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17 Articles in Volume 20, Issue #3
20/20 with Dr. Suzanne Amato Nesbit: Clinical Pharmacy Roles and Disparities
A Clinician’s Guide to Treating Chronic Overuse Injuries
Adhesive Arachnoiditis: No Longer a Rare Disease
Analgesics of the Future: Cebranopadol as an Opioid Alternative
Ask the PharmD: What role do vitamin D supplements play in treating dysmenorrhea?
Behavioral Pain Medicine: Managing the Affective Components of Pain
Chronic Fatigue Syndrome: Naltrexone as an Alternative Treatment
Chronic Pain and Coronavirus
Connecting the Dots: How Adverse Childhood Experiences Predispose to Chronic Pain
Editorial: Why Are ER Opioids Out of Favor?
Fibromyalgia as a Neuropathic Pain Disorder: The Link to Small Fiber Neuropathy
How the COVID-19 Pandemic Is Transforming Pain Care
Hydroxychloroquine Use and Risk in the Management of Systemic Lupus Erythematosus
Management of Trigeminal Neuralgia in Multiple Sclerosis
Optimizing Care Using a Trauma-Informed Approach
Pediatric Pain Management: A Review of Clinical Diagnosis and Management
The Use of Low Dose Naltrexone in the Management of Chronic Pain

Optimizing Care Using a Trauma-Informed Approach

Traditional perceptions of patient behaviors may derail pain care for trauma-affected patients. A trauma-informed approach can optimize care, reduce barriers to the treatment and management of pain, and foster trust and collaboration.
Pages 29-31

Although pain can present under myriad conditions and often occurs in concert with a variety of physical and mental health comorbidities, there is evidence suggesting that childhood trauma or adverse childhood experiences may convey risk for the development, maintenance, severity, and exacerbation of chronic pain.

(See “Connecting the Dots,” by Dr W. Clay Jackson)

Implications of Trauma in Providing Pain Care

In addition to affecting underlying physiology, health behaviors, affect and pain itself, trauma can and does influence the way people interact with the healthcare system. For example, persons with trauma histories can be sensitive to power differentials. Accordingly, the hierarchical nature of traditional provider/patient interactions may be triggering. Physical exams, requirements to wear hospital gowns, invasive procedures and tests, and well meaning, but forceful recommendations can all be reminiscent of prior traumatic episodes. Busy offices, rotating providers, televisions blaring the news, lack of privacy, provider gender/body language–even temperature can contribute to feeling overwhelmed and lacking control.

Accordingly, persons with trauma histories may shut down or withdraw during appointments. They may avoid appointments altogether, anger easily, become emotional, fail to follow through with recommendations, struggle to adopt and maintain prescriptions for healthy behavior change, and/or engage with medical teams during times of acute crisis then disappear once stabilized only to emerge again months later when in crisis again.

Unfortunately, when these interactions happen, it is not uncommon for providers to assume that “non-adherence” is a sign of disinterest, lack of motivation, or failure to take pain seriously. Similarly, providers may assume that displays of anger signal manipulation or rudeness, which is often met with dismissal. Withdrawing during an appointment is often taken for disinterest when in fact the patient may be triggered and trying desperately to self-soothe.

On the surface the traditional assumptions providers make appear to be reasonable conclusions given the circumstances. The problem is that these assumptions are not always accurate, and they rarely lead to optimized outcomes or patient satisfaction. They also likely contribute to frustration and provider burnout. Notably, persons with pain routinely express high levels of dissatisfaction with their care,1 and providers who care for persons with chronic pain report significant strain.2  

Pain patients with trauma histories may shut down or withdraw during appointments. There are ways to take their full history and treat their pain. (Image: iStock)

 

How to Adopt a Trauma-Informed Approach

What, then, is the solution? Frequently, providers who treat persons with pain may be unaware of a patient’s psychosocial history and the presence of childhood (or any) trauma. Even if a provider asks, there is no guarantee that a patient will truthfully disclose; trust issues are common among those who have experienced trauma.

Fortunately, providers need not confirm the presence of trauma in order to treat a survivor sensitively. Indeed, in most cases, it is neither necessary nor appropriate for a pain provider to treat trauma directly, however the preponderance of trauma among treatment-seeking persons with chronic pain belies the importance of utilizing trauma-informed practices when approaching any person with pain. Just as the use of sterile gloves has become a standard universal precaution in healthcare, so too should the provision of trauma-informed practices, especially in the treatment of persons with pain.

Trauma-informed care is a way of approaching patient care that seeks to establish safety, trustworthiness, choice, collaboration, and empowerment.3 It requires attention to the physical environment, patient preferences, and a willingness to anticipate, identify, and address specific facilitators and barriers to an individual’s care.

Clinical Examples: Be Cognizant of Attributions, Reframe Assumptions

Beyond these tangible behaviors, trauma-informed care involves being cognizant of the ways in which traditional medical attributions or perceptions of patient behaviors may derail pain care. Simultaneously, it encourages providers to reframe these attributions in ways that will facilitate trust rather than thwart collaboration. For example, recent changes to opioid prescribing policies and the knowledge that long-term opioids are of limited effectiveness, have resulted in efforts to forcibly wean persons with pain from their medications. For an individual with a traumatic past, this news may be jarring – especially if the patient has no say in the decision; they may become dysregulated, angry, even downright aggressive.

In response, many providers might understandably assume the person is “difficult” or “manipulative.” Such an assumption might prompt the provider to be dismissive, or to take a hard line that could result in discontinuation of care, doctor shopping, or decompensation.

Taking a more trauma-informed approach would encourage the provider to recognize that the individual’s lack of control in this situation may be evoking fears reminiscent of trauma and the individual is lashing out in response. The provider might recognize that the individual is just trying to get their needs met – albeit in a maladaptive way. A more practical response would involve acknowledging the fear/lack of control and verbalizing a commitment to work with the patient to establish a schedule and engage patient agency in selecting alternative modalities to address pain.

A second example involves the person with pain who fails to follow up on provider referrals for physical therapy. In such a situation many providers might customarily abandon efforts to engage the individual in this modality further. The assumption being that the person is indifferent or disinterested. Utilizing a trauma-informed lens, the provider might explore barriers to engaging in prescribed care. For example, fears about the physical therapy setting, the gender of the provider or being touched by a stranger. With a better understanding of the barriers/fears, the provider may be equipped to address them directly, and/or identify alternative options with which the individual may be more comfortable.

In both examples, the trauma-informed approach has the potential to optimize pain care, reduce barriers to the treatment and management of pain, foster trust, and/or encourage collaboration. By contrast, the more traditional attributions unequivocally halt progress, and in the former example, may lead to a contentious relationship, frustration by both parties, and/or discontinuation of care altogether.

Notably, the suggestions made here for adopting a more trauma-informed approach do not necessarily translate to a greater expenditure of time, and they transcend diverse settings. Whether the individual with pain presents at an inpatient unit, an emergency department, an outpatient clinic, a pain clinic, a mental health center, or a physical therapy and rehabilitation center, the same principles apply (see also Mental Health indicators in chronic pelvic pain). While not all persons with chronic pain have a history of childhood trauma, treating all individuals with pain as if they do have that history is “at its core, good patient-centered care.”4 Nascent research outlining the benefits of trauma-informed approaches are promising. Their implementation produces improvements in patient satisfaction, utilization metrics, and workplace satisfaction. 

Last updated on: June 18, 2020
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Pediatric Pain Management: A Review of Clinical Diagnosis and Management
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