>>> GOOD AFTERNOON.

THANK YOU FOR ALL WHO HAVE

JOINED US HERE IN LIP SET AND

THOSE WHO ARE VIEWING THE

WEBCAST.

WE SUSPECT THE WEATHER, SOME OF

YOU WHO ARE VIEWING THERE AND

NOT HERE BUT WE ARE THANKFUL

THAT ALL OF YOU ARE HERE AND I

WANT TO WELCOME YOU TO THE SEX

DIFFERENCES AND PAIN RESEARCH,

WOMEN'S HEALTH SEMINAR.

I WANT TO RECOGNIZE THE SEMINAR

SERIES AND THE CO-CHAIRS OF THAT

SERIES ARE JOYCE RUDDIC HERE AND

JUDITH COOPER AND THEN SEVERAL

FOLKS ON THE SEMINAR COMMITTEE

WHO HAVE BEEN PARTICULARLY

ACTIVE IN THE FORMATION AND

ESTABLISHMENT OF THIS PARTICULAR

SYMPOSIUM AND JENNY, WHO YOU

WILL BE HEARING FROM THIS

AFTERNOON, CHERYL KITT AND LINDA

PORTER.

WITHOUT FURTHER ADIEU, LET ME

BRING UP JENNY TO THE PODIUM AND

SHE WILL INTRODUCE OUR FIRST

SPEAKER.

>> THANK YOU DR. CLAYTON.

OUR FIRST SPEAKER IS OUR

MODERATOR, DR. EMMELINE EDWARDS

THE DIRECTOR OF THE DIVISION OF

EXTRAMURAL RESEARCH AT THE

NATIONAL CENTER FOR

COMPLEMENTARY AND ALTERNATIVE

MEDICINE HERE AT THE NATIONAL

INSTITUTES OF HEALTH.

DR. EDWARDS.

>> GOOD AFTERNOON, EVERYONE.

THANKS FOR COMING.

I HAVE TO SAY THAT THE TOPIC OF

PAIN HAS BEEN GETTING A LOT OF

TRACTION, AS VERY WELL DESERVING

TOPIC.

LAST WEEK, FOR EXAMPLE, AT

HOPKINS GRAND ROUNDS TOPIC ON

TOPIC OF PAIN MANAGEMENT AND

YESTERDAY AT THE COLLEGE WE HAD

A FORUM ON PAIN MANAGEMENT

FOCUSING ON SEX DIFFERENCES.

I JUST WANTED TO PUT THIS SET OF

TALKS IN CONTEXT OF THE WORK

THAT HAS BEEN GOING ON, NOT ONLY

AT NIH BUT ALSO IN OTHER

SETTINGS ON THE TOPIC OF PAIN

AND PAIN MANAGEMENT.

SO, EARLIER THIS SUMMER, THE

INSTITUTE OF MEDICINE RELEASED A

REPORT THAT WAS COMMISSIONED BY

THE DEPARTMENT OF HEALTH AND

HUMAN SERVICES ON PAIN AND BEING

CONSIDERED AS AN ISSUE OF GREAT

IMPORTANCE AND IMPACT ON PUBLIC

HEALTH.

THIS IS ONE OF THE CONCLUSIONS

OF THAT IOM REPORT.

[READING]

ONE OF THE REAL GOALS OF THE

WORK DONE BY THE IOM WAS TO

REALLY GO INTO A SHIFT IN ORDER

THAT WE CAN GET A BETTER

UNDERSTANDING OF PAIN OF ALL

TYPES AND MAKE STRONG EFFORTS,

NOT ONLY TO PREVENT BUT ALSO

ASSESS AND TREAT PAIN.

WHAT THE NIH HAS BEEN DOING FOR

QUITE A WHILE NOW.

SINCE 1996, THE NIH HAD THE PAIN

CONSORTIUM.

BUT I HAVE TO SAY, THE PAST

SEVEN OR EIGHT YEARS, THE

CONSORTIUM REALLY HAS PICKED UP

THE LEVEL OF ACTIVITY AND A LOT

MORE COHESIVENESS IS

CHARACTERIZED THE WORK OF THAT

CONSORTIUM.

BUT THE GOALS OF THE NIH

CONSORTIUM HAVE BEEN TO REALLY

ENHANCE RESEARCH.

AND TO DO THIS, THEY DEVELOP A

TRANS-NIH RESEARCH STRATEGY AND

IDENTIFY RESEARCH OPPORTUNITIES,

THEY PURSUE PUBLIC-PRIVATE

PARTNERSHIPS AND THEY ALSO

INCREASE THE VISIBILITY OF

NIH-SUPPORTED RESEARCH IN THE

TOPIC OF PAIN.

WE HAVE FIVE CO-CHAIRS TO THE

NIH CONSORTIUM AND THIS IS QUITE

APPROPRIATE THAT ALL FIVE OF THE

CO-CHAIRS ARE WOMEN.

SO DR. BRIGGS IS THE DIRECTOR

FOR THE NCCAM.

DR. GRADY IS THE DIRECTOR OF THE

NURSING INSTITUTE.

DR. LANDIS IS THE DIRECTOR OF

THE NEUROLOGY INSTITUTE,

DR. SOMMER MAN IS THE DIRECTOR

OF THE INSTITUTE FOR DENTAL AND

CRANIOFACIAL RESEARCH AND

DR. VOLKOW IS THE DIRECTOR FOR

INSTITUTE OF DRUG ABUSE.

NOW THE CONSORTIUM REALLY HAS

INCREASED ITS LEVEL OF

MEMBERSHIP AND IN FACT, THERE

ARE 23 PARTNERS NOW, AND THOSE

PARTNERS ARE INSTITUTES,

CENTRES, AND ALSO OFFICES OUT OF

THE NIH DIRECTOR'S OFFICE.

SOME OF THE SHARED INTERESTS OF

THE PAIN CONSORTIUM HAVE BEEN

REALLY IN BETTER UNDERSTANDING

OF CHRONIC PAIN.

AND ESSENTIALLY, THIS IS DONE BY

FOCUSING ON BASIC RESEARCH,

TRYING TO UNDERSTAND THE UNIQUE

AND SHARED MECHANISM OF CHRONIC

PAIN, TRANSLATIONAL RESEARCH

WITH A PUSH TOWARDS THERAPY

DEVELOPMENT, AND I'LL SAY THAT

ON THAT TOPIC, THERE IS A COMMON

FUND INITIATIVE THAT DR. COLLINS

IS CURRENTLY REVIEWING THAT

FOCUS ON PAIN AND THERAPY

DEVELOPMENT.

WE DON'T KNOW THE OUTCOME YET

BUT THIS WAS ONE OF THE

INITIATIVES PUT BY NIDA AND THE

PAIN CONSORTIUM.

CLINICAL RESEARCH, PAIN

MANAGEMENT AND PREVENTION AND WE

ARE GOING TO TALK ABOUT THAT

TODAY.

AND EDUCATION.

PAIN MANAGEMENT.

ANOTHER INITIATIVE THAT I WILL

HIGHLIGHT IS WE ARE IN THE

PROCESS OF DEVELOPING SOME

CENTRES OF EXCELLENCE FOR PAIN

EDUCATION AND SOMETIMES THIS

SPRING, WE WILL BE DEVELOPING

CURRICULUM TO HELP US IMPROVE

PAIN EDUCATION AT MEDICAL

SCHOOL, NURSING SCHOOL, DENTAL

SCHOOLS.

JUST TO GIVE YOU A FLAVOR OF THE

LEVEL OF FUNDING FOR CHRONIC

PAIN RESEARCH.

IT IS SIZEABLE AMOUNT.

COULD BE BETTER.

BUT IT HAS STEADILY INCREASED.

HOPEFULLY IF WE CAN MAINTAIN A

LEVEL OF FUNDING THAT DOESN'T

INCLUDE SUCH A BIG DECREASE FROM

OUR BUDGET, IT SHOULD BE --

OR IN THE LEVEL OF 368 MILLION

OR SO FOR THE NEXT YEAR.

THE CONSORTIUM IS ENGAGED IN A

NUMBER OF STRATEGIC ACTIVITIES.

IT INCLUDES PRIMARILY SHARING OF

RESOURCES.

IT IS VERY CLEAR THAT NO ONE

INSTITUTE WAS RESPONSIBLE FOR

PAIN RESEARCH BECAUSE IT CUTS

ACROSS THE MISSION OF SO MANY

INSTITUTES.

SO GETTING TOGETHER WAS ACTUALLY

AWAY TO LEVERAGE THE RESOURCES

OF MANY OF THE INSTITUTES.

SO THROUGH THE CONSORTIUM, A

NUMBER OF INITIATIVES HAVE BEEN

PUT FORTH TO INCLUDE THINGS LIKE

SOME OF THE ROAD MAPPING

INITIATIVES, THE NEUROSCIENCE

BLUEPRINT, AND ALSO INVOLVEMENT

WITH A NUMBER OF WORKING GROUPS.

SO FOR EXAMPLE, WANT CTSA,

CLINICAL TRANSLATIONAL SCIENCE

AWARD CENTRES HAVE REALLY BEEN A

VERY ACTIVE COMPONENT OF THE

CONSORTIUM'S INTERESTS.

PARTNERSHIP ALSO IS A BIG PART

OF WHAT THE PAIN CONSORTIUM IS

PURSUING.

SO WE HAVE SOME INTERACTIONS

WITH THE FDA AND ALSO

CO-SPONSORING OF A NUMBER OF

WORKSHOPS WITH ADVOCACY GROUPS.

AND THE LAST AREA IS WORKSHOP

AND SYMPOSIUM.

THE CONSORTIUM HAS REALLY MADE A

STRONG EFFORT TO DISSEMINATE

INFORMATION ABOUT RESEARCH ON

PAIN.

AND THIS PARTICULAR SEMINAR

SERIES TODAY IS AN EXAMPLE OF

THAT TYPE OF ACTIVITY.

IF YOU ARE INTERESTED IN GETTING

MORE DETAILED INFORMATION ABOUT

THE CONSORTIUM, THEY HAVE A

WONDERFUL WEBSITE.

I ENCOURAGE YOU TO TAKE A LOOK

AT IT.

IT ALSO HIGHLIGHTS FUTURE

EVENTS.

THIS IS AN EXAMPLE OF THE TYPE

OF SIM TOESIUM THAT OCCURRED IN

THE PAST FEW MONTHS AND THIS

VARYEES FROM THE ANNUAL

CONFERENCE, WHICH ACTUALLY

FOCUSED ON MECHANISM AND

MANAGEMENT OF CHRONIC PAIN, TO

VERY SPECIFIC TOPICS SUCH AS

TRANSLATIONAL ADVANCES,

TRANSLATIONAL RESEARCH IN A

PARTICULAR TYPE OF PAIN, LIKE

MIGRAINES.

NOW THAT BRINGS ME TO TODAY'S

TOPIC.

SO, THERE HAS BEEN A LOT OF

INTEREST ON SEX DIFFERENCES AND

THE IMPACT THAT IT WOULD HAVE ON

VARIOUS TYPE OF RESEARCH.

IN MARCH OF 2010, THE INSTITUTE

OF MEDICINE FORM THE

NEUROSCIENCE AND NERVOUS SYSTEM

DISORDERS AND HAD A WORKSHOP ON

SEX DIFFERENCES AND THE

IMPLICATION OF DIFFERENCES FOR

TRANSLATIONAL NEUROSCIENCE

RESEARCH.

FOUR CONDITIONS WERE HIGHLIGHTED

AND PAIN WAS ONE OF THEM.

DR. MAREIO WAS ONE OF THE

SPEAKERS AT THAT MARCH 2010

FORUM.

AS A FOLLOW UP TO THIS FORUM,

YESTERDAY, ACTUALLY, WE HAD A

WORKSHOP AT BERNARD COLLEGE THAT

ACTUALLY ADDRESSED A NUMBER OF

THESE ISSUES IN SEX DIFFERENCES

IN THE CONTEXT OF PAIN

MANAGEMENT.

AND WE HAD JEFF MOGUL PRESENTING

THE NEUROMECHANISMS OF THOSE SEX

DIFFERENCES AND WE HAD RICHARD

SMILEY, A CLINICIAN THAT DOES

WORK ON GENETICS OF LASER PAIN.

OUR NCCAM DIRECTOR, DR. BRIGGS,

TALKED ABOUT NONPHARMACOLOGICAL

ASPECT OF PAIN MANAGEMENT AND WE

ALSO HAD DR. MARK, AN

ENDOCRINOLOGIST THAT WORKED FOR

NASA.

AND MADE SOME VERY INTERESTING

OBSERVATIONS IN TERMS OF

STUDYING PAIN IN THE CONTEXT OF

MICROGRAPHITY AND HOW THAT COULD

BE PROVIDING AN HAVING CONTEXT

TO THE STUDY.

 --

AN INTERESTING CONTEXT TO THE

STUDY.

AND OF COURSE TODAY, WE ARE

PRIVILEGED TO HAVE THREE

WONDERFUL TALKS.

WE HAVE THE UNIVERSITY OF

FLORIDA THAT WILL GIVE US AN

OVERVIEW OF CLINICAL AND

EXPERIMENTAL FINDINGS, BOTH OF

SEX AND GENDER DIFFERENCES IN

PAIN AND ANALGESIA.

AND THEN DR. MAHER WILL FOCUS ON

THE SEX DIFFERENCES IN PAIN

SYNDROMES AND DR. GREEN WILL

HAVE A DIFFICULT JOB OF

OVERLAYING RACE, GENDER AND AGE

AS FACTORS THAT INFLUENCE PAIN.

SO, WHAT WE WILL TRY TO DO IS TO

HAVE OR GIVE EACH OF THE

SPEAKERS ABOUT 20 MINUTES OR SO

FOR THEIR TALK AND WE WILL LET

YOU KNOW IF YOU'RE GOING OVER.

AND WE WILL HOLD THE QUESTIONS

TO THE END AND WE WILL HAVE THE

QUESTION-AND-ANSWER SESSION

AFTER ALL THREE TALKS.

SO WITHOUT FURTHER ADIEU, I WILL

BRING DR. ROGER TO THE PODIUM

AND LET HIM GIVE HIS TALK.

THANK YOU.

[APPLAUSE]

>> THANK YOU DR. EDWARDS AND

THANK YOU TO THE ORGANIZING

COMMITTEE FOR PUTTING THIS

SESSION TOGETHER AND FOR

INCLUDING ME IN THIS.

AND I WILL BE GIVING AN

OVERVIEW, REALLY, OF MUCH OF THE

HUMAN RESEARCH ON SEX AND GENDER

DIFFERENCES IN PAIN.

THE GOALS OF THE TALK ARE JUST

DISPLAYED HERE, STARTING WITH A

FEW COMMENTS I MIGHT MAKE ON

SOME HISTORICAL AND CONCEPTUAL

ISSUES RELATED TO THE FIELD.

SO ONE THING I WOULD POINT OUT

IS THAT INTEREST IN SEX, GENDER

AND PAIN, HAS ESSENTIALLY

EXPLODED IN THE LAST 15-20

YEARS.

SO BY DOING A PUBMED SEARCH OF

PAIN, HERE ARE THE INCREASES IN

PUBLICATIONS ON PAIN, PERCENTAGE

WISE, AND HERE ARE THE INCREASES

IN PUBLICATIONS ON SEX GENDER

AND PAIN.

AND YOU CAN SEE THAT

PUBLICATIONS GO UP NO MATTER

WHAT YOU'RE STUDYING BUT FOR

SEX, GENDER AND PAIN, THE

INTEREST AND PRODUCTIVITY AND

THE SCHOLARSHIP RELATED TO THAT

TOPIC INCREASED DRAMATICALLY.

I THINK THIS REALLY TOOK OFF

WITH WHAT I WOULD REFER TO AS

THE DECADE OF SEX, GENDER AND

PAIN, FROM 1990 TO 2000.

AND THERE ARE SEVERAL EVENTS

THAT ONE MIGHT PUT FORWARD AS

PROVIDING SOME I TUS TO THIS

BURGEONING FIELD.

IN 1990, THE OFFICE OF RESEARCH

ON WOMEN'S HEALTH WAS

ESTABLISHED.

IT SIGNALED, PERHAPS, THAT IT IS

OKAY NOW TO ADMIT THAT MEN AND

WOMEN MIGHT BE DIFFERENT AND TO

APPRECIATE AND STUDY THOSE

DIFFERENCES.

AND THEN THERE WERE SOME

IMPORTANT PUBLICATIONS THAT CAME

OUT IN THE EARLY 1990s.

I'LL TRY TO AVOID SHAMELESS SELF

PROMOTIONS BY TALKING ABOUT OUR

ARTICLE, BUT THEN A MAJOR EVENT

WAS IN 1997.

NIH ISSUED REQUEST FOR

APPLICATIONS SUCH THAT ALL OF US

SCRAMBLED TO GET MONEY TO STUDY

THIS TOPIC.

AND THAT FUNDED 10 OR 12

APPLICATIONS AT THAT TIME BUT

THEN, A NUMBER OF APPLICATIONS

THAT WEREN'T FUNDED INITIALLY

WENT FORWARD AND SO IT SORT OF

HAD THIS GEE METRIC AFFECT ON

RESEARCH IN THIS AREA.

NIH SPONSORED A MEETING ON SEX,

GENDER AND PAIN IN 1998.

THERE WAS A SPECIAL INTEREST

GROUP ON SEX, GENDER AND PAIN

ESTABLISHED, A SPECIAL INTEREST

GROUP OF THE INTERNATIONAL

ASSOCIATION FOR THE STUDY OF

PAIN.

AND THEN THERE WAS A BOOK

PUBLISHED ON SEX, GENDER AND

PAIN IN 2000.

THERE WAS AN ABUNDANCE OF

ACTIVITY THAT FUELED THIS FIELD.

NOW I HAVE BEEN MENTIONING SEX,

GENDER AND PAIN.

AND YOU MIGHT INFER THAT SEX AND

GENDER WAS NOT THE SAME THING,

WHICH WAS NEWS TO ME WHEN I GOT

INTO THIS FIELD.

BUT WE MAKE A DISTINCTION

BETWEEN THESE TWO CONSTRUCTS SO

SEX IS ESSENTIALLY THE

BIOLOGICAL COMPONENT.

IT'S RELATIVELY CLEAR-CUT FOR

MOST OF US WHETHER WE ARE MALE

OR FEMALE AND THAT IS BASED ON

CHROMOSOMES AND ANATOMY.

GENDER IS A MORE COMPLEX

CONSTRUCT THAT INCLUDES SOCIAL

INFLUENCES, CONCEPTS, FOR

EXAMPLE, LIKE STEREO TYPIC

GENDER ROLES THAT MAY VARY FROM

SOCIETY TO SOCIETY AND SO IT

KIND OF REFLECTS THE COMPLEXITY

OF INFLUENCES THAT MIGHT BE

CONTRIBUTING TO SEX AND GENDER

DIFFERENCES AND PAIN.

ANOTHER CONCEPTUAL POINT I WOULD

MAKE IS THAT IN SCIENCE, WE ARE

OFTEN ENAMORED WITH QUANTITATIVE

DIFFERENCES.

WHO HAS MORE?

WHO HAS MORE PAIN?

MEN OR WOMEN?

WHO GETS MORE ANALGESIA?

MEN OR WOMEN?

THOSE THINGS ARE IMPORTANT.

DON'T GET ME WRONG.

THAT'S NOT THE ONLY STORY.

SO IMAGINE THAT IN STEREO

TYPICAL PINK AND BLUE, WE HAVE

INDEXES OF PAIN SENSITIVITIES.

AND THE MEAN FOR THE PINK WOMEN

IS HIGHER THAN THE MEAN FOR THE

BLUE MEN.

THAT DIFFERENCE MAY BE

SIGNIFICANT.

IT MAY NOT.

BUT WHAT YOU'LL SEE IS THAT THE

RANGE OF PAIN SENSITIVITY VALUES

WITHIN WOMEN AND WITHIN MEN IS

FAR GREATER THAN THE MEAN

DIFFERENCE BETWEEN THEM.

AND SO WE NEED TO APPRECIATE THE

QUALITATIVE DIFFERENCES THAT

CREATE THIS VARIABILITY WITHIN

EACH SEX.

SO WHAT I'M SUGGESTING IS THE

FACTORS THAT CONTRIBUTE TO PAIN,

REGARDLESS OF WHO HAS MORE OR

LESS, THE FACTORS THAT

CONTRIBUTE, COULD BE

FUNDAMENTALLY DIFFERENT IN MEN

VERSES WOMAN.

AND IF THAT IS THE CASE, WE MAY

NEED FUNDAMENTALLY DIFFERENT

TREATMENTS FOR MEN VERSUS WOMEN.

NOW, I DON'T MEAN TO IMPLY THAT

GROUP DIFFERENCES ARE

UNIMPORTANT.

LET'S IMAGINE THAT SOME

THRESHOLD FOR PAIN SENSITIVITY

IS REQUIRED FOR YOU TO MEET

DIAGNOSTIC CRITERIA FOR SOME

PAIN CONDITION.

IF THAT WERE THE CASE, THEN 20%

OF THE FEMALE POPULATION WILL

MEET THOSE CRITERIA WHEREAS ONLY

10% OF MEN WOULD MEET THOSE

CRITERIA.

AT A POPULATION LEVEL, THAT'S A

IMPORTANT PUBLIC HEALTH ISSUE.

BUT WE NEED TO APPRECIATE BOTH

THE BETWEEN GROUP DIFFERENCES

AND THE WITHIN GROUP

DIFFERENCES.

SO LET ME JUST TOUCH ON A FEW OF

THE EPIDEMIOLOGIC AND CLINICAL

FINDINGS RELATED TO SEX

DIFFERENCES AND PAIN.

THIS SLIDE SHOWS SEVERAL COMMON

PAIN DISORDERS AND THE MIDDLE

HERE YOU HAVE THE POPULATION

PREVALENCE THAT IS LIFETIME

PREVALENCE IN THE POPULATION AND

HERE YOU HAVE THE FEMALE TO MALE

RATIO AND YOU SEE THAT FOR EVERY

ONE OF THESE COMMON PAIN

CONDITIONS, THERE ARE MORE

FEMALES THAN MALES WITH THE

CONDITION.

THIS IS A CONSISTENT FINDING.

AND SOME OF THESE FEMALE TO MALE

RATIOS ARE QUITE DRAMATIC,

SUGGESTING THAT FEMALES ARE AT

GREATER RISK FOR THESE SPECIFIC

CHRONIC PAIN SYNDROMES.

IF YOU LOOK AT POPULATION DATA,

WHERE THEY SIMPLY DO SURVEYS OF

THE POPULATION AND THEY CREATE

SOME DEFINITION OF CHRONIC PAIN,

FOR EXAMPLE, HAVE YOU HAD PAIN

ON MORE DAYS THAN NOT OVER THE

PAST SIX MONTHS?

THAT'S A VERY COMMON

EPIDEMIOLOGIC DEFINITION.

DOESN'T MATTER WHAT KIND OF

PAIN.

AGAIN, IN BLACK, YOU SEE THE

SIGNIFICANT SEX DIFFERENCES

WHERE WOMEN --

THAT FORM OF CHRONIC PAIN IS

MORE PREVALENT IN WOMEN THAN IN

MEN AND EVEN THE HIGHLIGHTED

COLORS, WHICH ARE NOT

STATISTICALLY SIGNIFICANT, ARE

STILL IN THE SAME DIRECTION.

SO WE ARE GETTING THIS PICTURE

THAT WOMEN SEEM TO BE REPORTING,

AT LEAST, MORE PAIN THAN MEN AND

IN THE POPULATION.

BUT WE NEED TO MAKE SURE THAT WE

DON'T JUST THINK ABOUT SEX,

RIGHT?

PEOPLE BRING OTHER

CHARACTERISTICS WITH THEM TO THE

CLINIC AS WELL.

THEY BRING THEIR AGE AND ETHNIC

BACKGROUND AND THEIR

PSYCHOLOGICAL CHARACTERISTICS

AND SOME OF THESE THINGS MIGHT

INTERACT WITH SEX THAT INFLUENCE

PAIN.

HERE IS DATA FROM LINDA LAERER

AND COLLEAGUES AT THE UNIVERSITY

OF WASHINGTON AND THIS IS THE

PREVALENCE OF --

I'M SORRY.

THREE OR MORE OF THESE FIVE PAIN

CONDITIONS, HEADACHE, BACK PAIN,

CHEST PAIN, AB ABDOMINAL PAIN
AND

TEMP ROMAN DIBULAR PAIN.

WHAT CAN YOU SEE IS IN THE ADULT

YEARS AND THE REPRODUCTIVE

YEARS, WOMEN HAVE FAR GREATER

PREVALENCE THAN MEN BUT LATER IN

LIFE, THAT PREVALENCE COMES

TOGETHER.

MANY WOULD BE PRE-PUBITAL

INDIVIDUALS.

AGAIN, YOU SEE THIS HORMONAL

LOOKING PROFILE WHERE PEAK PAIN

IS EXPERIENCED BY WOMEN IN THE

REPRODUCTIVE YEARS AND BEFORE

PUBERTY AND AFTER MENOPAUSE, FOR

EXAMPLE, THOSE DIFFERENCES

SUBSIDE.

AND I DON'T WANT TO GIVE THE

COMPLETELY BIASED STORY THAT

WOMEN ARE ALWAYS AT GREATER

RISK.

HERE IS A CLASSIC PAIN CONDITION

MORE COMMON IN MEN AND STILL YOU

SEE THIS AGE-RELATED

DISTRIBUTION WHERE CLUSTER

HEADACHE IS SIGNIFICANTLY MORE

COMMON IN MEN IN YOUNGER AGE

GROUPS BUT THEN THAT SEX

DIFFERENCE DECREASES WITH AGE.

THOSE DATA ARE ABOUT PREVALENCE

OF PAIN.

WHAT ABOUT SEVERITY OF PAIN?

IN A CLINICAL SETTING THAT IS A

IMPORTANT CONSIDERATION.

THERE HAVE BEEN A NUMBER OF

STUDIES, MANY MORE THAN

PRESENTED HERE ON THIS TABLE,

THAT HAVE LOOKED AT SEX

DIFFERENCES IN, FOR EXAMPLE,

POSTOPERATIVE OR PROCEDURAL

PAIN.

IN BLACK YOU SEE THE STUDIES

THAT HAVE FOUND FEMALES REPORT

MORE PAIN THAN MALES BUT YOU SEE

DEPENDING ON THE END POINT,

TRACKS ON THE FIRST DAY, WOMEN

REPORTED MORE PAIN AFTER

ARTHROSCOPIC SURGERY BUT ON DAYS

TWO AND 3, THEY HAD THE SAME

AMOUNT OF PAIN.

PAIN AT ONE YEAR AFTER

ARTHROSCOPIC SURGERY WAS THE

SAME OR AS TWO HOURS

POST-SURGERY IN THE SAME COHORT,

WOMEN REPORTED MORE PAIN.

SO THERE IS SOME SUGGESTION THAT

WOMEN ARE EXPERIENCING MORE PAIN

HERE BUT IT'S CLEARLY NOT AS

SIGNIFICANT OR CONSISTENT AS WE

SEE WITH THE EPIDEMIOLOGICAL

FINDINGS.

AND THESE ARE CONFOUNDED WITH

THE DRUGS THEY WOULD BE TAKING

AFTER SURGERY IN MOST OF THESE

STUDIES.

WHAT WE HAVE BEEN INTERESTED IN

OVER THE YEARS IS THE

POSSIBILITY THAT SOME OF THESE

SEX DIFFERENCES IN PAIN ARE DUE

TO THE FACT THAT THE PAIN

PERCEPTION SYSTEM WORKS

DIFFERENTLY IN WOMEN AND MEN.

AND SO WE BROUGHT PEOPLE INTO

THE LABORATORY AND INFLICTED

PAIN ON TEMAND STUDIED THEIR

RESPONSES.

MY COLLEAGUE AT UNIVERSITY OF

FLORIDA, JOE RILEY, DID A

METANALYSIS OF THIS LITERATURE

SEVERAL YEARS AGO.

THE CONCLUSION WAS THAT FOR

SEVERAL TYPES OF EXPERIMENTAL

PAIN, PRESSURE, THERMAL,

ELECTRICAL AND ISCHEMIC, WOMEN

REPORT SIGNIFICANTLY LOWER

THRESHOLDS AND LOWER TOLERANCES

THAN MEN.

AND THESE AFFECT SIZES WERE

MODERATE.

SO THAT SUGGESTS THAT THE

MAGNITUDE OF THE DIFFERENCES

LARGE ENOUGH TO PAY ATTENTION TO

BUT NOT SO LARGE AS TO BE THE

ONLY THING WE PAY ATTENTION TO.

SINCE TA TIME, WE HAVE WRITTEN A

REVIEW ARTICLE AND SUMMARIZED

THE LITERATURE THAT CAME OUT

BETWEEN 1989 AND 2009 AND HERE I

JUST HAVE A TALLY OF STUDIES.

HERE IS THE TALLY OF STUDIES

WITH PAIN THRESHOLD AND

TOLERANCE THAT SHOWED WOMEN HAVE

HIGHER PAIN THRESHOLD AND

TOLERANCE THAN MEN.

THERE ARE NONE.

THIS IS A RIDICULOUSLY

CONSISTENT PATTERN OF AFFECTS IN

THE HUMAN LITERATURE.

MALES HAVING HIGHER THRESHOLD

AND TOLERANCE THAN FEMALES.

QUITE FREQUENT, AND OCCASIONALLY

WE HAVE STUDIES THAT SHOW NO

SIGNIFICANT SEX DIFFERENCE,

ALTHOUGH THEY ARE GENERALLY IN

THIS DIRECTION.

SO THE MORE RECENT FINDINGS ARE

POINTING IN THE SAME DIRECTION.

WE HAVE PAIN RATINGS INSTEAD OF

JUST THRESHOLD OR TOLERANCE.

WE DELIVER A PAINFUL STIMULUS

AND ASK PEOPLE TO RATE HOW

PAINFUL IT WAS.

THE PREPONDERENCE OF EVIDENCE,

HAS FEMALES REPORTING THESE

TYPES OF PAIN AS BEING GREATER

THAN MALES.

AND THEN THERE ARE OTHER

TECHNIQUES THAT HAVE BEEN USED,

FOR EXAMPLE, TEMPORAL SUMMATION

OF PAIN WHERE ONE DELIVERS

REPETITIVE, RAPID HEAT PULSES,

FOR EXAMPLE, AT THE SAME

INTENSITY, BUT BECAUSE OF A

RAPID FORM OF CENTRAL

SENSETISSATION, IT ACTUALLY

HURTS MORE.

THE STIMULUS IS THE SAME BUT THE

SPINAL NEURONS ARE RESPONDING

MORE VIGOROUSLY WHICH PRODUCES A

GREATER PAIN PER SEP AND MANY

YEARS AGO, BILL AND I PUBLISHED

THESE DATA SHOWING THAT WHILE ON

THE FIRST PULSE, MEN AND WOMEN

HAD SIMILAR PAIN RATINGS AS THE

PULSES PROGRESSED, WOMEN SHOWED

GREATER TEMPORAL SUMMATION.

GREATER INCREASE IN PAIN THAN

MEN.

OTHERS HAVE LOOKED AT HEAT PAIN

AND AGAIN SHOWN GREATER TEMPORAL

SUMMATION IN WOMEN.

MECHANICAL PAIN, GREATER

TEMPORAL SUMMATION IN WOMEN IN

MOST STUDIES.

THERE IS NO EVIDENCE THAT

SPACIAL SUMMATION OF PAIN

DIFFERS ACROSS SEXES.

THAT IS, A SMALL PAIN STIMULUS

HURTS LESS THAN A BIG PAIN

STIMULUS OF THE SAME INTENSITY.

THAT AFFECT IS THE SAME IN MEN

VERSUS WOMEN.

SO WHATEVER THE MECHANISMS

UNDERLYING SPACIAL SUMMATION,

THEY DON'T SEEM TO DIFFER AS A

FUNCTION OF SEX.

THOSE ARE MEASURES OF BASELINE

PAIN SENSITIVITY.

THERE HAS BEEN A LOT OF INTEREST

IN METHODS FOR MEASURING ONE'S

ABILITY TO CONTROL PAIN.

SO WE ALL HAVE PAIN INHIBITORY

SYSTEMS THAT WE CAN RELY ON TO

HELP US CONTROL PAIN WHEN IT

OCCURS AND THE WAY WE TEST THIS

IN THE LABORATORY IS I DELIVER A

HEAT STIMULUS TO YOUR HAND.

YOU RATE IT AT A 75 OUT OF 100.

I THEN ASK YOU TO STICK YOUR

OPPOSITE FOOT IN COLD WATER AND

DELIVER THE SAME HEAT STIMULUS

YOUR HAND.

IT HURTS A LOT LESS WHEN YOU

HAVE THE COMPETING PAIN STIMULUS

ON YOUR FOOT.

I THEN HAVE YOU TAKE YOUR FOOT

OUT OF THE HOT WATER AND THE

HEAT ON YOUR HAND IS BACK TO

HURTING 75 OUT OF 100.

THIS DECREASE IS A MEASURE OF

YOUR INHIBITORY SYSTEM'S ABILITY

TO FUNCTION.

AND LINDA LAERER TAQUESTA OF

WASHINGTON DID A SYSTEMATIC

REVIEW OF --

TO EXAMINE THESE DIFFERENCES IN

MEN VERSUS WOMEN AND STRIKINGLY,

MEN SEEM TO SHOW MORE ROBUST

INHIBITION OF PAIN IN THE

LABORATORY THAN WOMEN DO.

THIS MIGHT BE IMPORTANT BECAUSE

THERE ARE NOW A COUPLE OF

STUDIES THAT SUGGEST IF YOU

MEASURE THIS PAIN INHIBITORY

RESPONSE BEFORE SURGERY, IT MAY

PREDICT RISK FOR DEVELOPING

CHRONIC PAIN AFTER SURGERY.

SO THIS MAY BE A CLINICALLY

RELEVANT INDEX.

SOME OF YOU MAY BE THINKING,

WELL, EVERYTHING HE IS TALKING

ABOUT IS SELF REPORTED IN NATURE

AND WE KNOW MEN AND THEY SAY IT

DOESN'T HURT AND WE KNOW WOMEN

TEND TO EXAGGERATE PAIN OR

WHATEVER WE MIGHT THINK.

SO THERE HAVE BEEN A FEW STUDIES

THAT USED MORE PHYSIOLOGICAL

MEASURES, NOW THAT IS NOT PAIN.

RIGHT?

PAIN IS A SUBJECTIVE

PSYCHOLOGICAL EXPERIENCE BUT

THESE THINGS CAN BE CORRELATED

WITH PAIN.

HERE IS A STUDY WHERE THEY

APPLIED INCREASING AMOUNTS OF

PRESSURE AND MEASURED PUPIL

DILATION AS A NERVOUS SYSTEM

RESPONSE TO THE PAIN AND YOU SEE

WOMEN SHOW MORE ROBUST PUPIL

DILATION AS THE STIMULUS

INTENSITY INCREASES AND THIS

MATCHES QUITE WELL WITH THE

PATTERN OF INCREASES IN PAIN

REPORT THAT THEY SHOWED.

OTHER STUDIES HAVE LOOKED AT A

REFLECTION REFLEX SO YOU CAN

STIMULATE A NERVE BEHIND THE

ANKLE.

YOU CAN MEASURE A MUSCLE REFLECT

IN THE HAMSTRING CORRELATED WITH

PAIN.

AND WHAT WE SEE HERE ACROSS TWO

STUDIES OF HEALTHY CONTROLS IS

THAT WOMEN SHOW THAT REFLECT AT

A LOWER STIMULUS INTENSITY THAN

MEN DO.

THIS STUDY WAS NOT SIGNIFICANT,

ALTHOUGH THIS INCLUDED THE

CLINICAL POPULATION OF PEOPLE

WITH OSTEOARTHRITIS PAIN BUT

THERE IS AT LEAST SOME EVIDENCE

WHEN YOU USE PHYSIOLOGICAL

MEASURE SYSTEM THAT THE SEX

DIFFERENCES HOLD UP.

I DON'T KNOW WHAT WE WILL HEAR

LATER, BUT MAYBE SOME OF THE

BRAIN IMAGING WORK THAT HAS BEEN

DONE IN THIS AREA AS WELL.

AND WHAT ABOUT RESPONSES TO PAIN

TREATMENT?

THERE HAS BEEN A RELATIVE

ABUNDANCE OF RESEARCH LOOKING AT

SEX DIFFERENCES IN RESPONSES TO

OPIOIDS.

THESE DATA WERE RECENTLY

REVIEWED BY A GROUP IN THE

NETHERLANDS FOR NEW OPIOID

STUDIES.

THESE ARE CLINICAL STUDIES.

ALMOST ALL POSTOPERATIVE PAIN

STUDIES.

WHEN YOU COLLAPSE THE STUDIES

TOGETHER, THERE IS NO SEX

DIFFERENCE IN THE AMOUNT OF

OPOID CONSUMED.

WHEN YOU LOOK, FOR EXAMPLE, ONLY

AT MORPHINE STUDIES IN WHICH

PATIENT CONTROLLED ANALGESIA WAS

USED, SO THE PATIENTS WERE

DELIVERING THEIR OWN DRUG, YOU

GET A ROBUST SEX DIFFERENCE HERE

SUCH THAT WOMEN ARE REQUIRING OR

CONSUMING LESS OPIOIDS THAN MEN.

WE DON'T KNOW THAT THIS MEANS

BETTER ANALGESIA BECAUSE PAIN

ISN'T THE END POINT IN THESE

STUDIES.

OPIOID CONSUMPTION IS.

IT SUGGESTS THAT MORE 15 MIGHT

BE WORKING BETTER FOR WOMEN --

MORPHINE --

ALSO AN EXPERIMENTAL STUDY, WHEN

YOU DO AN EXPERIMENTAL PAINEST

AND DELIVER MORPHINE AND REPEAT

THE EXPERIMENTAL PAIN TEST,

WOMEN ARE AGAIN SHOWING TENDENCY

TOWARDS GREATER ANAGESIA IN THE

LABORATORY.

PROBABLY THE BEST KNOWN AND MOST

CONSISTENT SEX DIFFERENCES ARE

SEX DIFFERENCES DIFFERENCES IN

RESPONSE TO THE CAPA OPIOID

DRUGS WHIH ARE REALLY

MIXED-AGONIST ANTAGONIST DRUGS.

HERE ARE STUDIES FROM A GROUP IN

SAN FRANCISCO WHERE AFTER PEOPE

HAVE GOTTEN THEIR WISDOM TEETH

OUT AND THEY START TO DEVELOP

POSTOPERATIVE PAIN BECAUSE THE

LOCAL ANESTHETIC IS WEARING OFF,

THEY DELIVER A DRUG AND HERE IS

HOW MUCH PAIN RELIEF WOMEN GOT

AND IT LASTED A NICE LONG TIME

WHEREAS MEN GOT VERY LITTLE PAIN

RELIEF AND THEIR PAIN GOT WORSE.

AND YOU SEE THE PATTERN AND NO

SEX DIFERENCES IN PLACEBO.

AND THESE FINDINGS HAVE BEEN

CONSISTENTLY REPORTED IN THE

CLINICAL SETTINGS SO THIS IS A

LARGE SEX DIFFERENCE FOR THESE

MIXED ACTION OPIOIDS AND WOMEN

SHOWING BETTER ANALGESIA.

HERE WE SEE NO SEX DIFFERENCE

WHATSOEVER IN RESPONSE TO THESE

MIXED ACTION DRUGS IN THE

LABORATORY.

WOMEN HAVE ALSO SHOWN GREATER

SIDE EFFECTS TO OPIOIDS

INCLUDING RESPIRATORY

DEPRESSION, NAUSEA AND EM SIS

AND IT MAY THAN WOMEN CONSUME

LESS OPIOIDS BECAUSE THEY ARE

HAVING MORE SIDE EFFECTS.

HERE ARE SOME SIDE EFFECTS FROM

ONE OF OUR STUDIES ARE WOMEN ARE

REPORTING MORE SEDATION, DRY

MOUTH AND NAUSEA IN RESPONSE TO

MORPHINE AND THIS WAS IN HEALTHY

VOLUNTEERS AFTER A SINGLE DOSE.

ON THE OTHER HAND, JIM AND HIS

COLLEAGUES SHOWED THAT WHEN IT

GETS TO FUN SIDE EFFECTS, MEN

LIKE THESE DRUGS MORE.

AND SO WOMEN HAVE MORE

UNPLEASANT SIDE EFFECTS, MEN

TEND TO HAVE MORE PLEASANT SIDE

EFFECTS, WHICH SOUNDS LIKE AN

ADVANTAGE FOR MEN BUT OF COURSE

MEN SEEM TO BE AT GREATER RISK

FOR OPIOID ABUSE OR NONMEDICAL

USE OF OPIOIDS AND IT MAY BE

BECAUSE THE DRUGS MAKE THEM FEEL

GOOD RATHER THAN BAD.

SO WHAT ARE SOME OF THE

MECHANISMS THAT MIGHT UNDERLIE

PAIN?

SEX HORMONES HAVE TO BE PART OF

THE CONVERSATION.

PAIN CHANGES ACROSS THE

MENSTRUAL CYCLE IN THE CLINICAL

AND GENERAL AND IN CLINICAL

POPULATIONS.

AND USE OF HORMONES HAS BEEN

ASSOCIATED WITH INCREASED RISK

FORAIN AND INCREASED SEVERITY OF

PAIN IN SOME STUDIES.

THESE ARE SOME DATA FROM LINDA

AT WASHINGTON.

AND THESE ARE PATIENTS.

THESE ARE THEIR WORST PAIN.

IT PEAKS DURING THE MENSTRUAL

PAYS.

COMES DOWN AND SHOWS A BLIP

DURING OVALATION AND INCREASES

IN THE LATE LINIAL PHASE.

YOU SEE THE SAME PATTERN IN

WOMEN ON ORAL CONTRACEPTIVES

BECAUSE THEY ARE NOT OVULATING,

THEY DON'T GET THE OVLATORY BUMP

IN PAIN BUT THEY GET THE REST OF

THE PATTERN AND OF COURSE MEN

ARE FAIRLY CONSISTENT ACROSS

THEIR MENSTRUAL CYCLES.

IN TERMS OF EXPERIMENAL PAIN,

JOE RILEY DID A SYSTEMATIC

REVIEW OF THESE DATA AND

SUGGESTED THAT PAIN SENSITIVITY

WAS GREATEST IN THE PREMENSTRUAL

VERSUS POST MENSTRUAL PHASE.

BUT THESE AFFECTS ARE FAIRLY

SMALL AN INCONSISTENT ACROSS

STUDIES.

REBECCA CRAFT TALKED ABOUT THE

MULTIPLE PERIPHERAL, CENTRAL

IMMUNE, SKELETAL, CARDIOVASCULAR

AFFECTS OF ESTROGEN WHEREBY

VARIOUS PAIN COMPLAINTS COULD BE

INFLUENCED SO THERE ARE MULTIPLE

ROLES OF THESE SEX HORMONES.

ENDOGENOUS OPIOID FUNCTION HAS

BEEN FOUND TO BE DIFFERENT IN

MEN VERSUS WOMEN THROUGH

MICHIGAN.

IN RESPONSE TO AN EXPERIMENTAL

PAIN STIMULUS, MALES SHOWED

GREATER BRAIN OPIOID RECEPTOR

ACTIVATION THAN DID FEMALES.

INTERESTINGLY, WHEN THEY

PROVIDEDDESTRA DIAL TREATMENT

FOR FEMALES, THEIR NEW OPIOID

RECEPTOR BINDING WENT UP AND

BECAME EQUAL TO MALES.

SO IT SUGGESTS THAT WOMEN AT

BASELINE SHOW LEFT NEW OPIOID

RECEPTOR BINDING BUT THAT MIGHT

BE ENHANCED WITH ESTROGEN

TREATMENT.

THERE HAS BEEN A LOT OF RESEARCH

ON GENDER ROLES IN PAIN

RESPONSES, MEASURES OF

MASCULINITY ASSOCIATED WITH

HIGHER PAIN THRESHOLD

INTOLERANCE.

ONE STUDY SHOWED THAT MEN REPORT

LESS PAIN TO A FEMALE THAN A

MALE EXPERIMENTER.

HOWEVER, BOTH WOMEN AND MEN SAY

THAT MEN ARE BETTER ABLE TO

COLRATE PAIN AND THAT WOMEN ARE

MORE WILLING TO REPORT PAIN.

AND A RECENT STUDY SUGGESTED

THAT SOME OF THESE GENDER ROLES

EXTEND TO OUR THOUGHTS ABOUT HOW

PEOPLE COPE WITH PAIN.

PEOPLE TEND TO THINK THAT WOMEN

USE MORE NEGATIVE COPING

STRATEGIES AND MEN TEND TO

IGNORE PAIN SENSATIONS.

SO HERE IS ONE OF THESE

EXPERIMENTER GENDER STUDIES

WHERE IN RESPONSE TO A MALE

EXPERIMENTER, WOMEN ARE

REPORTING HIGHER PAIN TOLERANCE

IN RESPONSE TO A FEMALE

EXPERIMENTER.

MEN --

MALES ARE REPORTING HIGHER PAIN

TOLERANCE.

THIS SUGGESTS THE SOCIAL

INTERACTION MAKES A DIFFERENCE.

AND SO, RELATIVELY QUICKLY, I

TOLD YOU THAT WOMEN ARE AT

GREATER RISK FOR A VARIETY OF

PAIN CONDITIONS.

THEY SHOW INCREASED EXPERIMENTAL

PAIN SENSITIVITY, THERE ARE SEX

DIFFERENCES AND OPIOID RESPONSES

BUT THESE DEPEND ON WHICH

OPIOIDS WE ARE TALKING ABOUT.

AND THAT THERE ARE MULTIPLE

BIO-PSYCHO-SOCIAL MECHANISMS

THAT CONTRIBUTE TO THESE

DIFFERENCES.

AND I THANK YOU FOR YO TIME.

[APPLAUSE]

>> THANK YOU.

I'D LIKE TO INTRODUCE OUR NEXT

SPEAKER.

HE IS DR. MAHER DIRECTOR OF THE

GALE AND GERARD OPPENHEIMER

CENTER FOR BIOLOGY OF STRESS AT

THE DIVISION OF DIGESTIVE

DISEASES AND THE DAVID GEFFEN

SCHOOL OF MEDICINE AT THE

UNIVERSITY SCHOOL OF MEDICINE

L.A.

HE WILL BE SPEAKING ABOUT SEX

DIFFERENCES AND PERSISTENT PAIN

SYNDROME.

>> I WOULD ALSO LIKE TO THANK

THE ORGANIZERS INVITING ME TO

THIS EVENT.

IT'S ALWAYS GOOD TO COME BACK

HERE EVEN A FEW DAYS BEFORE THE

SUBMISSION.

I THINK THIS IS A VERY IMPORTANT

FUNCTION TO PROMOTE THE

IMPORTANCE OF SEX DIFFERENCES

AND THE RESEARCH THAT IS BEHIND

IT.

IN MANY WAYS, WE HAVE ALREADY

SAID MOST OF THE THINGS THAT I

THINK CAN BE SAID ABOUT SEX

DIFFERENCES IN PAIN.

LI FOCUS ON A SLIGHTLY DIFFERENT

ANGLE WITH AN EMPHASIS ON BRAIN

MECHANISMS.

AND ALSO SINCE OUR RESEARCH HAS

BEEN PRIMARILY BEEN IN THIS

GROUP OF DISORDERS, THAT MORE

COMMONLY OCCUR IN WOMEN AND THAT

STILL STRUGGLING FOR THE CORRECT

NAME, PERSISTENT PAIN DISORDERS

AFFECT MULTIPLE SITES IN THE

BODY OVERLAPPING OR MORE COMMON

IN WOMEN.

I WOULD LIKE TO THANK THE NIH

SUPPORT WITH THE SCORE GRANT

WHICH HAS MADE A TREMENDOUS

DIFFERENCE BOTH IN THE EMPHASIS

OF OUR GROUP ON SEX DIFFERENCES

BUT ALSO MOSTLY ON THE

ATTRACTION OF THIS RESEARCH

PROGRAM TO YOUNG FEMALE

INVESTIGATORS THAT MAKE UP 95%

OF OUR GROUP RIGHT NOW.

SO I WAS GOING TO GO THROUGH A

FEW AREAS AND GIVE YOU EXAMPLES

OF EACH OF THOSE WITHOUT BEING

ABLE TO GIVE YOU DEFINITIVE

ANSWER.

TOUCH A LITTLE BIT ABOUT THIS

TOPIC AND THIS TRANSITION FROM

THE PREVIOUS TALK.

SEX DIFFERENCES IN PREVALENCE IN

PERSISTENT PAIN SYNDROMES AND

EXPERIMENTAL PAIN RESPONSES.

AND THEN THE MAIN EMPHASIS ON

OUR EFFORTS TO DECONSTRUCT THESE

SUBJECTIVE PAIN EXPERIENCES INTO

SEX-RELATED NEUROBIOLOGICAL

ENDOPHENOTYPES.

AND I'LL SHOW YOU SOME DATA ON

SEVERAL OF THESE.

THERE IS OBVIOUSLY A LONG LIST

OF THEM.

SOME WITH LARGE AFFECT SIZES AND

OTHERS WITH SMALLER ONES.

THE ONES I WILL BE TALKING ABOUT

IS THE EXPECTATION OF PAIN,

PREATTENTIVE RESPONSES TO PAIN,

THE ACTUAL PAIN EXPERIENCE WHEN

A STIMULUS IS GIVEN, THE RESTING

BRAIN, THE ACTIVITY OF THE BRAIN

WITHOUT PAIN STIMULUS IN

PATIENTS WHO HAVE THESE

CONDITIONS AND THEN THE RECENT

EVIDENCE, AND THIS IS A WORK IN

PROGRESS ON THE ASSOCIATION OF

STRUCTURAL CHANGES IN THE BRAIN

BASED ON SEX DIFFERENCES.

SO THERE ARE MANY VARIATIONS OF

THIS SLIDE BASICALLY EMPHASIZING

THAT A GROUP OF PERSISTENT PAIN

DISORDERS WHICH AFFECT DIFFERENT

PARTS OF THE BODY, SOMATIC AND

VISCERAL DOMAIN, OFTEN OVERLAP

WITH EACH OTHER.

FOR SOME OF THOSE IT'S CLEAR

THAT THE --

I DIDN'T PUT A RATIO HERE

BECAUSE IT'S CLEAR THESE ARE

FEMALE DISORDERS, COMMON,

SIGNIFICANT IMPACT ON THE

QUALITY OF WOMEN.

THEY ARE AFFECTED.

OTHERS THAT AFFECT BOTH MEN AND

WOMEN SUCH AS PAINFUL BLADDER

SYNDROME, GASTROINTESTINAL

DISORDERS SUCH AS IBS.

SO THE INTERESTING DEVELOPMENT

HAS BEEN IN THIS.

SO WHEN YOU SEE SOME OF THESE

TRAUMATIC NUMBERS, SOME PEOPLE

SAY THAT IF YOU DO AWAY WITH THE

TRIGGER POINT DEFINITION, THE

SEX DIFFERENCE CHANGES

SIGNIFICANTLY AND BECOMES LESS.

SIMILAR NATURE WE THINK IS GOING

ON IN THE AREA OF THE

NEUROLOGICAL PAIN CONDITIONS

BECAUSE IT INCLUDES CHRONIC

PROSTATITIS IN MEN AND ASSUMES

THE DIFFERENCES ARE GOING WAY

DOWN.

SO I PERSONALLY THINK THIS IS

THE NUMBERS HERE ARE IN AREA OF

FLUX.

IT'S IMPORTANT THAT THIS IS

REALLY ONLY ONE ASPECT OF WHY

SEX DIFFERENCES ARE POTENTIALLY

IMPORTANT.

THIS WAS MENTIONED ALREADY.

IT'S QUITE POSSIBLE THE

GENERATION OF SUBJECTIVE PAIN IN

MEN AND WOMEN IS DIFFERENT EVEN

THOUGH THEY MAY HAVE THE ACTUAL

SEX DIFFERENCES MAY NOT BE THAT

TRAUMATIC AS WE INITIALLY

THOUGHT.

SO JUST BECAUSE IN PREVALENCE.

SO SOME OF THE KEY QUESTIONS,

WHAT ARE THE SHARED BIOLOGICAL

MECHANISMS UNDERLYING DIFFERENT

PERSISTENT PAIN SYNDROMES?

I THINK THE EMPHASIS IN THIS

AREA HAS SHIFTED A LOT FROM

TRYING TO UNDERSTAND THESE

SPECIFICS AND THE PERIPHERAL

FACTORS THAT ARE RESPONSIBLE FOR

DIFFERENT PARTS OF THE BODY TO,

WAARE THE SHARED MECH
NISMS THAT

MIGHT ALSO HAVE TO DO WITH

SEX-RELATED FACTORS.

A RELATED QUESTION, WHAT ARE THE

FACTORS RESPONSIBLE FOR THE

TRANSITION OF ACUTE SYMPTOMS OF

DISCOMFORT AND PAIN THAT ALMOST

EVERYBODY HAS EXPERIENCED IN ALL

THESE DOMAINS THAT I SHOWED

BEFORE TO A PERSISTENT PAIN

SYNDROME?

AND AGAIN, IS THERE SEX

DIFFERENCE IN THAT CONDITION?

AND WHY WOMEN ARE MORE

VULNERABLE TO THESE CONDITIONS?

SO, I THINK IN TERMS OF STUDYING

SEX-RELATED DIFFERENCES, SOME OF

THE KEY QUESTIONS THAT HAS

REDEFINED AND SHIFTED THE FOCUS

OF RESEARCH INTO THIS DIRECTION.

SO I'M NOT GOING TO GO THROUGH

THIS AGAIN.

THE EVIDENCE FOR A CLEAR SEX

DIFFERENCE IN THE RESPONSES FOR

MEANT RECALL VISCERAL PAIN IS

INCONSISTENT.

I THINK IT'S CLEARER FOR SOMATIC

PAIN, POSSIBLY BECAUSE IT'S

SOMEWHAT MORE DIFFICULT TO STUDY

VISCERAL PAIN WITH INVASIVE

TECHNOLOGIES THAT INTRODUCE

SIGNIFICANT AMOUNT OF

INVASIVENESS INTO THE PROCEDURE.

SO FACTORS LIKE THE EXPERIMENTER

WHO IS DOING THE STUDIES PLAY

ACE GREATER ROLE.

OUR ONLY INTEREST IS TRIGGERED

BY SIMILAR DEVELOPMENT IN

PSYCHIATRY.

PSYCHIATRY IS STILL

SYMPTOM-BASED SYNDROMES AND THE

QUESTION IS HOW THEY HAVE RUN

INTO EQUALLY PAIN RESEARCH.

HOW DO YOU FIND THE BIOLOGICAL

BASIS OF A SUBJECTIVE EXPERIENCE

THAT VARIES DEPENDING ON HOW IT

IS BEING EXPERIENCED BY THE

SUBJECT AND BEING COMMUNICATED?

ONE APPROACH TO THAT HAS BEEN

ONE POSSIBLE APPROACH IS TO

DECONSTRUCT THE COMPLEX

SYNDROMES THAT ARE CURRENTLY

DEFINED BY SUBSPECIALTIES IN

PAIN.

AND IF YOU TAKE A CLOSER LOOK AT

THIS, THESE DEFINITIONS ARE LESS

THAN SCIENTIFIC, I WOULD SAY.

THERE IS NEW DEFINITIONS EVERY

THREE YEARS AND THEN A CHANGE IN

PREVALENCE.

SO GOING FROM THESE SYNDROME

LEVEL, DOWN TO LOWER LEVELS,

GOING TO THE SYMPTOMS, THE

PHENOTYPES UNDERLYING THE

SYMPTOMS, THE NEURAL SYMPTOMS,

SO BASICALLY GOING DEEPER AND

DEEPER INTO THE BIOLOGY AND SO

INSTEAD OF HAVING OR DEALING

WITH ONE SYNDROME YOU ASSUME IS

ONE TENTH OF THE ENTITY.

YOU END UP WITH A LOT OF THOSE

ENDOPHENOTYPES AS THEY CONVERGE

TO DEFINE THE SYNDROME AND A

DIFFERENT COMBINATION OF THESE

ENDOPHENOTYPES MAKE UP DIFFERENT

SUBSETS OF THE SYNDROMES ACROSS

THE VARIOUS SYNDROMES.

SO ONE SIMPLE WAY TO LOOK AT

THIS IN TERMS OF PAIN IS THAT

THE SUBJECTIVE PAIN EXPERIENCE

IS OBVIOUSLY NOT SOMETHING THAT

IS A LINEAR TRANSLATION BETWEEN

AN EXPERIMENTAL OR AN ACUTE

STIMULUS TO THE PERCEPTION, BUT

IT'S A HIGHLY-PROCESSED --

PROCESS THAT INVOLVES PAIN

INHIBITION AND FACILITATION

SYSTEMS, EMOTIONAL AROUSAL

NETWORKS THAT ARE CONNECTED TO,

FOR EXAMPLE, PAIN FACILITATION.

REWARD NETWORKS AND ALSO WE

TALKED ABOUT THIS BEFORE, BUT

PAIN INHIBITION NETWORKS.

ONE VERY IMPORTANT --

IF YOU SEEN THE DATA, IF YOU

TAKE AN EXPERIMENTAL STIMULUS

AND THE PAIN RATING IN TERMS OF

INTENSITY AND THE PERCEPTION,

THE GENERAL TREND IS IN THE

DIRECTION THAT WOMEN EXPERIENCE

PAIN AT GREATER EXTENT AND LOWER

THRESHOLDS BUT IT'S NOT 100%

CONSISTENT.

HOWEVER, WHAT WE ARE INTERESTED

FROM THE CLINIC IS WHERE THE

SPONTANEOUS PAIN EXPERIENCES

THAT AFFECTS A INDIVIDUAL TO GO

TO SEEK HEALTH CARE.

AND THERE IS A WHOLE OTHER

MODULATION OF THIS ENTITY.

ONE IS CLEARLY THE PAIN

PERCEPTION THROUGH THESE

NETWORKS WHICH COMES UP FROM THE

BODY BUT OTHERS ARE EMOTIONAL

AND COGNITIVE MODULATORS, FOR

EXAMPLE, THIS WORST OUTCOME

ASSUMPTION THAT SEEMS TO BE

PLAYING A BIG ROLE IN THE

SPONTANEOUS PAIN EXPERIENCE.

AND THE SEX RELATED DIFFERENCES

AS WE SEEN EARLIER ARE LARGER IN

THESE SPONTANEOUS WRITINGS.

IF YOU REALLY WANT TO UNDERSTAND

AND TREAT PAIN, I THINK WE HAVE

TO SORT OF GET CLOSER TO THIS.

WHAT HAPPENS IN THE REAL WORLD,

AND WHAT ARE THE UNDERLYING

MECHANISMS?

ONE IS CLEARLY BEING THE MOST

RECEPTIVE INPUTS AND A LOT OF

OTHER FACTORS THAT CONTRIBUTE TO

IT.

THERE IS ALSO --

AND THIS IS ANOTHER WAY TO

DECONSTRUCT IT ON A TIME SCALE,

A LOT OF DIFFERENT THINGS THAT

HAPPEN THAT COME INTO PLAY FROM

EARLY ON AND EVEN BEFORE THE

STIMULUS IS DELIVERED OR BEFORE

AN EVENT HAPPENS, SO THIS WHOLE

CONCEPT OF THE PREDICTION OF A

INDIVIDUAL, HOW BAD IT'S GOING

TO BE, TO VERY EARLY EVENTS,

PREATTENTIVE EVENTS, SENSORY

MOAT REDATING.

AUTOMATIC RESPONSE OF BRAIN

SYSTEMS, BRAINSTEM SYSTEMS, HOW

MUCH INFORMATION THEY LET INTO

THE BRAIN FROM THE PERIPHERY.

AND THEN A VARIETY OF OTHER

MECHANISMS THAT COME INTO PLAY

ONCE THE STIMULUS IS ACTUALLY

DELIVERED OR THE EVENT HAPPENS.

AND FINALLY, AFTER A LONG DAY,

WEEK OR YEARS OF EXPERIENCE IN

THAT PAIN, WHAT ARE THE

CONSEQUENCES IN THE CENTRAL

NERVOUS SYSTEM, SPINAL CORD AND

HIGHER.

THIS IS WHERE WE CAN MEASURE

WHERE IT HAPPENS IN THE

PERIPHERY.

WHAT ARE THESE STRUCTURAL

CHANGES AND WHAT ROLE DO THEY

PLAY ULTIMATELY IN THE

PERCEPTION?

ONE THING THAT WE FIND OF

PARTICULAR INTEREST IS TO LOOK

AT ALL OF THESE DIFFERENT

COMPONENTS THAT THE SUBJECTED

PAIN EXPERIENCE IS MADE UP OF

AND LOOK AT WHAT ARE THE

SEX-RELATED DIFFERENCES IN EACH

COMPONENT?

SO FAR, MOST OF THESE, WE HAVE

DETECTED SEX-RELATED

DIFFERENCES.

MAYBE NOT STRONG IN SOME OF

THESE AREAS AND NOT AS STRONG IN

OTHERS.

BUT WE FEEL THAT THE ULTIMATE

CONTRIBUTION OF HOW DIFFERENT A

WOMAN EXPERIENCES PAIN IN THE

SYNDROMES COMPARED TO MEN HAS TO

DO WITH HOW MANY OF THESE SEX

BIASED PHENOTYPES CONTRIBUTE TO

THAT SYNDROME.

SO LET ME GIVE YOU A FEW

EXAMPLES, PAIN EXPECTATION.

SO I MENTIONED THAT ALREADY THIS

ASSUMPTION OF A WORST-CASE

OUTCOME WITH VERY HIGH

PROBABILITY BEING A STRONG

PICTUROR OF CHRONIC PAIN

SEVERITY, INCLUDING AN IBS AND

THIS IS CLEARLY MORE COMMON IN

WOMEN.

SO, IT POINTS SOMEWHAT --

AND THIS IS MORE OF THE

HYPOTHESES THAN FACT, TOWARDS

THAT PREMECHANISMS INVOLVED IN

MAKING PREDICTIONS, MAY SHOW

SIGNIFICANT SEX-RELATED

DIFFERENCE BETWEEN MEN AND

WOMEN.

WORRY ABOUT WHAT MAY HAPPEN IS

HIGHLY CORRELATED WITH IBS

SYMPTOM SEVERITY.

SO, CLEARLY AGAIN THIS

PREDICTION IS BASED ON ENCODED

MEMORIES AND THEN MAKING A WRONG

PREDICTION BASED ON THESE.

GIVEN THE EXAMPLES, SCHEMATIC

EXAMPLES, WE SEE THIS ALL THE

TIME IN OUR PATIENT IN THE

CLINIC.

PATIENTS WILL SAY THEY WAKE UP

IN THE MORNING OR EVEN GOING TO

BED.

AND WORRIED THIS PAIN WILL BE

UNBEARABLE OR UNCOMFORTABLE.

AND THE NEXT DAY, DURING THE

DAY, IN A BUSINESS MEETING OR

BEING ON THE FREE WAY, JUST BY

ITSELF, THIS FEELING WILL

ALREADY CREATE A SENSE OF

DISCOMFORT.

AND THEN WE HYPOTHESIZED THAT

ANY NORMAL ACTIVITY OF THE GI

TRACT DRIVEN BY HYPERACTIVITY,

SUCH AS EXCESSIVE CONTRACTION

AND BLADDER CONTRACTION OR

DISSENSION, THIS WILL BE

AMPLIFIED CENTRALLY AND THIS

WOULD CREATE A PAINFUL

EXPERIENCE.

BROUGHT THE PRESENCE OF A EVENT

IN THE PERIPHERY.

AND MANY STUDIES SHOWED FROM OUR

OWN WORK THAT THE EXPECTATION OF

PAIN, IF YOU TELL AN INDIVIDUAL

THAT THEY GET OR EXPERIENCE A

PAINFUL DISSENSION, YOU CAN DO

THIS WITH A TUBE.

WHENEVER THEY GET A RED LIGHT,

THEY KNOW IN THE NEXT FEW

SECONDS, THEY WILL GET THE

STIMULUS OR UNCERTAIN SO THEY

WILL NOT KNOW THE 5 MINUTES IF

THEY HAVE A PAINFUL EXPERIENCE.

YOU CAN SEE THE DIFFERENCE

BETWEEN IBS AND CONTROL

SUBJECTS.

THE EXPECTATION THEY CAN'T DO

ANYTHING ABOUT, BEING ROBBED

INTO THE SCANNER.

THEY DEACTIVATE CERTAIN BRAIN

AREAS DRAWING ATTENTION TO THE

INSULA, THE REGION THAT HAS TO

DO WITH THE CONSCIOUS PERCEPTION

OF PAIN AND ALSO THE AMYGDALA.

AROUSAL AREAS.

AND IN THIS STUDY, THESE ARE HOW

PATIENTS FAILED TO DOWN REGULATE

THESE AREAS.

IF IT'S AN EXPECTATION OR THE

BRAIN OR PATIENT WANTS TO

MAXIMIZE THE SENSITIVITY TO MAKE

SURE THAT IT IS QUICKLY AND

ACCURATELY ESTIMATED WHEN THE

PAIN HITS THEM, IT'S A DIFFERENT

PATTERN.

SO THERE WAS LITTLE RESPONSE.

THIS WAS ONE STUDY.

MANY STUDIES OUT THERE WITH

DIFFERENT PARADIGMS.

AND A CHARACTERISTIC FINDING IS

THAT IBS PATIENTS WOULD SHOW

ENGAGEMENT IN CORTEXES DURING

EXPECTATIONS SIMILAR TO THE

ACTUAL DISSENSION.

THEY SIMULATE THIS EXPERIENCE

ALREADY OR AS SHOWN THEY

SATURATED RESPONSE FOR THIS.

WE DID ANOTHER STUDY LIKE THAT

WHERE WE DIDN'T DO A DISSENSION

BUT WE PUT ELECTRODES IN THE

LEFT LOWER ABDOMEN OR IC

PATIENTS TO THE AREAS AND THE

PATIENTS MADE THIS EXPERIENCE

ANY TIME DURING THE EXPERIMENT.

AND WE FOUND THAT MALE PATIENTS

IN THIS AREA SHOWED A GREATER

INSULAR RESPONSE THAN FEMALE

PATIENTS DURING THIS ABDOMINAL

PAIN THREAT.

SO, PRERESPONSE TO PAIN AND

LONG-TERM COLLABORATOR AND

COLLEAGUE, SORT OF DONE A WHOLE

SERIES OF STUDIES.

I HAVE TO PRESS THIS.

THEY ARE DIFFICULT TO EXPLAIN

AND SUMMARIZE IN THE SUMMARY

SLIDE WITH AS MANY TIMES.

THERE IS A VARIETY OF PARADIGMS,

EXPERIMENTAL PARADIGMS THAT HAVE

TO DO WITH THE STARTLED RESPONSE

AND MODULATION OF THE STARTLED

RESPONSE.

SO ANY CREATURE ALL THE WAY DOWN

TO AMOEBA IN RESPONSE TO A LOUD

OR EXCESSIVE STIMULUS WILL SHOW

A STARTLED RESPONSE.

AN ARMADILLO WILL JUMP UP TWO

FEET IN THE AIR AND A BABY WILL

SHOW A STARTLED RESPONSE.

THIS IS A BASIC BRAINSTEM WIRED

RESPONSE.

THE REASON IS IT OF INTEREST TO

PAIN RESEARCHERS IS BECAUSE YOU

CAN MODULATE IT EITHER WITH

EMOTIONAL STIMULI, IF THERE IS A

THREAT OF PAIN GIVEN BEFORE OR

IF THE CONTEXT OF THE STARTLED

EXPERIMENT, AND YOU CAN INCREASE

OR NOT CHANGE THE STARTLE

RESPONSE.

OR INHIBIT OR FACILITATE BY

GIVING A POST-PRIOR TO THE

STARTLED RESPONSE TO SEE IF YOU

MODULATE THIS.

I WILL NOT GET INTO DETAILS

BECAUSE THIS IS A SEPARATE TALK.

I'LL SUMMARIZE.

SO IT SUMMARIZE THE FINDINGS.

THIS HAPPENS TO BE A VERY GOOD

PARADIGM TO TEST THE SEX

DIFFERENCES.

SO, GENERALLY THERE WAS AN

INCREASED STARTLED RESPONSE ON

THE CONDITIONS OF UNPREDICTABLE

THREAT IN IBS PATIENTS AND

PATIENCE WITH --

INDICATING A GREATER EMOTIONAL

AROUSAL RESPONSE TO A THREAT AND

THIS WAS LATER IN PART TO THE --

SO AT A BASICALLY HAVE THESE

PATIENTS WITH HIGH ANXIETY WITH

A GREATER RESPONSIVENESS
RESPONSIVENESS TO
 THAT

SYSTEM.

ALSO A STRONG SEX GROUP

INTERACTION WITH SIGNIFICANT

VARIATION DEPENDING ON THE

MENSTRUAL CYCLE OR THE --

IF THE PATIENTS WERE ON BIRTH

CONTROL PILLS OR MENOPAUSAL.

LET ME SKIP THIS.

ONE OF THE THINGS THAT WE ARE

DOING IN STUDIES IN HUMANS IS TO

STUDY RODENTS, BOTH MICE AND

RATS WITH AN IMAGING PARADIGM, A

FUNCTIONING PARADIGM THAT ALLOWS

US TO MOVE IN UNTETHERED ANIMALS

WHICH WE THINK IS ESSENTIAL FOR

UNDERSTANDING PAIN SYNDROMES IN

EMOTIONAL FACTORS.

AND WE FOUND TO OUR GREAT

SURPRISE, SOME OF THE BASIC

DIFFERENCES WE SAW IN OUR

PATIENTS AND HEALTHY CONTROLS,

WE ALSO SAW IN THIS RODENT

STUDY, MAINLY GREATER CORTICAL

MODULATION OR RESPONSE IN MALE

ANIMALS IN A GREATER LIMBIC

RESPONSE INVOLVING THE AMYGDALA

AND THE CORTEX IN THE RODENTS.

THAT ALLOWS US TO GO BACK AND

FORTH.

>> LOOKING AT SEX DIFFERENCES

AND DISEASE DIFFERENCES, A LOT

OF INTEREST HAS IN THE LAST FEW

YEARS FOCUSED --

AND THIS IS EVOLVING, STILL NOT

TOTAL CONSENSUS WHAT THE BEST

ANALYSIS TECHNIQUE IS, DIFFERENT

RESULTS COME OUT DEPENDING ON

THE WAY THEY ARE ANALYZED.

BUT JUST TO SHOW YOU THIS:

ONE OF OUR JUNIOR FEMALE

INVESTIGATORS ON THIS STUDY, WE

FOUND THAT THE RESTING STATE

FLUCTUATE.

YOU FIND IF YOU COMPARE HEALTHY

CONTROL SUBJECTS WITH IBS

STATIONS THAT THERE IS A GREATER

FLUCTUATION OF NIECE LOW

FREQUENCY --

IN THE LOW FREQUENCY DOMAIN IN

THE PATIENTS.

SO THESE INDIVIDUALS THAT DON'T

DO ANYTHING IN THE SCANNER, NOT

JUST SYMPTOMS AT THE TIME OF THE

SCANNING.

AND NO CORRELATION.

THE CONNECTIVITY OF THE WHOLE

NETWORK IS ALTERED IN THE

RESTING BRAIN OF THESE PATIENTS.

LET ME SHOW A FEW MORE SLIDES

HERE.

THIS IS ANOTHER AREA THAT

RECEIVED A LOT OF ATTENTION.

THESE SHOW CORTICAL VOLUME OR

THICKNESS AND CONNECTIVITY IN

DIFFERENT PAIN SYNDROMES.

WE DON'T KNOW AT THIS POINT IF

THERE IS INDIVIDUAL FINGERPRINTS

FOR EACH SYNDROME OR IF THIS IS

A GENERALIZE BRAIN RESPONSE IN

THE BRAIN IN ASSOCIATION WITH

CONIC PAIN EXPERIENCE.

SO WE ARE LUCKY THAT WE WERE

ABLE TO ESTABLISH A

COLLABORATION WITH THE

LABORATORY OF IMAGING AT UCLA.

A RECORD OF VERY LARGE DATABASES

ESSENTIALLY WHAT WE HAVE DONE IN

THE LAST FEW YEARS IS TO COLLECT

OR BUILD THIS DATABASE TO NOW

FULL OF 290 FEMALE BRAINS, A

SMALL NUMBER OF MALE BRAINS AND

WE USE THE PIPELINE THAT LONI

HAS ESTABLISHED TO BASICALLY

ASSIST A WHOLE ARRAY, SOMETIMES

15 DIFFERENT PARAMETERS OF

CORTICAL VOLUME,

CURVATURE-SHAPED PARAMETERS IN

CORTICAL WEAKNESS AND ENROLL IN

AN AUTOMATED WAY TO TAKE OR

RUNNING ON A SUPER COMPUTER AND

IDENTIFY YOU.

FOR EXAMPLE, WE ASK IN THIS

CASE, WHAT AREAS TO THE BRAIN

ARE DIFFERENT IN WOMEN AS

OPPOSED TO MEN?

NOT ASKING FOR ANYTHING.

IDENTIFIES THE INSULAR CORTEX AS

ONE AREA NA IS DIFFERENT.

THEN THE NEXT QUESTION IS, THERE

IS A DIFFERENCE IN CORTICAL

THICKNESS AND THE FIRST WAS IN

VOLUME AND THE SECOND OF THE IN

THICKNESS.

THE LEFT INTERIOR INSULA RUNNING

IN A DIFFERENT PARADIGM.

AND WE CAN SAY THIS SHOWS YOU

COLOR-CODED THAT YELLOW, THIS IS

THE REGION OF THE BRAIN THAT WE

SHOWED DIFFERENCE ARE GREATER IN

FEMALE SUBJECTS AND IDENTIFIES

THE INSULA.

SO THE GREATER CORTICAL

COMPLEXITY IN THE FEMALE

SUBJECTS AND WHAT THAT MEANS.

THE EXCITING THING IS WE CAN

ALSO CORRELATE THIS WITH A

VARIETY OF BEHAVIORAL PARAMETERS

SO AN UNPRECEDENT THE

OPPORTUNITY TO PROBE TH BRAIN

BASED ON THE RESTING ACTIVITIES

AND THESE VERY COMPLEX

STRUCTURAL CHANGES THAT OCCUR IN

THE SYNDROMES.

SO IN SUMMARY, WE FEEL THE

MULTIPLE DISTINCT NEUROLOGICAL

COMPONENTS, FUNCTIONAL AND

STRUCTURAL.

SOME SHOW RELATED DIFFERENCES.

I WOULD HAVE TO SAY ALL OF THEM

THAT WE LOOKED AT SHOWS

DIFFERENCES.

SOME MORE THAN OTHERS.

AND WE FIND IT INTERESTING THAT

A LARGE NUMBER, MAYBE NOT --

MAYBE A LARGE NUMBER OF

DISEASE-RELATED PHENOTYPES

SERVED PRIOR TO EXPERIENCE OF

PAIN.

SO THE RESTING STATES WHERE

THERE IS NO PAIN EXPECTATION OF

PAINS AND PREDICTION IN THESE

PREATTENTIVE MEASURES.

AND IT'S QUITE POSSIBLE THAT THE

FIXED DIFFERENCES ARE PRIMARILY

CONTRIBUTING TO THE PAIN

EXPERIENCE OF GREATER PREVALENCE

OF SPONTANEOUS PAIN SYMPTOMS TO

THESE MODITORY CIRCUITS THAT FOR

SOME REASON ARE FUNCTIONING

DIFFERENT IN WOMEN THAN IN MEN.

THANK YOU FOR YOUR ATTENTION.

SORRY FOR GOING OVER TIME.

[APPLAUSE]

>> OUR FINAL PROFESSOR IS CARMEN

GREEN AT THE HEALTH MANAGEMENT

AND POLICY AND OBSTETRICS AND

GYNECOLOGY AT THE UNIVERSITY OF

MICHIGAN SPEAKING ON THE SCIENCE

OF INCLUSION, RACIAL RACIAL

GENDER AND AGING INFLUENCEOS

PAIN.

>> GOOD AFTERNOON.

BILANGUAGEIO, ITALY, FOR THOSE

WHO WANT TO GO.

NEXT.

I'M A PHYSICIAN SO I HAVE

NOTHING TO DISCLOSE IN REGARDS

TO CONFLICTS OF INTEREST.

LET ME TALK TO YOU A LITTLE BIT

ABOUT HOW SOME OF MY CAREER

BEGAN AND THAT WILL SET THE

STAGE FOR THE CONVERSATION THAT

WE ARE GOING TO HAVE ABOUT THE

SCIENCE OF INCLUSION.

SO THIS WONDERFUL PEANUT HERE IS

MY NIECE.

AND SO, ABOUT THE TIME THAT I

STARTED MY PAIN MEDICINE

FELLOWSHIP, SHE WAS ABOUT THIS

AGE.

AND I STARTED WONDERING WHEN I

WAS TAKING CARE OF PATIENTS, WHY

WE ASKED CERTAIN PATIENTS TO

SORT OF CLARIFY MORE ABOUT THEIR

PAIN AND SOME WE DIDN'T.

WHY SOME PEOPLE HAD TO PROVE

THAT THEY HAD PAIN AND SOME

PEOPLE DIDN'T.

AND SO, TODAY, I WILL ACTUALLY

SORT OF GO THROUGH FAIRLY

QUICKLY AND TRY NOT TO RUN OVER

TIME HERE, FOR YOU DR. EDWARDS,

IN REGARDS TO THE INTEREST AND

WHY WE SHOULD BE INTERESTED IN

RACE, ETHNICITY, GENDER AND

CLASS.

AND, I WILL DO THIS IN SEVERAL

DIFFERENT PARTS.

THE FIRST PART WE WILL TALK

ABOUT JUST A SHORT BACKGROUND AS

IT RELATES TO HEALTH

DISPARITIES.

WE WILL THEN MOVE INTO SORT OF

PAIN FROM THE PATIENT

PERSPECTIVE AND THEN WE WILL

MOVE FORWARD TO TALKING ABOUT

CLINICIAN VARIABILITY AND

DECISION-MAKING AND POTENTIALLY

STRUCTURAL BARRIERS IN CARE.

AND THEN WE WILL FINALLY SORT OF

WRAP UP WITH A DISCUSSION OF

SOME OF THE GAPS IN THE

LITERATURE, WHERE WE NEED TO GO

AND POLICY RECOMMENDATIONS.

AND I WILL ALSO THROW IN ONE

STORY SO WE DON'T FORGET THAT WE

DON'T FORGET THAT THE WORK WE

ARE DOING, WHETHER IT BE LOOKING

AT NIECES OR LOOKING AT HUMANS

SO THE PATIENT STORY IS NOT

FORGOTTEN.

SO, HEALTH DISPARITIES.

A LOT OF YOU KNOW OF THIS

PARTICULAR STUDY SO I WON'T GO

INTO A GREAT DEAL OF ISSUES,

BOREAL GIVE AN OVERVIEW.

THIS IS THE SHUL MAN STUDY IN

WHICH THEY TOOK ACTORS AND THESE

ARE BLACK AND WHITE ACTORS, MALE

AND FEMALE AND I KIND OF THINK

THEY LOOK ALIKE.

THE MEN LOOK LIKE THEY HAVE BEEN

DRAGGED THERE BY SOME WOMAN.

AND THEY KIND OF LOOK A LITTLE

BIT SOUR PUSSY.

BUT THE WOMEN, OKAY, SO WADO

THAT THEY DO?

THEY SAID IT HURTS HERE AND GOES

DOWN HERE.

IT GOES DOWN THERE.

SORT OF CLASSIC-TYPE OF CHEST

PAIN.

THE PART OF THE STORY THAT WAS

LEFT OUT WAS IT'S ABOUT PAIN.

NOW I ASKED PHYSICIANS --

THEY WERE ACTORS.

RIGHT?

SO THEY ASKED PHYSICIANS HOW

THEY WOULD TREAT THESE PATIENTS.

AND THERE IS A GREAT DEAL OF

VARIABILITY IN HOW THEY TREATED

THE PATIENTS AND MINORITIES

RECEIVING LESSER QUALITY CARE.

THAT COULDN'T BE EXPLAINED BY

THE DESCRIPTION THAT THE PATIENT

PUT FORTH.

SO WE THINK ABOUT DISPARITIES IN

ACCESS TO CARE AND HEALTH

STATUS, OR IN HEALTH CARE

QUALITY.

WE THINK ABOUT THAT AND

DIFFERENCES IN OUTCOMES THAT ARE

ASSOCIATED WITH DISADVANTAGE.

ALTHOUGH A LOT OF DIFFERENT

DEFINITIONS, THAT IS THE ONE I

TEND TO USE.

NOW, ROGER HAS GONE THROUGH A

LOT ABOUT PAIN, BUT LET ME TELL

YOU ONE OF THE THINGS, THE

INSTITUTE OF MEDICINE WROTE A

REPORT ON THE UNEQUAL TREATMENT.

AND THIS DOUBT IS CONSIDERED TO

BE THE BIBLE AS IT RELATES TO

HEALTH DISPARITIES.

BUT PAIN WAS NOT REALLY COVERED

IN THIS PARTICULAR DISCUSSION.

NOW, THE MECHANISMS AS IT

RELATES TO THE UNDERLYING

DIFFERENCES, SEX-RELATED

DIFFERENCES IN PAIN, ARE VARIED.

FIRST OF ALL, WE NEED TO THINK

ABOUT WHERE WE COME FROM, OUR

GENETICS DETERMINES OUR SEX,

DETERMINES A LOT ABOUT US.

WE HAVE NOT REALLY DONE A LOT OF

GENETIC STUDIES AS IT RELATES TO

SEX AND WE HAVEN'T DONE THEM IN

LOOKING AT A

NATIONALLY-REPRESENTATIVE

SAMPLE.

THEN YOU THINK ABOUT THE ROLE OF

AGE, WHERE WE ARE IN OUR

LIFESPAN AND WE ARE PREVIOUSLY

TALKING ABOUT WHERE WE ARE IN

OUR LIFESPAN, PARTICULARLY AS A

WOMAN, HOW THAT MIGHT PLAY IN

DIFFERENCES.

ANOTHER FACTORS ARE RACE AND

ETHNICITY.

SO IN 1998, THEY HAD THE FIRST

NIH PAIN CONSORTIUM THAT FOCUSED

ON GENDER AND YOU HAD SEVERAL

DIFFERENT SEMINARS THROUGHOUT

THE YEARS.

HOWEVER, WE REALLY HAVE NOT PAID

A LOT OF ATTENTION TO RACIAL AND

ETHNIC DIFFERENCES.

NOW, THE CONSEQUENCES OF PAIN

CAN BE VARIED AND SO I'M TALKING

ABOUT THIS FROM THE WOMAN'S

PERSPECTIVE AND WE KNOW THAT

THERE IS PHYSICAL, SOCIAL,

EMOTIONAL IMPLICATIONS TO HAVING

PAIN.

HOWEVER, ONE OF THE THINGS WE

HAVEN'T STUDIED IS THE

40-50-YEAR-OLD FEMALE WHO HAS A

CHILD, WHO HAS A PARTNER, WHO

MAY HAVE AGING PARENTS, AND WHAT

THE IMPACT THAT PAIN HAS ON

THEIR LIVES.

SO WE HAVEN'T DONE SOME OF THOSE

STUDIES AND THEY DEFINITELY NEED

TO BE DONE.

NOW, INSTITUTE OF MEDICINE DID A

REPORT ON QUALITY, TOKER IS

HUMAN.

AND THEY TALKED ABOUT AMONG THE

COMMITTEE'S MOST DISTURBING

FINDINGS IS THE FREQUENCY OF

WHICH PARENTS EXPERIENCE PAIN.

INSTITUTE OF MEDICINE RECEIPT

REPORT TALKS ABOUT 116 MILLION

PEOPLE LIVING WITH PAIN AND MOST

OF THEM ARE UNDERTREATED.

SADLY, THIS STATEMENT IS STILL

TRUE, MANY PATIENTS FAIL TO

RECEIVE THE STATE-OF-THE-ART

PAIN CARE.

NOW, I TALKED A LITTLE BIT ABOUT

RACE AND ETHNICITY AND I TALKED

A LITTLE BIT ABOUT AGE.

LET'S TALK ABOUT THE CHANGING

DEMOGRAPHICS OF THIS SOCIETY.

WE KNOW THAT THE FIRST

BABYBOOMER TURNED 65 RECENTLY.

WE KNOW THAT OUR SOCIETY ALSO IS

CHANGING IN REGARDS TO

DIVERSITY.

WE ARE INCREASINGLY DIVERSIFYING

THIS SOCIETY SUCH THAT PEOPLE OF

COLOR WILL BECOME THE INCREASING

MAJORITY AND THIS IS --

IN THIS SOCIETY.

AND ONE THING THAT HAS NOT BEEN

TALKED ABOUT DR. CLAYTON, IS THE

FACT THAT AGING REALLY IS A

WOMAN'S HEALTH ISSUE.

WE TALK ABOUT AGING.

WE DON'T TALK ABOUT IT REALLY AS

A WOMAN'S HEALTH ISSUE.

WE NEED TO HAVE THAT

CONVERSATION.

WHAT WE HAVE IS IN CREASINGLY

AGING, INCREASINGLY DIVERSIFYING

AND INCREASINGLY FEMALE

POPULATION.

OUR POPULATION WILL LOOK MORE

AND MORE LIKE THIS.

SO AGING IS PAIN.

THAT'S NOT ME OR ANYBODY THAT I

KNOW.

SO WE KNOW THAT THE PREVALENCE

OF PAIN WILL INCREASE WITH

AGING.

WE ALSO KNOW THAT ACCELERATED

AGING, THAT MEANS HAVING MORE

CHRONIC DISEASES, INCREASES WITH

BEING A RACIAL AND ETHNIC

MINORITY, WE ALSO KNOW THAT

OLDER PEOPLE ARE, OLDER ADULTS

ARE LESS LIKELY TO RECEIVE

ADEQUATE ANALGESICS AND LESS

LIKELY TO HAVE THEIR 59

ASSESSED.

AND WE ALSO --

THEIR PAIN ASSESSED THERE IS A

HIGH CORRELATION BETWEEN

DEPRESSION AND PAIN BUT THE

THING ABOUT IT IS, THE PAIN

COMES FIRST.

AND THEN THE DEPRESSION.

MINORITY ELDERS ARE PARTICULARLY

AT RISK.

SO, WHEN I TALKED ABOUT AGING IN

A WOMAN'S HEALTH ISSUE, I GIVE

TALKS TO THE COMMUNITY

PERIODICALLY AND I WAS AT A

CHURCH WITH A WHOLE LOT OF

AFRICAN-AMERICAN ELDERS AND I

SAID HOME OF YOU HAVE PAIN?

ALL OF THEM RAISED THEIR HAND

EXCEPT FOR THREE.

I SAID, WHAT IS WRONG WITH YOU?

AND THEY SAID, I JUST PRAY ON

IT.

SO WE KNOW THAT OLDER ADULTS

ABOUT 50% OF OLDER ADULTS HAVE

PAIN BUT WE STILL DON'T HAVE

REALLY GOOD REPRESENTATION AS IT

RELATES TO THAT INCREASINGLY

DIVERSIFYING POPULATION.

SO I'M HERE TO TELL YOU THAT

THERE IS GOING TO BE A TSUNAMI

OF PAIN MEDICS COMING.

NOW, GENDER AND AGING, I'M NOT

GOING TO BELABOR THE POUNDS MY

COLLEAGUES TALKED ABOUT.

BUT WHETHER WE WANT TO TALK

ABOUT EXPERIMENTAL PAIN OR WHAT

IS GOING TO IN THE BRAIN, WE

KNOW THAT THE PAIN COMPLAINTS OF

WOMEN AND THE PAIN COMPLAINTS OF

RACIAL AND ETHNIC MINORITIES

OFTEN GO UNTREATED.

MINORITIES ARE LESS LIKELY TO

HAVE THEIR PAIN SCORES REPORTED

AS SHOWN OVER AND OVER AGAIN.

THEY HAVE LESS ACCESS TO PAIN

CARE.

THEY ALSO ARE LESS LIKELY TO

RECEIVE ADEQUATE PAIN TREATMENT

AND I'M GOING TO SHOW YOU SOME

OF THAT.

WE ALSO KNOW THAT THEY ARE AT

RISK FOR DIMINISHED HEALTH IN

THE CONSEQUENCE OF PAIN.

THIS IS A QUICK STUDY WHERE IT

SHOWS YOU HAVE AFRICAN-AMERICANS

AND IN THE BLUE YOU HAVE

CAUCASIAN.

DONE BY THE UNIVERSITY OF

MICHIGAN.

0 BEING NO PAIN AND SIX BEING

THE WORST PAIN.

CONSISTENTLY THE

AFRICAN-AMERICAN REPORTING

HIGHER PAIN SCORES THAN THE

CAUCASIAN AMERICANS, WHETHER YOU

ARE YOUNG OR WHETHER YOU ARE

OLD.

YOU LOOK AT THE CAUSAL

ATTRIBUTIONS OF PATIENTS WHO

CAME TO A PAIN CLINIC, YOU SEE

THAT MEN TEND TO REPORT THAT

ACCIDENTS WERE MORE LIKELY THE

CAUSE OF THEIR PAIN THAN WOMEN.

SO IF YOU LOOK AT THE PAIN

DISABILITY INDEX, HOW MUCH DOES

PAIN INTERFERE WITH YOUR LIVES,

YOU SEE THAT WOMEN, PARTICULARLY

AFRICAN-AMERICAN WOMEN ARE

IMPACTED.

NOW, THIS IS IMPORTANT BECAUSE

YES, SO WOMEN HAVE HIGHER

DISABILITY SCORES.

BUT IF THEY VERY CHILDREN, FROM

MY EXPERIENCE AS A PAIN MEDICINE

DOCTOR, THEY ALWAYS TAKE CARE OF

THEIR KIDS.

SO THERE IS SOMETHING THAT GOES

ON.

SO AS MUCH AS WE TALK ABOUT

MALADAPTIVE TYPE OF COPING, THEY

TAKE CARE OF THEIR KIDS.

AND WHEN I SEE MALE PATIENTS,

TEY AREN'T TAKING CARE OF THEIR

KIDS.

SO MAYBE SOME THINGS ARE GOING

ON, AGAIN THAT WE NEED TO

EXPLORE SCIENTIFICALLY.

THIS IS A STUDY IN WHICH WE

ACTUALLY TOOK A LOOK AT OLDER

WOMEN WHO CAME TO A PAIN CLINIC

AND THEN WOMEN WITH WHO HAD

CHRONIC PAIN IN THE BLUE.

AND WE TOOK A LOOK AT OUR

HEALTHY VOLUNTEERS FROM OUR QUAD

PEPPER CENTER.

AND IT TURNED OUT OF THE HEALTHY

VOLUNTEERS, WE HAD TO KICK OUT

50% OF THEM.

BECAUSE THEY ACTUALLY MET THE

CRITERIA FOR CHRONIC PAIN.

THEY WERE JUST CALLING IT

SOMETHING ELSE.

AND THIS IS PRIMARILY A

CAUCASIAN GROUP.

THERE WERE VERY FEW MINORITIES

IN THIS.

IT SHOWS HERE THAT FOR WOMEN

WITH CHRONIC PAIN, THEY HAVE

DECREASED HEALTH AND QUALITY OF

LIFE.

NOW, IF YOU LOOK AT BLACK WOMEN,

AND COMPARED TO WHITE WOMEN AND

YOU LOOK AT PAIN DISABILITY, YOU

SEE HERE AGAIN THAT BLACK WOMEN

HAVE MORE DISABILITY DUE TO PAIN

THAN CAUCASIAN WOMEN.

IF ACCIDENTS CAUSE THE PAIN, WE

THINK ABOUT PTSD.

WOMEN REPORTED MORE PTSD

SYMPTOMS THAN WHITE WOMEN.

YOU SEE THE SAME FOR BLACK MEN

AND WHITE MEN.

IF YOU LOOK AT PAIN CONTROL

ACROSS THE LIFESPAN, YOU SEE

THAT BLACK WOMEN REPORTED LOWER

PAIN CONTROL THAN CAUCASIAN

WOMEN.

SO I'M HERE TO TELL YOU THERE IS

AN UNEQUAL BURDEN OF PAIN AS IT

RELATES TO MINORITY WOMEN AND

THEY HAVE DIMINISHED HEALTH DUE

TO THIS AS WELL.

NOW, WE DID A STUDY AND LOOKED

AT PATIENTS WHO CAME TO THE PAIN

CLINIC.

THESE PEOPLE HAD ACCESS TO CARE.

AND WE ASKED THEM SOME

QUESTIONS, BECAUSE SOMETIMES WE

LEAVE THE PATIENT OUT OF THE

CONVERSATION.

AND WE ASKED THEM ABOUT THEIR

DIFFICULTY AND ABILITY TO PAY

FOR CARE AND ABOUT THE ABILITY

TO AFFORD CARE AND WHETHER

CHRONIC PAIN WAS A MAJOR PROBLEM

AND CONSISTENTLY, THE

AFRICAN-AMERICAN POPULATION

REPORTED THAT THEY HAD

DIFFICULTY PAYING FOR CARE,

COULDN'T AFFORD HEALTH CARE AND

CHRONIC PAIN WAS A MAJOR
PROBLEM.

THESE PEOPLE PEOPLE ALL HAVE
ACCESS TO A C
ARE

CENTER.

ATTITUDES MAKE A DIFFERENCE.

PEOPLE SAY GOSH, WELL, THEY ARE
JUST MYTHS
 AND IF

WE EDUCATE PEOPLE, THEY WILL GO
AWAY.

BUT AT SOME LEVEL, THERE IS SOME
PART THAT
 IS

ABOUT THEIR MYTHS BEING BASED
UPON THEIR

EXPERIENCE.

AND SO HERE WE ASKED, WHETHER OR
NOT YOU E
NDORSE

THIS OR WHETHER OR NOT GOOD
PATIENTS AVOID
 TALKING

ABOUT PAIN.

WE SEE AFRICAN-AMERICAN WOMEN

AND CAUCASIAN WOMEN TEND TO

AGREE MORE WITH THAT STATEMENT.

NOW, TRANSITION.

TO THE CLINICIAN ROLE, ONE OF

THE THINGS PEOPLE TALKED ABOUT

IS THE WHOLE, I'M SORRY, I KEEP

STOPPING IN FRONT OF YOU.

SO, WE KEEP TALKING ABOUT OPIOID

ANALGESICS.

AND AT SOME LEVEL, THE WHOLE

CONVERSATION HAS GOTTEN INTO

WHETHER OR NOT PEOPLE ARE

DESERVING OR NOT DESERVING OF

QUALITY PAIN CARE.

BUT I WOULD SAY IN ACTUALITY WE

NEED TO SORT OF UTILIZE A NUMBER

OF MODALITIES THAT WE ACTUALLY

HAVE AVAILABLE TO US TO TAKE

CARE OF PATIENTS WITH PAIN.

NOW, LET'S THINK ABOUT HOW OR

WHO WE ARE, CHANGE IS SOME OF

THE CONVERSATION.

SO, THIS WAS A PAPER AND PENCIL

TEST WE GAVE TO 400 PHYSICIANS

IN THE STATE OF MICHIGAN.

AND WE ACTUALLY SAID, WE HAVE

ONE WOMAN WHO HAD BREAST CANCER

WITH METASTATIC DISEASE TO THE

BONE.

MAN HAD PROSTATE CANCER WITH

METASTATIC DISEASE TO THE BONE.

SO YOU'RE TREATING METASTATIC

DISEASE TO THE BONE.

AND YOU HAVE TO TRUST ME.

TRUST ME, I'M A DOCTOR.

TRUST ME THEY HAVE THE SAME

PROBLEMS.

AND WHAT WE FOUND IS THAT THE

PHYSICIANS TREATED THE WOMEN,

GAVE THE WOMEN LESSER QUALITY

CARE.

LESS REFERRALS TO PAIN THAN THE

MEN.

THIS IS ANOTHER SLIDE THAT SHOWS

ON ADMISSION TO THE PAIN CENTER

THAT THERE WAS --

AND WE DID THIS FORMULA TO LOOK

AT THE QUALITY OF ANALGESICS

THAT THE PATIENTS WERE

RECEIVING.

AND WE SEE HERE THAT CAUCASIANS

IN GENERAL RECEIVE BETTER

QUALITY ANALGESIC CARE COMPARED

TO THE MINORITIES.

IT SAYS TO US THAT THIS

VARIABILITY OF THE

DECISION-MAKING IS POTENTIALLY

IN THE PRIMARY CARE ARENA AND

PROBABLY EXTENDING INTO THE

TERTIARY CARE ARENA.

NOW, NEIGHBORHOODS ARE FULL OF

MATTER.

SO I'M GOING TO TAKE YOU --

I TOOK OUT A COUPLE OF THESE

SLIDES AND HERE IS A HIGH

SCHOOL.

THIS IS A PHARMACY.

AND THE PHARMACY THERE IS A SIGN

OF THERE WHERE IT SAYS, WE DON'T

CARRY A CERTAIN TYPE OF PAIN

MEDICATION.

ONE OF MY PATIENTS COME TO ME

AND THIS IS SUPPOSED TO BE A

QUICKIE VISIT.

YOU KNOW, BECAUSE I HAVE GOT EN

HER TAKEN CARE OF SO WE ARE JUST

HERE TO REFILL SOME MEDICATIONS

AND MAKE CERTAIN THERE ARE NO

SIDE EFFECTS.

FOLLOWING ME?

OKAY.

AND SHE SAYS, DR. GREEN, I CAN'T

GET THIS MEDICINE FILLED ANY

WHERE.

SO, LIKE EVERY GOOD CLINICIAN, I

FIND A WAY OR SOMEBODY TOLLS DO

THE WORK.

I CALL ME RESEARCH ASSOCIATES

AND IT IS SAY WE NEED TO LOOK

INTO THIS.

WE DID A SURVEY STUDY ACROSS THE

STATE OF MICHIGAN IN WHICH WE

LOOKED AT MINORITY AND

NONMINORITY.

AND MINORITY SHOWED 70% OF THE

PEOPLE WITHIN YOUR ZIP CODE

BEING MINORITY, CAUCASIAN

GREATER THAN 70% CAUCASIAN.

AND WE ASKED PHARMACISTS --

AND I'M GOING TO GIVE YOU JUST A

SNAPSHOT.

WE ASKED PHARMACISTS WHETHER OR

NOT THEY CARRY CERTAIN PAIN

MEDICATIONS.

AND YOU ONLY HAD TO HAVE ONE OF

EACH TYPE OF CATEGORY TO BE

CONSIDERED TO BE SUFFICIENT.

AND FOR THE CAUCASIANS, THEY HAD

NEARLY 90% OF THE PHARMACIES

CARRIED THE DRUG.

FOR THE MINORITIES, 50%.

NOW, YOU SAY, OKAY CARMEN, THIS

IS ABOUT CLASS.

SO ONE OF THE THINGS WE DID, WE

STRATIFIED THE DATA TO LOOK AT

THE ROLE OF SOCIOECONOMIC

STATUS.

WE LOOKED AT HIGH-INCOME

MINORITIES AND COMPARED THEM TO

LOW-INCOME CAUCASIANS.

AND WE FOUND THAT HIGH-INCOME

MINORITIES HAD LESS ACCESS TO

THE MEDICATIONS THAN LOW-INCOME

WHITES.

OKAY.

QUALITY OF LIFE.

CANCER.

A LOT OF INTEREST IN CANCER

THESE DAYS, RIGHT?

ESTIMATES OF ONE-3 AMERICANS

ACTUALLY HAVING SOME CANCER

DIAGNOSIS.

AND OUR PRESIDENT, CURRENT

PRESIDENT, FORMER PRESIDENTS,

TALKED ABOUT CANCER.

I WOULD ALSO SAY WE NEED TO HAVE

A CONVERSATION AS IT RELATES TO

PAIN.

BECAUSE WE CAN ACTUALLY, WE ARE

TRYING TO MAKE A TRANSPORTATION

THIS BEING A CHRONIC DISEASE BUT

WE ALMS NEED TO MAKE A

TRANSITION TO THINK ABOUT PAIN

AS SOMETHING PEOPLE CAN LIVE

WITH THAT DOESN'T INTERFERE WITH

THEIR QUALITY OF LIFE.

SO, WE DID A STUDY.

NOW I'M GOING TO GIVE YOU A

COUPLE OF THINGS.

I MADE MY CAREER TO A LARGE

EXTENT BASED ON STUDIES THAT

OTHER PEOPLE DIDN'T DO.

IN WHICH FIRST OF ALL, SOME OF

THE STUDIES, AND I'M MY FRIEND

ROGER IS VERY GOOD.

SO HE CONTINUES TO USE WOMEN IN

HIS STUDIES.

BUT, A LOT OF STUDIES DIDN'T

EVEN TALK ABOUT THE POPULATION.

THEY DON'T TALK ABOUT THE

PERCENTAGE OF WOMEN THAT ARE IN

THE STUDY.

THEY DON'T TALK ABOUT RACIAL

MINORITIES.

AND I JUST TOLD YOU WE HAVE

INCREASING AGING IN A

DIVERSIFYING SOCIETIY.

SO SOME OF THE STUDIES DONE IN

THE CANCER PAIN LITERATURE DID

NOT LOOK AT THIS PARTICULAR

POPULATION.

SO WE WENT AND WE DID, FIRST I

WANT TO TELL YOU THAT CANCER

SHOWS A LOT OF DISPARITIES.

YOU KNOW THAT.

AND THE CANCER PAIN LITERATURE

SHOWS DISPARITIES.

THE SURVIVOR LITERATURE, ONE OF

THE THINGS THAT WAS LOOKED AT

WAS BREAKTHROUGH PAIN.

AND AT A DIDN'T EVEN DESCRIBE

THE POPULATION.

SO WE WENT BACK AND WE DID THIS.

AND WE SHOWED THAT WOMEN AND

RACIAL ETHNIC MINORITIES ARE AT

RISK FOR HAVING MORE CONSISTENT

PAIN FOR PATIENTS WITH STAGE 3

AND STAGE 4 CANCERS.

THERE IS NO STAGE 5 CANCER.

HAVE MORE PAIN AND MORE

BREAKTHROUGH PAIN AND

BREAKTHROUGH PAIN IS THE PAIN

THAT IS THAT ACCELERATED PAIN

THAT HAS BEEN SHOWN TO DIMINISH

QUALITY OF LIFE AND MAYBE

POTENTIALLY HASTEN A MORTALITIY.

SO HERE IS THE SLIDE THAT SHOWS

CONSISTENT PAIN LOOKING AT YOUR

CAUCASIANS COMPARED TO YOUR

NON-WHITES.

AGAIN, STAGE 3 AND 4 CANCER.

BREAKTHROUGH PAIN, SAME

DIFFERENCE IN RACIAL AND ETHNIC

MINORITIES HAVING MORE RISK.

NOW, I WANT TO TELL YOU ONE

OTHER THING.

WE HAVE SHOWN WHERE WE TALK

ABOUT CANCER, CHRONIC

CANCER-RELATED PAIN.

CANCER-REALITY CHRONIC PAIN,

RATHER.

WE TALK ABOUT 20% OF OUR

PATIENTS TWO YEARS OUT STILL

HAVING CHRONIC PAIN.

AND RACIAL AND ETHNIC MINORITIES

OF WOMEN HAVE INCREASED RISK.

SES.

WE KNOW THAT SES AFFECTS HEALTH

AND WELL-BEING BUT LOW SES IS

NOT A GOOD THING AS WE THINK

ABOUT RESOURCES AVAILABLE TO THE

PATIENT.

WE ALSO KNOW THAT SES MAKES A

DIFFERENCE IN HOW WE TAKE CARE

OF PATIENTS.

SO THIS IS A STORY HERE AND I'M

NOT GOING TO BELABOR THIS BUT A

PATIENT WHO LIVES WITH CHRONIC

PAIN WHO REALLY ONLY HAS TYLENOL

FOR THEIR PAIN.

UNTIL THEY ACTUALLY DEVELOPED A

DIAGNOSIS OF CANCER.

AND ONCE THEY HAD A DIAGNOSIS OF

CANCER, THEY WERE ALLOWED TO

SORT OF GET OPIOID ANALGESICS

AND I WOULD SAY, WE ARE STILL A

BETTER COUNTRY THAN THIS.

MOVING FORWARD, THERE ARE MAJOR

RESOURCES WE NEED TO THINK ABOUT

FOR PATIENTS WHICH WE TAKE CARE

OF.

THERE IS POOR COLLABORATION

BETWEEN DISCIPLINES AND BETWEEN

INSTITUTES.

WE ALSO KNOW THAT THERE ARE MANY

PSYCHOSOCIAL ASPECTS.

WE HAVE NOT REALLY LOOKED AT THE

LIFESPAN PERSPECTIVE BUT I'M

TELLING YOU THAT IS CRITICALLY

IMPORTANT.

THE OTHER THING IS WE FAILED TO

TRANSLATE WHAT WE ALREADY KNOW

INTO BETTER QUALITY CARE AND WE

NEED TO THINK ABOUT INTERVENTION

STUDIES THAT ALLOW US TO DO

THAT.

IN ORDER TO DO THAT, WE NEED TO

HAVE POLICY AND RESEARCH THAT

ALLOWS US TO THINK ABOUT PAIN

FROM THE CHILDHOOD ALL THE WAY

TO THE ENDS OF OUR DAY.

SO THAT WILL REQUIRE US TO THINK

ABOUT NEW LEADERSHIP IN THE

HEALTH CARE COMMUNITY AS WELL AS

COMMUNITY ENGAGEMENT.

SO WE ARE GOING TO NEED OUR

HEARTS, HEADS AND HANDS IN ORDER

TO THINK ABOUT HOW DO WE PROVE

PAIN CARE AND HOW DO WE --

AND IT WILL BE BASED UPON

RESEARCH.

RECOGNIZING THE PROBLEM EXISTS

AND THEN WE NEED TO MAKE CERTAIN

WE HAVE EQUITABLE CARE.

WE NEED TO HAVE COMPREHENSIVE

GOAL ORIENTED PLANS OF CARE.

AND THAT MEANS THAT WE'LL NEED

TO HAVE MULTIDISCIPLINARY

APPROACHES AND INTERDISCIPLINARY

WORK.

SO THE PERSON WHO IS AT THE

BENCH NEEDS TO WORK WITH A

PHYSICIAN WHO IS AT THE BEDSIDE

AND WE WILL NEED TO THINK ABOUT

EXTRAPOLATING THAT TO OUR

COMMUNITIES.

I WANT TO END HERE WITH THE

MICHIGAN CENTER FOR URBAN

AFRICAN-AMERICAN RESEARCH WHICH

HAS ACTUALLY ONE OF THE FIVE

RESOURCE CENTRES OF MINORITY

AGING RESEARCH THOUGHT OR

STARTED DOING WORK AS IT RELATES

TO PAIN AND PUT THE COMMUNITY

FIRST.

ONE OF THE THINGS WE HAVE DONE

THE WORK IN THE COMMUNITY, THE

COMMUNITY KEEPS SAYING, WE WANT

TO KNOW MORE ABOUT PAIN.

AND SO I'M THINKING THAT IN MANY

OF THESE BIG PROGRAM PROJECT

GRANTS THAT THE OPPORTUNITY IS

THERE FOR US TO THINK ABOUT PAIN

IN A WORTHWHILE FASHION.

SO, AS I END, I WANTED TO SAY A

COUPLE OF THINGS.

ONE, THERE IS 1998 IS WHEN WE --

1996 IS WHEN THE PAIN CONSORTIUM

BEGAN AND WE HAVEN'T THOUGHT

ABOUT THE DEPTH OF THE

POPULATION THAT IS CONFRONTING

US, RACIAL, ETHNIC MINORITIES OR

WOMEN.

I HOPE I HAVE SHOWN YOU IF

YOU'RE A RACIAL ETHNIC MINORITY

AND A WOMAN, YOU'RE AT INCREASED

RISK OF HAVING DIMINISHED ACCESS

TO CARE, DIMINISHED ASSESS AND

TREATMENT AND POORER OUTCOMES

AND I'M HOPEFUL I CAN SHOW THRU

IS SAY NEED FOR CONTINUING

RESEARCH THAT IS

INTERDISCIPLINARY IN ORDER TO

CHANGE THIS CONVERSATION.

SO I THANK YOU FOR MUCH FOR YOUR

KIND ATTENTION, FOR THE

ORGANIZERS FOR INVITING MOO AND

HELL TOW TO MY NEW FRIENDS AND

COLLEAGUES.

[APPLAUSE]

>> THANK YOU DR. GREEN AND WE

ARE MOVING INTO THE

QUESTION-AND-ANSWER PORTION SO

IF I COULD ASK ALL OF OUR

SPEAKERS TO PLEASE APPROACH THE

PANEL.

IN THE AUDIENCE, IF YOU HAVE A

QUESTION, PLEASE APPROACH THE

MICROPHONES ON EITHER SIDE SO

FOLKS WHO ARE LISTENING CAN HEAR

YOUR QUESTION AND THE SPEAKERS

WILL HAVE A BUTTON TO PRESS TO

ANSWER FOR THE MICS AS WELL.

>> DR., YOU TALKED ABOUT OUR

DATA ON DIFFERENCES IN PAIN DUE

TO AGE.

NOW I WAS WONDERING IF THERE

WERE ANY STUDIES THAT WERE

LOOKING AT DIFFERENCES IN PAIN

OR GENDER DIFFERENCES IN PAIN

DUE TO GENERATIONAL DIFFERENCES.

AND I'M THINKING HERE MORE ABOUT

IF YOU COMPARE THE MILLENNIUM

GENERATION TO THE BABYBOOMER

GENERATION AND THAT IT'S NOT DUE

TO AGE, PER SE, BUT JUST DUE TO

THE WHOLE SOCIAL EXPERIENCE THAT

WE HAVE GONE THROUGH.

>> [OFF MIC]

>> I THINK ONE OF THE CHALLENGES

FROM A RESEARCH PERSPECTIVE IS

THAT AGE IS CONFOUNDED WITH

GENERATIONS.

AND THERE ARE DATA THAT I DIDN'T

SHOW THAT SUGGESTS THAT IN THE

GENERAL POPULATION, SOME OF US,

IF YOU GET OLD ENOUGH, HAVE YOU

LESS PAIN.

AND FOR EXAMPLE, IN SOME

STUDIES, OVER 85, THE PREVALENCE

OF PAIN IS LOWER WHETHER THAT'S

A COHORT AFFECT, BECAUSE THE

UNHEALTHY PEOPLE WHO HAD PAIN

DIED BEFORE THEY GOT THERE OR

WHETHER THAT IS A GENERATIONAL

AFFECT OR AN ADAPTATION, BUT I

WILL TELL YOU WHEN I TALKED TO A

POPULATION OF OLDER ADULTS ABOUT

THIS INFORMATION, THEY ARE NOT

SURPRISED BY THIS.

THEY SAY THEY LEARNED TO DEAL

WITH IT AND IT DOESN'T BOTHER US

ANYMORE.

SO THERE COULD BE GENERATIONAL

AFFECTS.

THERE WAS A STUDY OUT OF

SCANDINAVIA THAT I DON'T FULLY

UNDERSTAND, THEY HAD MULTIPLE

COHORTS OF PEOPLE FOLLOWED

LODGITUDEINALLY WHO WERE BORN IN

DIFFERENT DECADES.

THEY HAD LONGITUDINAL

AGE-RELATED DATA AND

GENERATIONAL DATA.

AND THEY DIDN'T LOOK AT SEX

DIFFERENCES.

THEY SHOWED A GENERAL TREND

TOWARDS MORE PAIN WITH AGING.

BUT THEY DIDN'T SHOW ANY TREND

TOWARDS GENERATIONAL DIFFERENCES

AND THE PREVALENCE OF PAIN.

BUT THEY DID LOOK AT

GENERATIONAL BY AGE INTERACTIONS

THAT I RECALL.

I DON'T THINK THERE ARE DIRECT

DATA TO ADDRESS YOUR QUESTION.

>> RALPH FROM THE CHILD HEALTH

INSTITUTE CENTER FOR MEDICAL

REHAB.

I THINK YOU ALL HAVE GIVEN THE

MESSAGE FOR THE NEED FOR

STRATEGIES OF COPING AND

TREATING CHRONIC PAIN BUT HOW

ABOUT DIFFERENCES EITHER GENDER

DIFFERENCES OR RACIAL ETHNIC

DIFFERENCES AND HOW PEOPLE ARE

COPING WITH IT, STRATEGIES THEY

HAVE FOR LIVING WITH PAIN AND

HOW THEIR LIVES, SPEAK ABOUT

DIFFERENCES IN THOSE STRATEGIES?

>> THERE IS SOME RESEARCH USING

SORT OF STANDARDIZED APPROACHES

TO ASKING MEN AND WOMEN, FOR

EXAMPLE, HOW THEY COPE WITH

PAIN.

IN GENERAL, THE LITERATURE

SUGGESTS THAT WOMEN SIMPLY COPE

MORE.

THEY USE A WIDER VARIETY OF

COPING STRATEGIES.

SOME OF WHICH ARE CONSIDERED

EFFECTIVE AND MALADAPTIVE.

THEY USE MORE SEEKING SOCIAL

SUPPORT FOR PAIN.

THERE ARE DIFFERENCES IN COPING.

THERE IS NOT A GOOD LITERATURE

ON DIFFERENCES AND THE

EFFECTIVENESS OF THAT COPING.

SO IS IT WORKING BETTER?

THERE ARE A FEW DAILY STUDIES

FOR ARTHRITIS PAIN, FOR EXAMPLE,

WHERE WOMEN COPE MORE ACTIVELY

ON A DAY OF BAD PAIN AND THE

NEXT DAY, THEY HAVE LESS

NEGATIVE AFFECT THAN MEN.

SO THERE IS A LITTLE HINT THERE

THAT WOMEN ARE COPING MORE

VIGOROUSLY AND IT MAY BE WORKING

BETTER BUT THERE IS REALLY VERY

LITTLE EVIDENCE TO ADDRESS THAT

THAT I KNOW OF.

>> [OFF MIC]

 --

A FINDING THAT COPING STYLE IS

MORE PARALLEL THAN WOMEN.

HOW DOES THAT MATCH WITH --

>> I MEAN THAT IS ONE OF THE

PATTERNS WHERE WOMEN COPE MORE.

THEY ARE FAIRLY CONSISTENTLY

REPORTING HIGHER LEVELS.

IF YOU HAD MEN AND WOMEN --

WHETHER IT WOULD PRODUCE

DIFFERENT OUTCOMES, WE DON'T

KNOW.

CATAFTIFIESING IS THOUGHT TO BE

ADVANCING TO DO ABOUT PAIN BUT

IT'S NOT THE ONLY THING THAT

WOMEN DO.

SO IN ADDITION, THEY DO LOTS OF

OTHER THINGS TOO LIKE SEEK

SOCIAL SUPPORT.

SO LET'S MANAGE TIN INCREASES

YOUR PAIN-RELATED FACTIVE

DISTRESS.

IN ORDER TO GET SUPPORT YOU

ENGAGE IN OTHER COPING

STRATEGIES AND THEN A MODEEL

SUGGESTS THAT IT MAY BE

ADAPTIVE.

IT'S THERE TO DRIVE US TO GET

SUPPORT AND HELP WHERE WE NEED

IT.

SO ULTIMATELY IT MIGHT PRODUCE A

POSITIVE OUTCOME.

>> WE KNOW PATIENTS WHO EMBRACE

SEEKING PSYCHOLOG CALLING

SUPPORT.

MAKES A BIG DIFFERENCE IN THEIR

ABILITY TO DEAL WITH PAIN.

I WAS TALKING TO D. DR. EDWARDS

ABOUT THE USE OF COMPLEMENTARY

AND ALTERNATIVE MEDICINE.

IN SOME PATIENTS THEY UTILIZE

THAT BUT THE QUESTION IS WHETHER

OR NOT THAT'S A MARKER OF

GETTING LESSER QUALITY CARE OR

HAVING DIMINISHED ACCESS TO

CARE.

I THINK YOU TURBED ON A COUPLE

OF THINGS THAT WE NEED TO SORT

OF EXPLORE.

BECAUSE AT SOME LEVELS, WHEN WE

HAVE DONE SOME WORK LOOKING AT

RACIAL AND ETHNIC MINORITIES,

PEOPLE TALK ABOUT CATAFTIFIESING

MORE.

BUT IF YOU ASK ABOUT COPING,

THEY COPE BETTER.

THERE SAFER SOMETIMES WHEN YOU

LOOK AT SCALES LIKE JOHN HENRY

ACTIVIST SCALE.

WHICH IS A HIGH OUTPUT TYPE OF

ACCESS TO COPING WHEN WE HAVE

ACTUALLY SEEN THAT THOSE PEOPLE

WHO HAVE TO DO MORE ACTUALLY

TEND TO UTILIZE THIS TYPE OF

COPING TECHNIQUE MORE SO THAN

OTHERS.

SO, AGAIN, I THINK THERE IS A

NEED FOR A CONTINUING RESEARCH

IN THAT ARENA.

>> I WONDER IN THE STUDIES WHERE

WE ARE LOOKING AT DIFFERENCES IN

ASSESSMENT AND TREATMENT OF

PAIN, IF THERE IS LOOKING AT

CONCORDANCE EITHER RACIAL OR

GENDER OR AGE CONCORDANCE WHERE

AFRICAN-AMERICAN DOCTORS ARE

MORE OR BETTER FOR

AFRICAN-AMERICANS OR NOT OR SAY

WITH MEN AND WOMEN WHERE MEN

WANT TO LOOK STRONG AND WOMEN

APPARENTLY WANT TO LOOK WEAK.

MOST ARE MEN.

DISPROPORTIONATELY THEY ARE

CAUCASIAN MEN.

IF YOU LOOK AT THE NUMBER OF

PEOPLE IN SOCIETY.

THERE ARE NOT PEOPLE WITH REALLY

LOOKED AT SOME OF THOSE THINGS.

IN A VERY CONSISTENT MANNER.

THERE ARE SOME STUDIES THAT LOOK

AT AND WHEN IT COMES TO A STUDY

THAT SAYS THAT BASICALLY IF YOU

WERE TO SEE A WOMAN PHYSICIAN,

YOU WERE MORE LIKELY TO GET

CERTAIN TYPES OF TREATMENT.

PAP SMEARS AND THINGS OF THAT

NATURE OFFERED.

WE NEED TO DO THAT.

THE PROBLEM IS, IN OUR STUDY

WHERE WE LOOKED AT THE PHYSICIAN

PIECE, WE DIDN'T HAVE ENOUGH

MINORITY PHYSICIANS TO LOOK AT

THAT PARTICULAR QUESTION.

IT IS CLEAR.

YOU CAN LOOK AT THE INSTITUTE OF

MEDICINE REPORTS THAT TALK ABOUT

THE SCIENCE OF INCLUSION OR OUR

COMPELLING INTERESTS OF BOOKS

THEY WERE TALKING ABOUT IN THAT

MINORITIES AND WOMEN TEND TO GO

INTO STUDIES OR TAKE CARE OF

PATIENTS THAT ARE MORE LIKE

THEM.

WHY THAT IS, WE NEED TO SORT OF

EXPLORE THAT MORE.

SO IT'S NOT SURPRISING THAT IF

YOU WERE TO GET DIFFERENCES IN

QUALITY OF CARE BASED ON THAT.

>> YOU MENTION THE USE OF MODELS

FOR DIAGNOSIS.

LIFT FRIDAY I WAS IN A MEDICAL

SCHOOL WHERE THEY HAD A WHOLE

LAB ON USE OF MODELS FOR

TRAINING OR FOR STUDENTS AND FOR

PHYSICIANS.

AND SOME OF THE THINGS THEY WENT

OVER WERE NOT ONLY THE MODELS

REALLY GOOD AT REPLICATING IN

THE STANDARDIZED WAY, PAIN

SYNDROMES, BUT THEY GAVE

FEEDBACK, OFTEN VERY AGGRESSIVE

FEEDBACK AS A TRAINING MECHANISM

AND THEY VIDEOTAPED WHAT WAS

GOING ON AND SHOWED THAT BACK TO

THE DOCTORS.

DOCTORS OFTEN SURPRISED ABOUT

WHETHER THEY REALLY KNEW WHAT

THEY WERE DOING OR WHAT THEY

WERE SAYING.

THEY ALSO INCLUDED FOCUS ON FOR

EXAMPLE, HOW DO YOU TALK TO A

PERSON WHO IS FIRST DIAGNOSED

WITH CANCER OR A FAMILY MEMBER?

I'M SURE YOU COULD DO IT WITH

PAIN.

I WONDER IN THE PAIN RESEARCH

COMMUNITY, IF THERE IS ANYTHING

LIKE THAT GOING ON AND WHAT THE

RESULTS MIGHT BE?

>> SO, YOU BRING UP A VERY

INTERESTING POINT.

THERE IS ONE STUDY THAT JUST

CAME OUT AND I READ AN EDITORIAL

ON THIS IN REGARDS TO --

BUT IT WASN'T REALLY PHYSICIANS.

IN THAT WE COME TO THIS

CONVERSATION WITH OUR BIASES.

I BRING THE BIAS OF BEING A

MILITARY KID.

ROGER BRINGS A DIFFERENT BIAS.

I ACTUALLY THINK THIS SPAIN A

RICH AREA FOR QUALITATIVE TYPE

OF RESEARCH IN WHICH WE CAN SORT

EVER TRY ANG LATE QUALITATIVE

AND QUANTITATIVE WORK TOGETHER.

FOR INSTANCE, THERE IS SOMETHING

THAT HAPPENS IN MEDICAL SCHOOL

WHERE YOU START OFF WITH A

CONVERSATION OF, HOW DOES THAT

MAKE YOU FEEL?

AND YOU LISSEN AND LISTEN.

AND THEN SOMEWHERE DOWN IN YOUR

FOURTH YEAR, YOU START TO TAKE

THAT PATIENT'S STORY AND

SHORTENING IT AND IT BECOMES SO

SHORT THAT WE FORGET WHO THE

PATIENT IS.

SO, YOU START OFF WITH, I'LL

GIVE YOU AN EXAMPLE.

65-YEAR-OLD FEMALE WITH

PANCREATIC CANCER AS OPPOSED TO

A 65-YEAR-OLD MRS. JONES

65-YEAR-OLD WOMAN WHO LIVES TWO

HOURS AWAY HAS JUST BEEN

DIAGNOSED WITH PAN KEY ATTIC

CANCER AND VERY SCARED.

SO I BRING THAT UP IN THE

CONTEXT OF THE FACT THAT WE TALK

ABOUT CULTURAL COMPETENCE,

RIGHT?

AND I THINK THAT THE BEST WE CAN

TRY TO DO IS TO BE CULTURALLY

SENSITIVE.

BECAUSE THERE IS NOT A PLACE IN

THE UNITED STATES OR IN THIS

COUNTRY THAT I CAN GO THAT I

CAN'T PUT MY FOOT IN MY MOUTH

AND I WOULD SAY THE SAME FOR

ANYBODY IN THIS AUDIENCE.

SO I THINK IT WILL TAKE ANOTHER

CONVERSATION ABOUT HOW DO WE

LISTEN?

WHAT WAS SAID?

DOES THIS MEAN SOMETHING IN ONE

CULTURE THAT DOESN'T MEAN IT IN

ANOTHER CULTURE?

IF YOU'RE NATIVE-AMERICAN DO YOU

ASK QUESTION OR QUESTION OR TURN

IT OFF?

SO I THINK THAT PAIN IS ONE OF

THOSE AREAS WHERE WE HAVE THE

OPPORTUNITY FOR THIS RICH TYPE

OF CONVERSATION.

AND I THINK IN ORDER TO MAKE THE

HEADWAY, ALSO NOT JUST IN

WOMEN'S HEALTH, HEALTH IN

GENERAL, WE NEED TO DO THAT.

>> I THINK THIS IS EXACTLY THE

KIND OF THINKING THAT WE ARE

GOING TO HAVE TO INCORPORATE

INTO OUR CENTRES OF EXCELEBS OR

PAIN ATTENTION WE ARE PLANNING

BECAUSE BECAUSE WE KNOW THAT

PEOPLE DON'T ACTUALLY --

DON'T APPRECIATE THE PAIN

EXPERIENCE BUT ALSO WAKIND OF

HEALTH TO --

HELP TO PROVIDE TO THE SUBJECT

OF THE SO WE ARE GOING TO

ACTIVELY DEVELOP SOME NEW

EDUCATIONAL PROGRAMS TO HELP

PHYSICIANS, NURSES AND OTHER

HEALTH PROFESSIONALS DEAL WITH

PAIN.

>> AND IF I COULD COMMENT ON

THAT.

I DON'T --

[OFF MIC]

>> SO WITH THIS HEALTH

DISPARITIES, RACIAL DISPARITIES

OF HAVING ACCESS TO EXPERTS,

THIS KIND OF ASSUMES --

CLEARLY IT IS OBVIOUS FOR CANCER

PAIN AND FOR MOST EFFECTIVE PAIN

THAT THAT MAKES A DIFFERENCE.

ACCESS TO CARE.

BUT THEN THERE IS A VERY LARGE

NUMBER OF PAIN CONDITIONS FOR I

DON'T THINK THE MEDICAL SYSTEM

REALLY DOES OR HAS ANY

SIGNIFICANT IMPACT ON THE PA

JORITIY OF PATIENTS.

AND I MEAN, I THINK JUST

EQUALING ACCESS TO PAIN EXPERTS

WITH BETTER CARE, THAT'S

MICKABLE TO CERTAIN TYPES OF

PAIN.

YOU I THINK THERE IS A HUGE

DISCREPANCY BETWEEN THE

PERCEPTION THAT IF YOU HAVE

ACCESS TO SOME PERSON WHO KNOWS

HOW TO DEAL WITH THESE --

LIKE THE SYSTEM PAIN

DISORDERS, --

>> SO, ONE OF MY IMMEDIATE

RESPONSES THAT THERE SHOULD BE

SUBSTANTIVE --

AND THERE ISN'T.

AND I'M NOT TALKING JUST ABOUT

PAIN SPECIALISTS.

I MEAN, THAT IS THE DATA I

PRESENTED.

ACTUALLY A LOT OF CARE, PAIN

CARE PROVIDED IN THE PRIMARY

CARE AREASON, WE JUST AREN'T

DOING IT.

IF YOU LOOK ACROSS THE COUNTRY,

WILL YOU SEE THAT PAIN IS ONE OF

THE NEGLECTED TOPICS IN MEDICAL

SCHOOLS AND NURSING SCHOOLS AND

ANY OF THE HEALTH PROFESSION

TYPE OF SCHOOLS.

I REITERATE THAT 116 MILLION

PEOPLE ARE AFFECTED BY PAIN.

AND MOST PEOPLE ARE UNDER

TREATED.

AND WE HAVE RACIAL AND ETHNIC

MINORITIES AT LESSER QUALITY

CARE.

LOW SES PEOPLE ARE AT RISK AND

WE KNOW THAT THE PAIN COMPLAINTS

OF WOMEN DON'T RECEIVE THE

ATTENTION THAT PAIN COMPLAINTS

OF MEN.

SO, I GUESS THAT'S HOW I WOULD

RESPOND TO THAT.

YES SOME THINGS WE DON'T HAVE A

VERY GOOD WAY OF TAKING CARE OF

THEM.

THAT DOESN'T MEAN WE CAN'T SEE

THE PATIENT.

IT DOESN'T MEAN WE SHUN THE

PATIENT.

AND SO, SOMETIMES ONE OF THE --

TWO THINGS THAT ARE REALLY

GRATIFYING IS ONE WHEN THE

PATIENT COMES TO ME AND SAYS

DR. GREEN, YOU ARE THE FIRST

PERSON WHOEVER LISTENED TO MY

STORY.

AND THEY HAD PAIN FOR FIVE

YEARS.

YOU PROBABLE HE THOSE

EXPERIENCES TOO.

THE OTHER PART IS WHEN I HAVE TO

SAY TO A PATIENT, I'M SORRY,

THERE IS NOTHING ELSE I REALLY

HAVE TO OFFER YOU.

AND SAYING TO THEM THAT THE PAIN

FIELD IS PROBABLY ABOUT 50 YEARS

BEHIND.

WE HAVEN'T INVESTED IN SOME OF

THE THINGS WE FEED TO INVEST IN

IN ORDER TO MAKE A DIFFERENCE.

>> I'M PAM STRATTON, I WONDER AT

NICHD AND DO CHRONIC PAIN

RESEARCH.

I'M CURIOUS DR. MEYERBA

SOMETHING THAT RESINATED WITH ME

THAT YOU HAD SAID.

THE FACT THAT FOR THESE

PERSISTENT PAIN SYNDROMES THAT

FREQUENTLY THEY ARE ASSOCIATED

WITH TRIGGER POINTS AND THE WHEN

YOU CONTROL FOR THAT, THAT THE

GENDER DIFFERENCE GOES AWAY.

SO I WAS WONDERING IF YOU COULD

TALK MORE

AS FAR AS I KNOW, IF YOU DO NOT

USE THE TRIGGER OR THE POINTS AS

THE DIAGNOSTIC CRITERIA, WILL

YOU GET SIMILAR SIMILAR

PREVALENCES OR MOST OF THE SEX

DIFFERENCES APPEARS IN TERMS OF

WIDESPREAD CHRONIC PAIN.

WHAT IS UNIQUE ABOUT TRIGGER

POINTS FOR FEMALES, I DON'T KNOW

IF YOU --

>> I SEEN THE SAME DATA AND SO

THE ASSESSMENT OF HOW PATIENT

SENSITIVITY BIASES THE DIAGNOSIS

TOWARDS WOMEN GETTING THE

DIAGNOSIS AND AWAY FROM MEN

GETTING DIAGNOSIS, WE COULD

ARGUE ABOUT WHY THAT IS.

>> THIS IS A VERY GOOD SEMINAR.

I'M TAMARA WITH NIAID.

THE QUESTION THAT I HAD FOR EACH

OF YOU IS IN TERMS OF WOMEN OR

SEX DIFFERENCES AND PAIN, IS THE

ISSUE OF TRAUMA.

WHETHER IT IS POSTTRAUMATIC

STRESS SYNDROME THAT SUBPOENA

MAY HAVE, SEXUAL TRAUMA THAT

SOMEONE MAY HAVE EXPERIENCED,

HOW EACH OF YOU MIGHT DEAL WITH

WHATEVER THE PERSON HAS TREATS

OR CANCER OR WHATEVER THEIR

OTHER SOURCE OF PAIN MIGHT BE.

HOW YOU DEAL WITH THOSE WHO ALSO

HAVE A HISTORY OF TRAUMA.

>> IF I COULD SAY A COUPLE OF

THINGS TO THAT.

CLEARLY EARLY ADVERSE LIFE

EVENTS, TRAUMA THAT OCCURS LATE

IN LIFE, HAS BEEN SHOWN TO

INCREASE VULNERABILITY TO PAIN

AND TO A VARIETY OF OTHER

CONDITIONS BOTH IN INTERNAL

MEDICINE AND PSYCHIATRIC

CONDITIONS.

TRAUMA IN THE VULNERABLE PERSON

SUCH AS POSTTRAUMATIC STRESS

SYNDROME AND EVERYBODY EXPOSED

TO TRAUMA BUT AT MUCH HIGHER

RATE IN INDIVIDUALS THAT HAD THE

EARLY LIFE HISTORY CLEARLY IS

ALSO ASSOCIATED WITH INCREASED

PAIN.

THERE ARE SOME EXCITING

BREAKTHROUGHS IN TERMS OF

UNDERSTANDING PILOTY AND THIS IS

NOT JUST --

BIOLOGY --

IT'S NOT ONLY PSYCHOLOGICAL

PHENOMENON BUT IT'S BEEN SHOWN

THAT THESE EARLY LIFE TRAUMA

ASSOCIATED WITH THE CORTICOID

RECEPTOR GENE PROMOTOR

METHYLATIONS.

THE WAY STRESS SYSTEM RESPONDS

WITH CORTIZOL RESONSES.

IF SOMETHING HAPPENS THROUGHOUT

LIFE, YOU HAVE GREATER DAMAGE

FROM YOUR CORTIZOL.

AND ALL THE CONSEQUENCES.

SO FOR THE BIOLOGICAL

STANDPOINT, THIS IS SOMETHING

THAT HAS SOME OF THE MOST

IMPRESSIVE --

SOME OF THE MOST IMPRESSIVE

PROGRESS HAS BEEN MADE AND I

THINK WITH THE POTENTIAL OF

INTERFERING WITH THIS

METHYLATION PROCESS OR REVERSING

IT, WE MAY HAVE TOOLS EVENTUALLY

COUNTER ACTING THIS.

>> AND JUST TO ADD BRIEFLY

DR. MEYER MENTIONED IN

VULNERABLE INDIVIDUALS,

CERTAINLY NOT EVERYBODY WHO

EXPERIENCED THAT EXPOSURE ENDS

UP SUFFERING THE ADVERSE HEALTH

CONSEQUENCES.

WE STUDIED MEN AND WOMEN WHO

REPORTED HISTORY OF PHYSICAL OR

SEXUAL ABUSE AND IN OUR HANDS,

PEOPLE REPORTING THAT HISTORY OR

LESS PAIN SENSITIVE IN THE

LABORATORY THAN PEOPLE NOT

REPORTING THAT HISTORY.

I THINK ONE INTERESTING THING

THAT WE COULD CONSIDER STUDYING

IS STUDIES OF PEOPLE WHO

EXPERIENCE THE EXPOSURE AND

RESILIENT AGAINST THE ADVERSE

AFFECTS OR THE CHARACTERISTICS

THAT PROTECTED THEM SO WE COULD

TRY TO EN VIEW THE PEOPLE WHO

HAVE EXPERIENCED THE ADVERSE

OUTCOMES WITH THE

CHARACTERISTICS AS A FORM OF

TREATMENT.

BUT I APPRECIATE --

[OFF MIC]

>> CLEARLY THE PREVALENCE OF

EARLY ADVERSE LIFE EVENTS IS

PRETTY HIGH OR PRETTY GOOD DATA

ON THIS TO SOCIOECONOMIC STATUS

AND HAS BEEN SHOWN EVEN WITH THE

STUDIES CORRELATING THE

INTERACTION BETWEEN ADVERSE LIFE

EVENTS, SOCIOECONOMIC STATUS AND

ADULTERY RESPONSIVENESS OF

STRESS SYSTEMS WITHIN THE BRAIN.

SO CLEARLY, THAT IS THE

VULNERABILITY.

>> SO, I HAVE ALWAYS BEEN A BIG

FAN OF ROGER'S WORK AND HE

ACTUALLY ENCOURAGED ME TO DO A

STUDY LOOKING AT ABUSE AND

ACTUALLY SO PATIENTS CAME TO OUR

PAIN CLINIC AND ON AVERAGE, THEY

TOLD US THE FIRST TIME THEY EVER

ACTUALLY TOLD ANYBODY THEY WERE

PHYSICALLY OR SEXUALLY ABUSED

WAS IN A PAIN CLINIC.

THAT TELLS ME THERE ARE SOME

PROBLEMS GOING ON.

THE FIRST TIME THEY ARE TELLING

IN A TERTIARY PAIN CARE CENTER,

IT TELLS US BUT HOW WE

STIGMATIZED THIS CONVERSATION

AND FOUND THAT IN SOME PATIENTS,

CLINICAL, THAT THERE ARE

PATIENTS WHO DON'T TELL ME THIS

ON THE FIRST VISIT.

WHY?

BECAUSE THEY DON'T TRUST ME.

RIGHT?

AND THEY THEN ONCE THEY

RECOGNIZE --

THEY DON'T TRUST ANYTHING.

AND THEN THEY COME BACK AND THEY

KIND OF HOPE THAT YOU ASK THIS

PARTICULAR QUESTION.

AND SO, IN ACTUALITY THIS IS HOW

I GOT STARTED DOING PAIN AND

GENDER RESEARCH BECAUSE I

WONDERED WHY WE ASK EVERY SINGLE

WOMAN WHO CAME INTO THE PAIN

CLINIC WHETHER OR NOT SHE WAS

PHYSICALLY OR SEXUALLY ABUSED

AND WE NEVER ASKED THE MEN?

SO, AS I EXTRAPOLATE THIS

FURTHER, WE FOUND THOSE PEOPLE

WHO HAVE PHYSICAL AND SEX ALL

ABUSE WERE MORE AT RISK FOR

HAVING PAIN PROBLEMS.

WE SHOWED CHILDHOOD AND

ADULTHOOD ABUSE INCREASED YOUR

RISK.

BUT THERE ARE ARE SOME PEOPLE

WHO ARE RESILIENT.

SOCIOECONOMIC STATUS MAY HAVE

SOMETHING TO SAY ABOUT THIS BUT

I AM NOT CERTAIN THAT HAVING

SOCIOECONOMIC STATUS IS ALL THAT

MUCH OF A RESOURCE BECAUSE I

THINK IN SOME PLACES WE CAN TALK

ABOUT IT.

WE EXPECT IT TO OCCUR.

I'D ALSO SAY SOME OF OUR

PARTICULAR RESEARCH, IT'S THE

FIRST TIME WE DID WORK ON

PHYSICAL AND SEXUAL ABUSE WAS WE

OBVIOUSLY LOOKED AT WOMEN.

WE ARE ALL AT RISK FOR HAVING

OUR OWN BIASES AND SO I SAID,

LET'S TAKE A LOOK AT MEN.

AND WE FOUND THAT ONE-10 MEN

ACTUALLY CAME TO THE PAIN CENTER

REPORTED SOME TYPE OF ABUSE.

NOW, THEY TENDED TO REPORT

PHYSICAL ABUSE AS OPPOSED TO

SEXUAL ABUSE.

BUT IT'S NOT UNHEARD OF THAT MEN

HAVE HAD SEXUAL ABUSE.

AND I THINK WE HAVE JUST BEGUN

THAT PARTICULAR PART OF THE

CONVERSATION.

SO AGAIN, WHEN WE THINK ABOUT

THE OFFICE OF RESEARCH AND

WOMEN'S HEALTH AND WHAT THEY CAN

DO.

IT'S ALSO THINGS THAT ARE COMMON

THREADS AND WHY IS IT THAT SOME

PEOPLE BEND AND OTHER PEOPLE

BREAK?

>> [OFF MIC]

>> I THINK IT'S REALLY IMPORTANT

FOR THE CLINICAL SETTING.

SEXUAL ABUSE FOR SAMPLING IN IBS

AND MANY RELATED DISORDERS HAS

RECEIVED MOST OF THE ATTENTION

INITIALLY BUT I THINK USING THAT

EXPRESSION EARLY ADVERSE LIFE

EVENTS, THAT'S A MUCH WIDER NET

THAT CATCHES THINGS LIKE LOSING

EITHER A SERIOUS ILLNESS OR

PRIMARY CAREGIVER, USUALLY THE

MOTHER, DEATH, DIVORCE, SO THERE

IS A LOT OF THINGS.

IF YOU USE THE OTHER CRITERIA

AND WE DON'T KNOW YET IF THEY

HAVE THE SAME --

IF THIS METHYLATION PROCESS OR

THIS EPIGENETIC INFLUENCES OF

THESE DIFFERENT TYPES OF

CIRCUMSTANCES ARE DIFFERENT OR

IF THEY ALL PRODUCE THE SAME,

AGAIN IN A VULNERABLE

INDIVIDUAL.

THAT'S A VERY IMPORTANT --

BECAUSE MY IMPRESSION IS FROM MY

OWN RESEARCH THAT SEXUAL ABUSE

IS THE MINORITY.

SPELL NET PATIENTS WE SEE.

WHEREAS OTHER THINGS ARE VERY

COMMON.

VERY COMMON.

AND IT'S QUITE EASY TO ELICIT

FROM THE PATIENTS BECAUSE IF YOU

ASK AN EASY QUESTION, CASUAL

QUESTION IN THE MIDDLE OF THE

INTERVIEW, DO YOU THINK HE HAD A

HAPPY CHILD HOD?

I WOULD SAY 70% OF PATIENTS WILL

START TALKING ABOUT THIS WITHOUT

ANY FURTHER --

I FOUND IT AMAZING.

SO, IF YOU ASK THEM DID YOU HAVE

SEXUAL ABUSE?

I THINK A LOT WILL NOT ON THE

FIRST ENCOUNTER, PURSUE THAT

BECAUSE THEY DON'T KNOW YOU AND

THAT OTHER QUESTION OPENS UP HOW

REMARKABLE IT IS HOW MANY PEOPLE

ARE WILLING TO OPEN UP AND TELL

ALL KINDS OF TRAUMATIC EVENTS

THAT WENT THROUGH AS A CHILD.

>> [OFF MIC]

 --

WHETHER OR NOT THERE WAS

DIFFERENCES, SEX DIFFERENCES IN

TREATMENT RESPONSE FOR THE --

[INAUDIBLE]

>> THAT'S VERY HARD TO SAY

BECAUSE THE INITIAL --

THIS IS ONE OF THE THINGS THAT

GOT OUR INTEREST TO GET INVOLVED

IN THIS AREA WAS WHEN A NEW

THERAPY FOR IBS CAME OUT AND THE

RECEPTOR ANTAGONIST THAT

INITIALLY WAS ALL THIS

EXCITEMENT THAT THIS WORKS IN

WOMEN AND WHY AND IF YOU REALLY

LOOK CLOSELY AT THE DATA, MOST

LIN CALL TRIALS SHOW DISORDERS

AS A SMALL NUMBER OF MALE

PATIENTS INVOLVED SO THE SAMPLE

SIZE IS NOT SUFFICIENT TO REALLY

SEE A DIFFERENCE.

THEN AFTERWARDS, WHEN THE

COMPANY DID A MALE STUDY, THEY

FOUND SIMILAR RESPONSE RATES,

SOMEWHAT LOWER THAN WOMEN BUT IT

WAS DEFINITELY NOT A SEX

SPECIFIC DRUG.

AND I THINK IN GENERAL, IT IS

HARD TO SAY BECAUSE THAT DOES

NOT EQUAL ENROLLMENT OF MALE

PATIENTS IN THE GREAT MATURITY

AND OF STUDIES.

I THINK AS A GENERAL FEELING

THAT WOMEN RESPOND BETTER TO

MANY OF THE DRUGS THAN MEN BUT

THAT'S MORE A FEELING.

>> SO, I WAS TRYING --

>> JUST ONE MORE.

>> ONE QUICK QUESTION.

BRIGITTE WILLIAMS, NINMHD.

IR WONDER IF YOU WOULD ADDRESS

GENETICS AND ETHNICITY LOOKING

AT FROM A DISPARITY STANDPOINT

WHERE SOME GENETIC STUDIES SHOW

WE ARE NOT WHO WE THINK WE ARE

PHENOTYPICALLY BUT GENETICALLY

WE CAN BE SOMETHING ON THE OTHER

HAND WHOM WE ARE BUT TREATMENT

MAY BE TREATING SOMEONE WHO SAY

WE THINK THAT PERSON IS

AFRICAN-AMERICAN BUT GENETICALLY

THEY MAY BE MORE SIMILAR TO

SOMEONE ELSE THAN WHAT THEY MAY

LOOK LIKE PHENOTYPICALLY.

AND DO YOU SEE --

WHAT DO YOU SEE AS PERHAPS

ISSUES RELATED TO HOW WE ARE

DOING TREATMENT BASED ON HOW A

PERSON SELF IDENTIFIES WHEN

GENETICALLY THEY MAY BE MORE

SIMILAR TO ANOTHER GROUP THAN TO

A DIFFERENT GROUP AND THEN

SECONDLY, YOU MENTIONED SEX

DIFFERENCES AND NOT A LOT WITH

GENDER DIFFERENCES, BUT IT KIND

OF RELATES TO THE SAME THING.

HOW DO YOU TREAT A GENDER

DIFFERENCE WITH PAIN COMPARED TO

A SEX DIFFERENCE WITH THE PERSON

LOOKS ONE WAY BUT ACTUALLY SEES

THEMSELVES AS BEING SOMETHING

OTHER?

THANK YOU.

>> SO THAT IS A VERY LOADED

QUESTION.

I HAVE TO GO.

I HAVE A PLANE TO CATCH.

SO, I WOULD JUST SORT OF MAKE

THE COMMENT THAT YOU'RE RIGHT.

THERE IS A GREAT DEAL OF

HETEROGENEITY IN OUR DNA.

AND IN ACTUALITY WE ARE OFTEN

TREATING OUR PHENOTYPE AND THAT

RACE IS SAY SOCIAL CONSTRUCT.

AND THAT SOCIAL CONSTRUCT MEANS

CERTAIN PEOPLE GET POWER OR NOT

POWER AND WE PERCEIVE PEOPLE

VERY DIFFERENTLY.

AND I WOULD EVEN SAY THE

EXAMPLES I SHOWED OF THE FOUR

PATIENTS, THE ONE WOMAN WHO WE

ALL ASSUMED IS CAUCASIAN, MAY

NOT BE CAUCASIAN AND A GREAT

DEAL OF DIVERSITY IN MY FAMILY

AND YOUR FAMILY AND WE ARE

ACTUALLY VERY SIMILAR

GENETICALLY.

BUT WE ARE ALSO PRETTY HUMAN.

I'LL LEAVE IT WITH THAT.

>> AND I NOTICED THAT DR. MEYER

SLID THE MIC OVER FOR THAT

LOADED QUESTION REALLY QUICKLY.

SO THE ISSUE OF THE GENET ISSUE

IN ETHNIC DIFFERENT STUDIES, I

THINK ONE THING YOU'RE REFERRING

TO ARE THESE GENETIC PAGES THAT

YOU CAN USE TO ESTIMATE

SOMEONE'S BIOGEOGRAPHICAL ANNE

CEST REAND SO, I COULD RUN MY --

ANCESTRY AND I COULD RUN MY

GENOME THROUGH THAT PANEL AND

THEY COULD TELL WHICH PERCENTAGE

OF ME IS EUROPEAN AND WHAT

PERCENTAGE IS AFRICAN AND

AMERICAN AND ASIAN AND SO ON AND

SO FORTH.

AND WE HAVE ACTUALLY DONE SOME

OF THAT WORK AND AS YOU MIGHT

EXPECT, THE GENETIC FINDINGS

CORRELATE STRIKINGLY WITH WHAT

PEOPLE TELL US THEY ARE.

AND SO IT'S HARD TO FIND

EXAMPLES WHERE WE HAD A SAMPLE

OF PEOPLE WHO SAID, FOR EXAMPLE,

THEY WERE AFRICAN-AMERICAN BUT

GENETICALLY THEY WERE REALLY

SOMETHING ELSE.

WHEN WE IGNORED WHAT PEOPLE TOLD

US ABOUT THEIR ETHNIC BACKGROUND

AND LOOKED AT WHAT THEIR GENES

SAID, WE FOUND THE SAME SORTS OF

CORRELATIONS.

AFRICAN-AMERICANS IN OUR STUDIES

SHOWED LOWER PAIN TOLERANCE AND

AFRICAN ANCESTRY WAS SIMILARLY

CORRELATED WITH LOWER PAIN

TOLERANCE.

BUT THAT IS STUDYING THE SAME

THING MEASURED IN TWO DIFFERENT

WAYS.

ONE WOB IS TO DATE, THE APPROACH

IS LET'S EXCLUDE EVERYBODY WHO

IS NOT WHITE FROM THESE GENETIC

STUDIES BECAUSE OF THIS

POPULATION STRATIFICATION,

BECAUSE OF THE VERY FACT THAT

SOME OF THE MARKERS WERE

INTERESTED IN STUDYING ARE KNOWN

TO VARY ACROSS ETHNIC GROUPS.

TANTS ONE THING WE HAVE TO

OVERCOME AND I THINK STATISTICAL

GENETICISTS ARE CONTROLLING FOR

THIS AN VEST RE.

AND WE HAVE ONE STUDY UNDER

REVIEW LOOKING AT A SPECIFIC

GENETIC MARKER THAT WE HAD

ASSOCIATED WITH PAIN AND WAS

ASSOCIATED WITH PAIN IN THE

PREDICTED DIRECTION OF WHITES.

THE MARKER WAS FAR LESS FREQUENT

IN AFRICAN-AMERICANS SO WE

COULDN'T STUDY IT IN

AFRICAN-AMERICANS.

AND IT WAS ASSOCIATED WITH PAIN

IN THE OPPOSITE DIRECTION IN

PEOPLE WHO DESCRIBED THEMSELVES

AS HISPANIC WHITES.

SO I THINK WE NEED TO INCLUDE

MULTIPLE ETHNIC GROUPS IN THESE

STUDIES IN ORDER TO UNDERSTAND

SITUATIONS WHERE THERE MIGHT BE

A GENETIC BIETHNICITY

INTERACTIONS.

BECAUSE THAT HAS IMPORTANT

PRACTICAL IMPLICATIONS DOWN THE

ROAD.

>> JUST ONE COMMENT AS I LIKE TO

MAKE AS I'M PARTIALLY DRIVEN BY

RECENT FINDINGS AND ALSO FROM

GROWING AWARENESS THAT THESE --

 --

DEFINITIVE STUDY IN GENETICS AND

STILL INVOLVED.

MOST DEFINITIVE STUDY IN GENETIC

PAIN VULNERABILITY.

THE EPIGENETIC INFLUENCES, I

THINK WILL PROBABLY TAKEN

CREASINGLY CENTER STAGE.

THE REASON I'M SAYING THIS IS

ONE, THERE IS VERY EXCITING DATA

FROM A GROUP IN CANADA THAT HAS

SHOWN THAT SOCIOECONOMIC STATUS

IN ENGLAND IS ASSOCIATED WITH

DIFFERENT DEGREES OF METHYLATION

OF GENE METHYLATION FROM WITH

THE SAMPLES OBTAINED FROM THE

LYMPHOCYTES.

SO YOU WONDER WHAT THE MEDIATOR

OF THAT AFFECT IS AND WE KNOW

THAT METHYLATION HAS A MAJOR

INFLUENCE ON GENE EXPRESSION SO

THAT COULD BE THE SOCIOECONOMIC

DATA INFLUENCE ON PAIN AND OTHER

CHRONIC ILLNESSES COULD BE --

ANOTHER ONE IS, SO WE FIND OUR

OWN ENHANCED COMPARING

LITERATURE IN OUR OWN DATA.

IF YOU LOOK AT DIFFERENCES IN

CANDIDATE GENES FOR EXAMPLE, IBS

PATIENTS, LARGE NUMBER AND

CONTROLS, IT IS QUESTIONABLE

THERE ARE MAJOR SIGNIFICANT

DIFFERENCES BUT THEY ARE PRETTY

DRAMATIC DIFFERENCES IN THE

GLUCOCORTICOID METHATION

REGARDLESS OF --

SO THAT IS JUST A GUT FEELING

AND I THINK THAT THIS WILL TAKE

CENTER STAGE TOGETHER WITH THE

DATA THAT IS COMING OUT OF THE

STUDY THAT YOU GUYS ARE DOING.

>> THANK YOU VERY MUCH.

[OFF MIC]

>> IF YOU COULD PLEASE RETURN

THE BLUE EVAUATION FORMS TO US,

THAT WOULD HELP US GIVE FEEDBACK

TO OUR SPEAKERS AND ALSO FOR THE

SERIES AND ALSO ALL OF THE NIH

STATUTES AND CENTRES PROVIDED

SOME MATERIALS ON PAIN RESEARCH

AND IT'S OUT IN THE LOBBY FOR

YOU TO PICK UP IF YOU LIKE.

THANK YOU VERY MUCH, EVERYONE

FOR COMING AND THANK YOU AGAIN

TO OUR SPEAKERS.