FEBRUARY 11, 2022
Trauma-Informed Pain Recovery Versus Pain Management
Bennet E. Davis, MD
Within our medical profession, there is a growing understanding of, and appreciation for, the fact that toxic stress changes the sensory processing function of the nervous system, resulting in pain that is not tied to tissue pathology. Studies have found that people with a history of developmental and adult trauma have significantly lower pressure pain thresholds and experience pain differently.1-
If trauma can lead to chronic pain, then it follows that our treatment of trauma should relieve pain. In fact, there are six randomized controlled trials supporting the idea that trauma recovery is pain recovery.4 Yet, we still tend to manage neuropathic pain from traumatic experiences as if the source of the patient’s distress were nociceptive, that is, coming from physical injury. We tend to prescribe antibiotics or opioids, for example, instead of addressing the mental health consequences of the trauma.
For the health of individual patients and our society at large, it’s time for primary care providers, pain specialists and other physicians, and behavioral health providers to change our thinking and treatment modalities.
A Case in Point: Held Hostage by Trauma
Most patients coming to our Sierra Tucson pain recovery program will describe their condition with emotionally charged words, such as “punishing” and “cruel.” Yet, the vast majority do not recognize that there could be a connection between their terrible pain and trauma.
One patient who I saw several years ago reported experiencing pain everywhere in her body. She had already been on disability for three years because of debilitating pain, which seemed to come out of nowhere. Over the course of those three years, she had been seen by a host of medical professionals who, finding no tissue source for her pain, separately diagnosed her with fibromyalgia, systemic lupus erythematosus, chronic Lyme disease and multiple sclerosis. She spent tens of thousands of dollars on antibiotics, oxycodone and benzodiazepine, with nearly no benefit.
Upon her first visit, her husband suddenly had an idea. “Wait a minute, honey,” he said. “About a month before your pain started, don’t you remember that you were held hostage at Kwik Mart, and the guy put a knife to your throat and the sheriff had to shoot him out from behind you? Doctor, could that have anything to do with her pain, even though she was physically unharmed?”
Without a doubt. The patient’s pain syndrome began about a month after her hostage situation, which is approximately how long it takes for the body’s nervous system to rewire itself to process pain differently.5 A trauma recovery treatment called somatic experiencing as well as group cognitive-behavioral therapy and dialectical behavioral therapy yielded results: After six months, she was back to work, off pain medication and doing very well.
Admittedly, enduring a hostage situation is rare. There is, however, another source of toxic stress that is far more prevalent in our country and is a source of much of the chronic pain that I’ve seen in my practice: developmental trauma. Studies worldwide have shown a dose–response relationship between traumatic childhood experiences and the development of chronic pain later in adulthood.6
According to the Substance Abuse and Mental Health Services Administration, more than two-thirds of children report an least one traumatic event by 16 years of age, including community or school violence; national disasters or terrorism; neglect; psychological, physical or sexual abuse; and witnessing or experiencing domestic violence.
Our society is hurting, literally and figuratively. We need to move beyond mere pain management to holistic pain recovery. In fact, Nadine Burke Harris, MD, California’s first surgeon general, has already begun the movement by calling for all students in the state’s public schools to be screened for developmental trauma. She believes that public health–scale intervention around adverse childhood experiences and toxic stress is going to be the biggest public health advancement of our time.
From Pain Management to Pain Recovery
To fully understand a patient’s chronic pain requires a multidisciplinary approach involving medical pain specialists working in tandem with our physical therapy and behavioral health colleagues. This multidimensional evaluation must then be followed by treatment of root causes of pain: integrative treatment that could include pain education; movement and experiential therapies; medication management; emotional processing through individual and group therapy; cognitive-behavioral work; and biofeedback and transcranial magnetic stimulation.
There will be patients who say they can’t do trauma work or physical therapy because their pain is too great. These patients won’t be able to talk about their nervous system, much less their trauma, or tolerate being touched by a physical therapist because they would reexperience the trauma as physical pain in their bodies. As medical professionals, we must meet these individuals where they are—even when we know that they clearly carry a heavy burden of trauma—by first addressing the “physical” pain they’re feeling through gentle trauma therapies.
However, it’s our duty to not stop there. We must then educate our patients about how their trauma-adapted nervous system is relaying pain to their brains. Once they begin to understand and accept the connection, we can begin treating the trauma, which will enable our profession to move beyond mere pain management to total pain recovery.
Davis is the former director of the University of Arizona Pain Center. He is board certified in anesthesiology and pain medicine.
Tesarz J. Distinct quantitative sensory testing profiles in nonspecific chronic low back pain subjects with and without psychological trauma. Pain. 2015;156(4):577-586.
Gomez-Perez L. Association of trauma, post-traumatic stress disorder, and experimental pain response in health young women. Clin J Pain. 2013;29(5):425-434.
Creech S. Written emotional disclosure of trauma and trauma history alter pain sensitivity. J Pain. 2011;12(7):801-810.
Tesarz J, Wicking M, Bernardy K, et al. EMDR therapy’s efficacy in the treatment of pain. J EMDR Pract Res. 2019;13(4):337-344.
McCarberg B, Peppin J. Pain pathways and nervous system lasticity: earning and memory in pain. Pain Med. 2019;20(12):2421-2437.
Jackson WC. Connecting the dots: how adverse childhood experiences predispose to chronic pain. Practical Pain Management. 2021;20(3):24-28.