Opioids, Expectations, and Ethos: A Global Take on Pain Management in Surgery and Pregnancy

“Successful modern perioperative and obstetric anesthesia care must emphasize culturally competent approaches to pain management and suffering mitigation.” “It is not death or pain that is to be dreaded, but the fear of pain or death.” —Epictetus, Stoic philosopherImage: J. P. Rathmell.In the classic Buddhist parable of the mustard seed, Kisa Gotami, a grieving mother whose only child has unexpectedly died, seeks help from the Buddha, hoping he can bring her child back to life. The Buddha promises that he can—if she brings him a mustard seed from a household that has never experienced death. Expectantly, she searches door to door. Soon, she realizes that everyone is willing to give her mustard seeds, but also, everyone has suffered loss. In this realization, Kisa Gotami understands the universality of human suffering and comes to embrace the Buddhist teaching of impermanence, ultimately finding peace through acceptance rather than resistance to pain and loss. Pain is not only a physical sensation but also a profoundly social and cultural experience, shaped by history, expectations, and personal beliefs. Although its mechanisms are neurologic and physiologic, responses to pain—including how it is reported, managed, and treated—vary across cultures and contexts. This issue of Anesthesiology includes important original research from Brett et al.,1 who conducted a large, multinational study examining prescription opioid use during pregnancy across four global regions from 2000 to 2020. Among more than 20 million pregnancies, opioid use varied widely, from 4 per 1,000 in the United Kingdom to 191 per 1,000 in the publicly insured U.S. population. Although overall trends remained stable or declined in most countries, notable regional shifts included a sharp decrease in Hong Kong and a significant increase in Iceland. Despite these geographic differences, patterns of opioid use by sociodemographic and pregnancy characteristics remained consistent across populations. Cultural Variations in Pain and Opioid Use Pain and suffering are deeply influenced by culture and individual life experiences. In Asian cultures, stoicism in the face of pain is often valued, reflected in Confucian, Buddhist, and Daoist traditions that emphasize endurance and communal harmony. Expressing pain too openly is perceived as a burden to others, influencing differences in how patients report pain or seek treatment. Traditional Eastern medicine approaches, such as acupuncture and herbal remedies with energy-based healing, also influence attitudes and beliefs toward pharmacologic pain management. In contrast, Western cultures, particularly in the United States, have long emphasized the aggressive treatment of pain, often framing it as a problem that must be eliminated. The “Pain as the Fifth Vital Sign” movement, which gained momentum in the late 20th century, contributed to a dramatic increase in opioid prescribing as healthcare providers were incentivized to prioritize pain relief, sometimes to the detriment of patient safety. However, this framework also reinforced public expectations that relief from pain is a right, making medication and opioid use a culturally ingrained response to discomfort. Indigenous and Aboriginal cultures take holistic approaches to pain management, emphasizing spiritual and communal perspectives in healing. For some Aboriginal communities in Australia and Canada, pain is not necessarily viewed as an individual experience but as something that exists in relation to the community and ancestors. Traditional healing practices like storytelling and connection to nature are as important as biomedical interventions in managing pain. Historically, pain relief strategies have evolved in response to broader societal changes. In pre-modern medicine, pain was often seen as an inevitable part of life, with limited options for relief. The introduction of opioids in medical practice, from the laudanum of the 17th century to the widespread availability of morphine and later synthetic opioids, revolutionized pain management but also led to patterns of addiction and regulatory cycles that persist today. Labor pain and analgesia attitudes have shifted significantly over history, reflecting advancements in anesthesia as well as cultural changes in expectations around birth experiences. In some parts of the world, readily available epidural analgesia as an option for childbirth is now the norm and expectation, whereas in others, unmedicated childbirth is preferred, sometimes due to cultural beliefs and other times due to limited access to anesthesia services or medications. Global Implications Brett et al.1 should be applauded for providing a population-based perspective on opioid use in pregnancy, an area in which contemporary research has been limited. Their findings reveal the existence of geographic and cultural variability in opioid use in pregnancy and urge a more critical examination of opioid use within the broader context of prescribing practices and cultural attitudes toward pain relief. The study highlights how health policies, system structures, and historical opioid use patterns all intersect to create vastly different opioid prescribing landscapes worldwide. The observed variation in opioid prescribing across countries raises important questions: Does higher prescribing reflect a more aggressive approach to pain management, or does it reveal a lack of viable alternatives? Conversely, does lower prescribing indicate better nonopioid pain management strategies, or does it suggest undertreatment of pain due to stigma or limited access? How do cultural perceptions of pain and suffering interact with opioid prescribing practices, and how can we distinguish between appropriately managed pain, overprescription driven by systemic factors, and undertreatment due to stigma, policy constraints, or limited access to alternative pain management strategies? Understanding these nuances will be critical for clinicians and healthcare systems as we work to balance optimal pain relief with responsible opioid stewardship. Policies, Disparities, and Cultural Competence Opioid prescribing has been under intense national and international scrutiny, particularly in the United States, where a confluence of factors—including the opioid epidemic fueled by greed and despair—have led to a rapid and dramatic restructuring of pain management policies. New prescribing guidelines,2 quality metrics,3 and regulatory oversight4 aim to curb opioid misuse. Simultaneously, obstetrics and women’s health clinicians are working to eliminate health disparities, including disparities in pain management. Policies and prescribing restrictions designed to mitigate opioid overuse may unintentionally contribute to disparities by disproportionately affecting marginalized groups who already face barriers to adequate pain management. Provision of culturally competent and individualized care requires that clinicians and regulators recognize that attitudes toward opioids are not uniform. If policies are applied rigidly without considering cultural variations in pain perception and reporting, disparities in opioid prescribing and use behaviors could potentially become exacerbated. Clinical and Educational Implications This study reinforces the need for a nuanced approach to pain management—one that acknowledges cultural differences while ensuring equitable access to appropriate treatment. Pain and suffering require individualized treatment plans and culturally competent responses. Residency programs and medical educators have a responsibility to train anesthesiology residents and other trainees in culturally competent care. The Accreditation Council for Graduate Medical Education core residency competencies explicitly emphasize the importance of understanding and respecting diverse patient backgrounds. Educators should incorporate case-based discussions, bias training, and best practices in cross-cultural communication skills into all aspects of anesthesiology training and pain management education. Toward Equitable, Culturally Attuned Obstetric and Pain Management Successful modern perioperative and obstetric anesthesia care must emphasize culturally competent approaches to pain management and suffering mitigation. Patients do not experience or express pain in the same way, and our clinical responses should reflect this diversity. As we strive to build equity in health outcomes—particularly in obstetrics but also broadly in anesthesia and perioperative care—we must move beyond one-size-fits-all solutions. Pain management must be safe, effective, and inclusive, respecting both the biologic realities of pain and the cultural narratives that shape how it is perceived and treated. If pain is universal, our response to it must be both scientific and deeply human. Research Support Dr. Lim receives salary and research support from National Institutes of Health (Bethesda, Maryland) grant Nos. UH3CA261067 and R01MH134538, Edwards Lifesciences (Irvine, California), Octapharma (Lachen, Switzerland), and Patient-Centered Outcomes Research Institute (Washington, D.C.) grant No. EASCS-34606. Competing Interests Dr. Lim receives research support and consulting honoraria and chairs or is member of advisory board from industry for Octapharma (Lachen, Switzerland), Heron Pharmaceuticals (Cary, North Carolina), Edwards Lifesciences (Irvine, California), and Haemonetics (Boston, Massachusetts), all unrelated to this publication. Dr. Lim receives stipends for medical expert testimony not related to this publication. Dr. Lim receives textbook royalties from Cambridge University Press unrelated to this publication.

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