According to the International Association for the Study of Pain, pain is defined as an unpleasant and emotional experience associated with, or resembling that associated with, actual or potential tissue damage (Brennstuhl et al., 2015). Pain is not located in one specific area of the body. It is a dynamic phenomenon understood in terms of four basic biopsychosocial components: sensory, cognitive, behavioral and emotional (Brennstuhl et al., 2015). Acute pain it limited to six months or less and is typically associated with physical trauma or injury. Chronic pain lasts longer than six months, persisting beyond the normal anticipated healing time. In 2021, an estimated 21% of U.S. adults experienced chronic pain (Rikard, 2023). A meta-analysis estimates worldwide prevalence of chronic pain ranges from 0% - 24% (Zimmer et al., 2022). 

Pain is a personal, subjective experience influenced by many factors. To be a trauma-informed treatment provider, it is critical to respect each patient's report of an experience of pain.  Their unique pain experience is whatever they define it as and exists when they say that it does.

Yamin and colleagues (2024) indicated the need to directly address trauma in the assessment and treatment of chronic pain.  They point out that traumas, including Adverse Childhood Experiences (ACES), are risk factors for the development, exacerbation and maintenance of chronic pain (Edwards et al., 2016) and advocated for training in trauma-informed care for chronic pain management specialists. 

What is Trauma?

Trauma = An event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful, or life-threatening, and has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being (SAMHSA, 2024).

What is Re-Traumatization?

When assessing patients/clients for chronic pain, is important to recognize that 70% of people have experienced at least one traumatic event in their lifetime (Benjet et al., 2016) and practitioners should avoid re-traumatizing them through their care. 

Re-Traumatization = A situation, attitude, interaction or environment that replicates the events or dynamics of the original trauma and triggers the overwhelming feelings and reactions associated with them.

What is Trauma-Informed Care?

•Care that assumes individuals are likely to have a history of trauma

•Care that avoids re-traumatizing or triggering those who have already experienced trauma

•Is not a specific treatment. It is an approach, a mindset and preparedness to assist and refer those who may disclose trauma 

Being trauma-informed is ensuring “universal precaution.” Similar to how health care professionals put on gloves when in contact with body fluid to prevent the spread of blood borne pathogens—they don’t ask “do you have __ disease?” They just automatically do it, just in case. 

Institute on Trauma & Trauma-Informed Care:  The Basics

Guiding Principles of Trauma-Informed Care

Chronic Pain Treatment as a Human Right

To assess and treat chronic pain, it is useful to acknowledge the history of pain management globally.  In 1961, nations around the world adopted the Single Convention on Narcotics, which addressed the control of illicit narcotics and obligated countries to work towards universal access to narcotic drugs necessary to alleviate pain and suffering (Lohman et al., 2010).  In 1986, the World Health Organization (WHO) proposed the WHO Analgesic Ladder, which recommends administering different types of pain medications depending on the severity of pain (Ventafridda et al., 1985). In response to gaps in pain treatment in the early 2000s, international pain and palliative care professional organizations created a series of declarations asserting pain management as a human right (Brennan et al., 2019).  Examples included the Panama Proclamation in 2008 and the Declaration of Montreal in 2011. The United States has not made an effort to establish a declaration of pain treatment as a human right. The common theme of the global efforts to manage pain has primarily been providing access to pain management medications and basic medical care. This approach does not address the full range of biopsychosocial assessment and treatment needed to manage chronic pain in a trauma-informed way for individuals of any nation . 

Chronic pain assessment is complex, based on each individual and their unique symptoms. Diagnoses criteria related to pain can be found in the 11th International Classification of Diseases (ICD11) (Treede et al., 2019). Some pain conditions, like fibromyalgia, are classified as primary pain disorders or diseases in themselves, and others are classified as secondary pain disorders which are a result of another disease, like diabetic polyneuropathy or osteoarthritis (Treede et al., 2019).

Key Instruments for Assessing Chronic Pain for Trauma-Informed Treatment Providers:

• Pain Catastrophizing Scale

A psychological assessment tool commonly used in the assessment of chronic pain measures catastrophizing thoughts that patients have regarding their pain. Catastrophizing thoughts are among the most important correlates of chronic pain intensity and pain-related disability because they can magnify the threat and interpretation of pain (Quartana et al., 2009). Examples of questions from this instrument include, "I worry all the time about whether the pain will end," and "There's nothing I can do to reduce the intensity of the pain." The Pain Catastrophizing Scale is widely used and is available in the public domain.

• International Trauma Questionnaire

To improve long-term treatment outcomes, it may be helpful to identify and address issues underlying the pain.  If this in not done, patients may continue to experience chronic pain. The International Trauma Questionnaire (ITQ) (Cloitre et al., 2018) was recently developed and could serve as a first step towards identifying trauma in chronic pain assessment. This instrument asks questions that focus on the core features of Post-Traumatic Stress Disorder (PTSD) and Complex Post-Traumatic Stress Disorder (CPTSD). The ITQ is freely available in the public domain.

Chronic Pain Risk Factors:

There is strong evidence that Post-Traumatic Stress Disorder (PTSD) and chronic pain have interdependent symptoms (Brennstuhl et al., 2015). There is also a strong link between early-life trauma and chronic pain development (Bussieres et al., 2023; Karimov-Zwienenberg et al., 2024). Reviewing this brief video about Adverse Childhood Experiences (ACEs) may be helpful to creating a comprehensive chronic pain assessment and treatment plan for your patients. 

Chronic Pain Resilience Factors:

Assessment and diagnosis of chronic pain frequently centers on symptoms of pain and other associated negative indicators, like poor sleep quality and deterioration of activities of daily living (ADLs). One of the principles of trauma-informed care is empowerment, which involves the recognition of strengths and skills that build a sense of hope towards the future (Institute on Trauma and Trauma-Informed Care, 2021). Resilience is a skill related to how one reacts to traumatic experiences and may even lead to posttraumatic growth. Posttraumatic growth is positive psychological changes that may result from persevering through highly stressful and challenging life events (Infurna & Jayawickreme, 2019). By measuring resilience factors, providers can identify and build on skills that patients already possess when developing treatment plans.

• Connor-Davidson Resilience Scale (CD-RISC)

This assessment tool contains 25 items on 0-4 Likert scales (Buckingham & Richardson, 2021). It measures resilience or how well one is equipped to bounce back after stressful events, tragedy, or trauma. Scores range from 0 to 100 with higher scores indicating greater resilience.  To obtain an official copy of the instrument, reach out to the authors at https://www.connordavidson-resiliencescale.com/ 

Recognize and Address Health Disparities in Assessment & Treatment

Chronic pain is experienced at higher rates among older adults, females, U.S. Veterans, adults living in poverty, those residing in rural areas and those with public health insurance (Rikard, et al, 2023). In addition, health disparities exist in the assessment and treatment of pain in marginalized communities. For example, Black, Indigenous, and people of color (BIPOC) are consistently rated by providers as having less pain than White individuals (Anderson et al., 2009). This underassessment of pain can lead to inadequate pain care, fewer medications prescribed to relieve pain, and fewer referrals for specialty care (Overstreet et al., 2023). In addition, BIPOC individuals are exposed to psychosocial stressors that can influence the biological systems that modulate pain (Overstreet et al., 2023). Additionally, lesbian, gay, bisexual, transgender, and queer (LGBTQ) people endure elevated levels of institutionalized prejudice, social stress and exclusion, hatred and violence that contribute to increased diagnoses of depression, anxiety and other health problems that contribute to chronic pain (Abd-Elsayed et al., 2021). 

The experience of pain by patients/clients is multifaceted and involves a wide range of factors. When diagnosing and creating a treatment plan for chronic pain patients, it is important to recognize and provide resources to address the following psychosocial stressors that place an additional burden on racial and sexual minority populations:

• perceived injustice

• discrimination

• race-based traumatic stress

• social stress and exclusion

• threats or instances of hatred and violence

Referral to peer support programs facilitated and attended by participants from minority groups may build trust and increase the effectiveness of treatment outcomes.  Policies and programs that address primary injury prevention, improved access to affordable, culturally responsive health care, and more effective pain management therapies may also alleviate the burden of chronic pain (Rikard et al., 2023). Patients in underserved groups may also need financial support, health insurance, or mental health counseling to support their chronic pain treatment. 

Take time to locate these resources for your patients/clients or contact a local social worker to assist you. 

[There are links in the resource section of this website for financial and health insurance resources.]