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5 Articles in this Series
Introduction
Breaking Down Barriers, Including Potential Trauma, When Treating Women in Chronic Pain
Key Goals, Including Healthcare Equity, Emerge from the Chronic Pain in Women Summit
Pain and Sleep: Why It Is So Crucial and How CBT May Help
Sex Differences in Pain Response Matter
Women in Chronic Pain Need More from their HCPs

Breaking Down Barriers, Including Potential Trauma, When Treating Women in Chronic Pain

Using the biopsychosocial approach to understand key challenges, including a potential history of trauma, and action plans for managing chronic pain in women, with Mary Driscoll, PhD, of Yale School of Medicine and the VA Connecticut Healthcare System.

 

Mary Driscoll, PhD, an associate research scientist at Yale School of Medicine, spoke at the July 2019 HealthyWomen Chronic Pain Summit session, held in Ellicott City, MD, on challenges faced by female patients, in particular, when seeking pain management. Dr. Driscoll also serves as a clinical psychologist at the VA Connecticut Healthcare System and often works with women veterans. Using the biopsychosocial model as a reference point, she focused on specific barriers to the treatment and management of chronic pain faced by women and provided a few ways that healthcare providers and patients themselves may address these barriers.

The Biology

Women often have pain of unknown etiology and, thus, their time to diagnosis is often longer than that for men, she said. In addition, hormonal factors come into play. Hormones affect the way certain medications are metabolized, and at the same time, pharmacologic agents cannot be studied in pregnant women, so the clinical community does not know for sure about the safety or efficacy of many medications in this population. During childbearing years and/or while pregnant and breastfeeding, particular care must be taken when prescribing potentially teratogenic medications, thus women may be more limited in their options for treatment These differences impact how pain is treated across a woman’s lifespan, including through pregnancy, breastfeeding, and menopause, she explained.

The Psychology

Another area of pain management impacted by sex is the utilization of self-management programs. Women respond differently, said Dr. Driscoll, with women being less afraid to participate in exercise based self-management programs. However, they may have difficulty engaging in them, often due to responsibilities they have as primary caregivers. Women may not sustain the gains made in self-management programs and they may be less likely to undergo surgical interventions. “Is that a preference or a bias?” she asked the audience. The answer, she noted, is that “We don't know.”

Depression, and interpersonal traumas, such as sexual trauma and post-traumatic stress disorder (PTSD), also impact pain and pain management in women. Like pain, depression is more common in women and is highly comorbid with pain. When present, the combination of pain and depression conveys greater risk for poorer outcomes among women.

One in 6 women in the United States has experienced sexual violence and this is a unique predictor for the onset, maintenance and exacerbation of chronic pain, noted Dr. Driscoll. PTSD is associated with higher pain, disability and emotional distress, for example. Among those with PTSD in a sample of Medicaid recipients in Michigan, there was an 11-fold increased risk in having four or more comorbid pain conditions—all of which then exist and must be managed in the setting of trauma, she noted (see Seng, et al, 2006, J Traumatic Stress). A history of trauma or violence may influence the way a woman engages with the healthcare system and therefore affects the management of her pain. She may be reluctant to see a male provider, be triggered by forceful recommendations, or be fearful of physical exams – as a result, she may not attend scheduled appointments, shutdown, or seem uninterested/quiet during an appointment or present for treatment only when pain is severe which can make it hard to establish ongoing care plans.

The Sociology

“It is irrefutable that social factors are barriers to treatment,” as well said Dr. Driscoll. With stigma, women with pain may be deemed anxious, hormonal, or to have pain that is “all in their head.” “This discounting by society, and sometimes by providers, dampens communication,” she explained. “Women communicate differently with providers about pain—they may be more emotional as it affects all areas of their life and yet, their pain may be discounted.” Additionally, relationship factors may interfere with pain self-management. “Women, who are more likely to be caregivers, may self-sacrifice and, as a result, they push through the pain; they may take a medication rather than a break so they can meet the needs of others.”

Breaking Down the Barriers

However, Dr. Driscoll, offered a a four-step strategy for providers to begin to break down these barriers, each described in more detail below.

  1. Validate and address the burden of pain (ie, empathize, assess, reflect, connect)
  2. Improve communication (ie, be transparent around treatment decisions and expectations)
  3. Practice trauma-informed care (assume that every patient may have a history of prior trauma and act accordingly)
  4. Sensitively address mental health (ie, normalize the overlap between pain and mental health; it’s not all in their head).

With regard to points 1 and 2, Dr. Driscoll used fibromyalgia as an example, sharing that healthcare providers often assume pain relief is the primary goal for women with fibromyalgia. However, in her experience, many are more concerned about the fatigue that comes with fibromyalgia and an inability to get good sleep. “This is where communication comes into play,” she said. It is critically important to ask women how their condition interferes in their life and what their goals for care are. In so doing, providers learn what’s important to the patient which can inform treatment recommendations that are relevant to a woman’s unique needs.  Stigma may also be reduced by more transparent communication. “Discrepancies between the guidelines that govern provider behavior and patient expectations can make for challenging interactions.”

Offering an example, of women with migraine, Dr. Driscoll said that many female patients may expect a provider to order an MRI. In such cases, if the provider does not recommend an MRI because it is not clinically indicated, the patient may walk away thinking her pain has been discounted—that is, unless the provider offers some explanation for their treatment recommendations, or lack thereof.

Dr. Driscoll also highlighted the importance of “trauma-informed care,” which she said, is “at its core, really good patient-centered care.” Because rates of trauma, particularly interpersonal traumas such as sexual abuse, are common among women with pain as noted above, this type of care is critical because it fosters trust which is necessary for patient engagement.  This involves being sensitive and may include eye contact, asking before touching, conducting a clinical interview while the patient is fully clothed, offering chaperones, asking about provider gender preferences, and allowing autonomy over treatment decisions.

With regard to mental health, Dr. Driscoll pointed out that it simply “cannot be left out of the plan. Normalizing the overlap between pain and distress can make a major difference,” she noted. To the extent that providers can validate pain while helping women to identify ways stress, mental health and/or trauma overlap, the better.” Simple questions like, “How does pain affect mood, and vice versa,” may help to facilitate this conversation.

Finally, Dr. Driscoll called on women with chronic pain to help providers to have better conversations—especially around function. It is important for women to reflect on “how pain interferes in life” and “what gets in the way of managing pain” and to identify their functional goals—it could be walking, or sitting at a pool with one’s grandchildren—for instance. “It may not always be about taking a pain level from a 10 to a 3, but rather, it may be about improving function.” By getting into details about how the pain interferes with a woman’s life—what she can/cannot do and what she wants to do—pain management can be more successful.

Dr. Driscoll recommends the free VA Pain Coach app, which will soon be available to the public. This app includes education about pain, opportunities to track pain and assess progress, as well as access to a menu of evidence-based pain self-management strategies (eg, activity pacing, relaxation, sleep hygiene). These strategies, when used regularly, may help women do more with less pain. And the availability in an app format can eliminate traditional barriers to accessing this kind of care.

 

More on managing pain in LGBTQ populations.

Next summary: Key Goals, Including Healthcare Equity, Emerge from the Chronic Pain in Women Summit
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