June 6, 2018

From Dan Harold, LSCW, CADC I

Pain affects more people in the U.S. than diabetes, heart disease, and cancer combined. Pain is also the number one reason people seek healthcare.  When talking about pain we can enter into the topic of pain management, which encompasses a range of human experiences. As Oregon, along with the rest of our country, has been inundated with large quantities of opiate medicines and opiate black market substances, managing opiate prescriptions can be very challenging work—we have people living with genuine chronic pain and/or disabilities who, on an either short-term or long-term basis, benefit from opiate medicines. When discussing pain management, we have to talk about integrative care and a multi-modal approach to managing pain and helping people heal. This entry will focus on how my professional experience has touched this intersection of pain management, disability, and substance issues. Working with reducing opiate medicines and working towards healing physical ailments is slow work that requires time and resources to be effective. Unfortunately, people in the most need have less time and resources than people of privilege.

Race & Culture

Race and culture play important roles, of course. There are studies that show race and ethnicity play a factor in how pain is treated, talked about, and prescribed for. As providers, we need to educate ourselves on the intersection of culture, race, and pain experiences. Making sure our assessment process is inclusive of a variety of experiences helps. Also, creating safe spaces for people to be clear and honest about their pain experience is crucial. Employing bi-lingual clinicians, and making forms more accessible via language and options beyond a binary lens, are some important tools to use. We also need to be clear about the history of real harm done by the medical community to marginalized groups.

Power & Fear

Patients feel a fear when attending visits with providers due to various power dynamics at play. If there is a prescription involved that the patient relies on to treat pain but leads to withdrawal symptoms when interrupted, then that fear is intensified. The power a provider has to remove pain medicine from a person’s life is real. And, the thought of facing physical withdrawals often sends people into anxious, depressed, and over all distressed states.

For opiates, the withdrawal symptoms include restlessness, severe muscle and bone pain, sleep problems, diarrhea and vomiting, cold flashes with goose bumps, uncontrollable leg movements, and intense cravings for the opiate substance. Benzodiazepine withdrawals are usually physically and mentally grueling and are known to last long periods—up to 30 days or more. People who are going through this need support. We need a system that addresses the mental, spiritual, cultural, physical, and emotional support of people who are being asked to stop taking these medicines no matter what the situation. In many cases people want to reduce their reliance on opiate medicines. Complex pain and addiction can often look like one and the same. We need to be more prepared for this.

As an example, when someone with a history of back pain, multiple back surgeries, and the loss associated with that type of condition has a new pain flare up in their back, it sends alarm signals to the brain much like a threatening experience would cause. The biological mechanism that causes pain is a process that sends alarm signals to the brain. Interestingly, these same neural pathways are also utilized by aspects of the stress experience, the substance craving experience, and the rejection experience.

The Patient Experience

Pain travels the same neural pathways as many stressors. This means that when someone with a history of excess physical pain experiences pain it can feel like their life is in danger, literally. That is one aspect to consider when looking at trauma informed care for chronic pain. When a patient raises their voice with a provider, seems irritable, and/or has trouble following through on tasks, we need a compassionate and caring approach, not an approach that labels these people “resistant.”  Folks with chronic pain experience increased pain levels during stressful events. And over time, the repeated exposure to this can lead to the same adrenal fatigue we see from other stress related problems. This often is confused with “drug seeking behavior” when, in many cases, it’s the physical pain that causes a distressed state.

In addition, our overall stance towards our patients affects our patients’ lives. A study was done looking at the response that pain sufferers receive from medical providers. When a patient feels “understood” or “believed” by a provider, the patient’s pain levels go down, but when a patient feels that their provider does not “believe” them or “understand” them, their pain levels go up. Remember, this physical pain, in the form of an alarm signal, feels like a “threat” to the brain, which leads to an increase in stress. So, if we believe the pain will not be addressed we get more stressed and the pain level can go up. This makes interacting with providers a potentially traumatizing experience.

I also see experiences by folks with chronic illness, disability, and chronic pain when the pain flare itself triggers past memories of disempowered experiences such as surgery, ER visits, shaming by providers, and interactions with medicines that are harmful. So, when the low-back-pain sufferer experiences low back pain followed by images of ER visits, surgeries, and traumatic experiences with medical providers, these possibilities trigger new stress and new fear associated with what may follow the physical pain. In other words, the pain flare itself triggers dysregulation due to all of the valid experiences that the patient has memories of, which includes interactions with helping professionals.

Safety & Healing

Through my years of working with people suffering from illness, disability, and chronic pain I have found that a safe, empathic, and nonjudgmental space where providers are willing to advocate for care is the healing space that needs to be provided to people. That care does not always involve medicines, by the way. It can include meditation, emotional support, anxiety treatment, trauma treatment, and many other interventions like psychical therapy and massage. Not only does this help ease the suffering of the patient, but it also seems to help providers.  When working with patients, we need to be open to a multi-modal approach that involves case management. This means that we will interact with other providers and build more of a “team” approach to care. The providers that I coordinate care with report a deeper sense of ease and safety interacting with patients when other providers are involved.

When there are other providers involved who bring hope and effectiveness to patients’ lives, it helps the patients’ overall experience improve, which improves future interactions with providers. This can be seen as a feedback loop or cycle. The confidence and patience that other providers feel when they know their patient is being cared for in multi-modal ways is an important result of trauma-informed practices. In other words, being trauma informed not only helps the patient but it also helps providers feel supported. Sadly, this approach is not embraced by all managed care organizations, however, many hospital systems and insurance providers are seeing the benefits to patients and the benefits to their overall bottom line.

By making it clear we understand how stressful the healing process can be, we are being trauma informed. When we trust our clients, we are being trauma informed. When we advocate for care, case manage, and find the right cultural fits for our clients, we are being trauma informed. And, when we hear someone tell us they are in the midst a pain flare, we need to be clear with ourselves that their brains are being hijacked by alarm signals. They might be exhausted, it’s likely they feel irritable, and they may not have the energy to force a smile. It’s the healthcare community’s job to allow people to have a valid reality and to create a safe space to heal.

While we are in the midst of a state and nationwide opiate problem, and as the pendulum swings to the side of safety and control of substances, we need to be mindful of the unique and personal experiences patients sitting in front of us are having. Our patients do not all fit into a tidy box. This work is slow, it can be messy. However, people are strong and resilient and find ways to progress. My hope is that by using a more trauma informed lens around the intersection of pain, illness, and addiction we can create more safe spaces for people to heal.