Trauma-informed high impact chronic pain care

Author

Judy Dercksen MD (biography and disclosures)

Disclosures: Included in the article are links to the author’s chronic pain information website: https://painimprovement.com/about/, no commercial interest. Received direct financial payments from Pain BC for the role as family physician on Pain BC ECHO for pain and the role as pain mentor. Not yet received funding for the Doctors of BC mentor role. Mitigating potential bias: Recommendations are consistent with current practice patterns.

What I did before

In 2016, the opioid epidemic was declared a public health emergency and the College of Physicians and Surgeons alerted me to my potentially unsafe prescribing habits.¹ My patients’ and my own stress levels rose exponentially with each opioid dose reduction.

Resource constraints in our rural area made matters worse. Patients with mild or bothersome pain usually improve with anti-inflammatories and physical therapy, but in 2016, I didn’t know how to effectively manage high-impact chronic pain, HICP, which the US National Pain Strategy defined as pain with a duration of six months or more that significantly impacts work, social, and self-care activities.²

Doubt in my ability to manage HICP overtook me. I have complex post-traumatic stress disorder (CPTSD)—my adverse child events score (ACEs) is 6 out of 10. Because of CPTSD, I have a high shame response which often leaves me feeling not good enough. My need to please and succeed overrode emotional exhaustion from working long hours in an underserviced rural area. I didn’t recognize I was one of the 50% of family doctors suffering from burnout.³

Burnout is associated with depersonalization, mine evident when Dragon Lady emerged, my callousness at times surely hard for my patients to bear.³ The less effective I felt, the more my defenses rose and a few patients suffered when my automatic fight response kicked in. I’d apologize, but harm had been done, the patient-provider relationship compromised.

I hadn’t learned yet about Maslach and the Maslach Burnout Inventory, but I recognized fatigue, occupational stress, and feelings of inadequacy were impacting my health and risking the safety of my patients.⁴

What changed my practice

At first, I was more focused on my patients. Frustrated because of lack of time in the office, I designed an internet-based website to streamline patient pain education. Populating this website led me to other resources, like Pain BC ECHO for Pain and Self-Management BC. In time, I discovered the key to HICP management lay in an approach that emphasized safety and collaborative care, essential when managing patients with the potential for having underlying trauma.

1. Safety: When I recognized the downstream consequences of past trauma, I realized how important it was to provide patients with a safe environment. Learning how to lower threat in the office became my goal. Chronic pain is associated with stigma and this can lead to patients feeling judged, as if they are to blame for their symptoms and disability. HICP required an approach that avoided inducing a shame response.

2. Collaboration: An effective patient-provider partnership relies on collaboration, but my anxiety and determination to cure pain symptoms pressurized patients and stood in the way of helping them on their unique healing journey. I began practising mindfulness and abdominal breathing.^5-8 When I noticed anxiety rising in my body, I focused on breathing, slowing my speech and racing thoughts while I allowed patients space to communicate. This helped improve the patient-provider relationship.

My interactions with HICP patients became more effective as my approach changed from a relentless pursuit to decrease their pain, to a more compassionate one, where in a safe space I listened as patients shared their needs and goals, while I provided them with tools when they were receptive to change.

What I do now

Simplifying an approach to a complex problem is possible. Here’s how I approach a patient presenting with pain, using the Graded Chronic Pain Scale-Revised (GCPS-R)⁹:

1. 1. “Could you please tell me how often you’ve had pain in the past 3 months?”

When patients report most days or every day, they have chronic pain (CP).

2. 2. “In the past 3 months, how often has pain limited your life or work activities?”

If patients have limited activities including socializing due to pain most or every day, or if they are not working or unable to work due to pain, they can be managed as a person with HICP.

The GCPS-R form uses pain (P), enjoyment of life (E), and general activity scale (G), or PEG scale, which is based on the Brief Pain Inventory scale (BPI) PEG pain scoring questions, which are listed as 3 to 5 in the GCPS-R.¹⁰

3. 3. “How would you best describe your pain intensity on average in the past week, where 0 is no pain and 10 is pain as bad as you can imagine?”
   4. “During the past week, how much has your pain interfered with your enjoyment of life, rating this on a scale of 0 to 10 where 10 is when pain completely interferes?”
   5. “In the past week, how much has pain interfered with your general activity?”

GCPS-R forms can be used for initial assessment, for monitoring progress of HICP, and for those who report pain that never or seldom bothers their lives, activities or work. The latter are non-HICP patients who are seen as having mild chronic pain (adding scores of questions 3, 4, and 5 to equal less than 12) or bothersome chronic pain (a score of 12 or more).

The validated GCPS-R form is shorter and quicker to self complete than the BPI, which is an advantage when managing patients overwhelmed with chronic pain. It also reliably predicts patients more likely to use long term opioids compared to those with mild to bothersome pain.⁹

Self report forms are by their nature subjective and patients may feel frustrated or experience shame answering these questions, which could lead to them minimizing their symptoms. As their sense of safety improves, their pain scores may increase.

Graded Chronic Pain Scale – Revised

Download the Graded Chronic Pain Scale PDF.

Managing HICP

Managing HICP can feel overwhelming, but the process is usually a marathon, not a sprint. Each visit is an opportunity to support the patient on their journey. Even short appointments can be used effectively, by utilizing self-report pain forms, or by introducing patients to education videos. Every appointment can be used to validate patients’ symptoms and reinforce hope.

As soon as time allows, arrange a counselling appointment to perform a narrative interview. The patient is given time to tell their pain story, and, to further increase safety, invite patients to bring a pain partner—a friend or family member.

• At the beginning of the visit, my opening sentence is usually, “Please tell me everything you feel I should know about your pain.” I avoid interrupting, other than using short phrases encouraging them to continue or phrases indicating I am listening. Patients need to feel heard.
• I endorse the patients’ symptoms as significant and explain how their pain causes hyperarousal (alarm) in their nervous system, leading to a cycle of pain causing alarm and alarm causing pain, and providing a link to a YouTube video Chronic Pain Explained.^11,12
• If there is time, I demonstrate the Two-Step technique to lower alarm in the nervous system, specifically the Limbic System.^11-13 I also provide a link showing Alternative Mindfulness Tools.
• I print or email a template showing a Two-Step Program which engages the five senses of sight, touch, hearing, smell, and taste. This one-minute exercise grounds patients in the present moment.^14-16 Abdominal breathing further relaxes the body and calms the mind.
• When done frequently, the lowered hyperarousal leads to improved cognitive abilities, allowing patients to better understand education on CP. Often they then begin to intuit the link between central hyperarousal and perpetuating pain.^11-13

Download Two-Step Grounding Exercise to Improve Pain PDF.

This handout can be freely copied without permission from author, Dr. J. Dercksen. It can be emailed/printed for patient use. Patients are advised they don’t have to believe it works, but they need to perform this exercise very many times during the day to lower alarm. Lowering their sense of alarm, decreases inflammation and pain and with time reprograms their brain, desensitizing the nervous system.

Follow up Visits

Regular visits can be used to reassure patients and support self-management of CP. It is important to assure patients that all biological causes of pain will be considered and have been investigated: “There are physical reasons for why you are experiencing pain, but right now you are in no immediate danger.”

The GCPS-R or BPI can be used to monitor progress. The BPI short form includes questions about sleep. Inadequate sleep needs to be addressed to effectively manage CP.¹⁷

When progress is suboptimal, consider asking: “What do you feel is causing your pain?” Patients’ answers may help stimulate further exploration for biological reasons for pain.

Reinforce the need for lowering alarm, asking, “Have you been able to practice any of the exercises?” and, “How often are you practising the mindfulness and breathing techniques each day?”

I emphasize the marvel of neuroplasticity and show patients a video demonstrating how behavior and thought changes can change the brain, but initially the exercises need to be practised very often to change the brain to lower pain.

If the patient admits to not doing the exercises, readiness to change can be explored:

• • “Do you feel you would be likely to use the steps I gave you?”
  • “Do you feel these steps would help your pain?”
  • “What do you feel is preventing you from making the changes?”

Patients are advised that hyperarousal leads to neurohormonal changes and other downstream consequences. They are advised of the benefits of lowering alarm, including improvement in physical and mental health. I provide a link to an education video The Limbic System and CP.

Barriers to Supported Self-Management

We can help patients improve their emotional regulation and provide them with the skills and tools necessary to manage their pain, but outcomes are often suboptimal.

Bessel van der Kolk’s The Body Keeps the Score and trauma courses offered by the National Institute for the Clinical Application of Behavioral Medicine (NICABM) have helped me understand why this is the case.

These are some factors contributing to reported high treatment dropout¹⁸:

1. A decrease sense of self-efficacy: Chronic illness may change the way individuals view themselves and the world. They can experience the environment as dangerous and feel a sense of helplessness. Patients with avoidance defence mechanisms are more likely to feel they cannot effect change.¹⁹
2. Pain sensations take on threatening significance²⁰: Threat can increase when patients are faced with demanding lifestyle changes. When the freeze response is activated, even small steps prove hard. Progress can be slow or non-existent.
3. Underlying shame influences healing in other ways. Resilient patients with HICP may fear disability and the stigma associated with CP. They overcompensate, doing more than their bodies are able. Rather than pacing, they force through pain and further injure themselves.
4. Persistent pain causes hyperarousal of the hypothalamic-pituitary-adrenal axis. This leads to increased inflammation and central sensitization.²¹
5. Multiple other pain influencers, like financial stressors, social stressors, healthcare inequities, or trauma from racism, can add stress burdens on the brain, further increasing alarm in the limbic system.
6. Disability, past adverse child events, experiences of abuse in adulthood, feelings of vulnerability or a sense of helplessness lead to shame responses, aggravated by the stigma associated with chronic pain, disability, mental illness and failure to cope. Patients blame themselves for their lack of progress. Introducing psychological reasons for pain too early in discussions can add to feelings of shame and increase alarm in the brain.

Conclusion

Moderate to severe pain can be perceived as a threat. A sense of danger can lead to hyperarousal in the nervous system. The construct of the limbic system, the brain’s threat warning system, includes the amygdala, orbitofrontal cortex, insula, hippocampus and cingulate cortex.^10-12 When there is a past history of trauma, neural connectivity in the limbic system between the thalamus, pain central station and the emotional, memory and learning areas of the brain explains alarmed responses to pain.

To avoid patients feeling as if they are to blame for their pain symptoms, I explain how pain causes hyperarousal in the nervous system, leading to a vicious cycle of pain causing alarm and alarm causing pain. Pain becomes the culprit, and they don’t feel blamed for inadequate coping mechanisms or unproductive behaviors.

Focusing on pain as the cause for an alarm response decreases the risk of patients feeling as if the pain is all in their heads, and, because they don’t feel blamed, collaboration improves and supported self-management, a necessary part of healing, is optimized.¹³

When patients achieve emotional and physiological regulation, their cognition improves and they can focus on pain education. As their fear decreases, they are more likely to engage in healthy lifestyle changes, making positive outcomes possible.

Not all patients are able to improve, but a structured approach with realistic expectations improves provider satisfaction and lowers the risk of physician burnout.²²

Handout for Practitioners

Download Summary of HICP PDF.

Resources

1. Pain BC
2. Pain BC: BC ECHO for Chronic Pain
3. Pain BC: Chronic Pain Management Pathway
4. BC Guidelines on Pain Management

References

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