we all rely on mental heuristics when short on time, pulled in too many directions, feeling pressured, or dealing with ambiguous situations [15, 16]—as is common in any pain management setting. But these heuristics are fallible and, simply put, it is our responsibility as ethical providers to work to recognize these biases and then to reduce harmful effects of them.
So how do we begin to address these issues? In the words of Sir Francis Bacon, ipsa scientia potestas est–knowledge itself is power . Educating ourselves about disparities in pain and pain treatment is an important first step. This includes practicing conscious self-reflection on biases and heuristics in decision-making as well as seeking out experiences and educational opportunities that help us learn to challenge them. At a broader level, evidence-based and patient-centered care can be supported through further development and use of clinical assessment tools normed for gender and minority populations as well as expanding gender and multiculturally-sensitive curricula in medical and graduate training. Lastly, future research should work to validate and disseminate methods for reducing impact of biases in health care. Social and cognitive psychology research supports a multimodal approach to bias-reduction that includes enhancing provider motivation for change, an emphasis on patient individuation vs. categorization, increasing perspective-taking, and improving provider-patient collaboration . These strategies will be discussed in more detail in a future issue of this newsletter.
1 Colloquial wisdom asserts just the opposite, on the basis of women’s ability (and willingness) to tolerate the immense pain of childbearing. The duration (e.g., acute vs. chronic), perceived cause, and one’s appraisals of pain significantly impact the pain experience. For an interesting review of pain coping factors, see: 11. Jensen, M.P., et al., Coping with chronic pain: A critical review of the literature. Pain, 1991. 47M: p. 249.
1. Fassler, J., How Doctors Take Women’s Pain Less Seriously, in The Atlantic. 2015.
2. Schafer, G., et al., Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness. Pain, 2016. 157(8): p. 1618-25.
3. Earp, B.D., et al., Gender Bias in Pediatric Pain Assessment. J Pediatr Psychol, 2019.
4. Hamberg, K., et al., Gender bias in physicians’ management of neck pain: a study of the answers in a Swedish national examination. J Womens Health Gend Based Med, 2002. 11(7): p. 653-66.
5. Hirsh, A.T., et al., The influence of patient sex, provider sex, and sexist attitudes on pain treatment decisions. J Pain, 2014. 15(5): p. 551-9.
6. Hollingshead, N.A., et al., Impact of race and sex on pain management by medical trainees: a mixed methods pilot study of decision making and awareness of influence. Pain Med, 2015. 16(2): p. 280-90.
7. Fillingim, R.B., et al., Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain, 2009. 10(5): p. 447-85.
8. Ruau, D., et al., Sex differences in reported pain across 11,000 patients captured in electronic medical records. J Pain, 2012. 13(3): p. 228-34.
9. Racine, M., et al., A systematic literature review of 10 years of research on sex/gender and experimental pain perception – part 1: are there really differences between women and men? Pain, 2012. 153(3): p. 602-18.
10. Rhudy, J.L., et al., Are there sex differences in affective modulation of spinal nociception and pain? J Pain, 2010. 11(12): p. 1429-41.
11. Jensen, M.P., et al., Coping with chronic pain: A critical review of the literature. Pain, 1991. 47M: p. 249.
12. Robinson, M.E., et al., Gender role expectations of pain: relationship to sex differences in pain. Journal of Pain, 2001. 2(5): p. 251-7.
13. Williams, J. and D. Best, Cross-cultural views on men and women, in Psychology and Culture, W. Lonner and R. Malpass, Editors. 1993, Pearson.
14. Bertakis, K.D., et al., Gender differences in the utilization of health care services. J Fam Pract, 2000. 49(2): p. 147-52.
15. Wigboldus, D.H., et al., Capacity and comprehension: Spontaneous stereotyping under cognitive load. Social Cognition, 2004. 22(3): p. 292-309.
16. Kahneman, D., S.P. Slovic, and A. Tversky, eds. Judgment under uncertainty: Heuristics and biases. 1982, Cambridge University Press.
17. Bacon, F., Meditationes Sacrae. 1597: Londini. : Excusum impensis Humfredi Hooper.
18. Burgess, D., et al., Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med, 2007. 22(6): p. 882-7.