I once cared for a 23-year-old African American woman with hemoglobin SC. She was six-months postpartum and was admitted to the hospital for an acute vaso-occlusive pain event. She reported always being in pain and taking opioids daily. After the 15th consecutive admission within a year, she presented to a clinic appointment reporting chest pain with a large upper lip abrasion. A chest radiograph revealed a healing ninth rib fracture and dislocated implanted port catheter with the distal fragment in right atrium. Her significant other had been using her as a “punching bag” for many months.
Trauma is an individual’s unique psychological, emotional, or physiological response to an event or series of events that are deeply distressing or disturbing enough to overwhelm the ability to integrate his/her emotional experiences.1 Interpersonal trauma (IPT) is strongly associated with somatic symptoms such as chronic pain (CP).2 Pain, conversely, is a private mental experience contextualized by an individual’s attempt to achieve coherence, control, and protection over their neurobiological and psychological systems after experiencing trauma or injury. When this attempt at coherence and control breaks down, as in the case of IPT, the individual may experience a pain response. There is a strong link between opioid misuse and a history of IPT, and past traumatic painful experiences are associated with ongoing chronic disability.
Sickle cell disease (SCD) is an inherited condition characterized by recurrent acute painful episodes caused by vaso-occlusion of blood flow to various organs and tissues. While acute pain is characteristic, more than half of adults with SCD develop CP with an unclear etiology believed to be partly due to alterations in pain processing. Treatment of CP with opioids has yielded unsatisfactory results, with increased suffering, morbidity, and mortality prompting increased interest in alternate effective strategies; however, the evidence for these is lacking. Clinicians and researchers alike have been unable to fully explain the preponderance of CP and psychological distress in SCD by the biology of the disease alone. Furthermore, most individuals with SCD in the United States are of African or Hispanic heritage and are also disproportionately over-represented among persons with a history of IPT.
It makes sense to explore the role of trauma in the etiology of CP in SCD, particularly as evidence-based interventions such as trauma-informed care may ameliorate its negative consequences. The relationship between depression, anxiety, CP, and prescription opioid use has not been fully explored in adults with SCD despite the clear link between these medical problems and exposure to IPT.
Dr. Julian D. Ford and colleagues conducted an elegant retrospective case control study of 50 consecutive adults with SCD to determine the relationship between exposure to IPT, CP, and opioid use. The a priori hypothesis was that there will be an association between the number of types of IPT exposure and the likelihood of both CP and daily opioid use in this population. They also hypothesized a similar association between the number and types of IPT exposure and the severity of depression and anxiety symptoms experienced. Lastly, they proposed that the relationship between the number of types of IPT exposure and CP and opioid use was expected to be observed independent of the effect of the severity of depression and anxiety symptoms.
All participants were administered standardized screening tools including the 18-item Traumatic Events Screening Inventory (TESI) to assess trauma exposure history throughout a lifetime, the nine-item Patient Health Questionnaire (PHQ-9) to identify patients meeting diagnostic criteria for major depression, and the 20-item Zung Anxiety Scale to assess self-report of anxiety symptoms. The presence of CP was elicited by response to the single question inquiring about the presence of moderate to severe pain on more than 50 percent of days in the past six months. Additional information on participant demographics and opioid use was abstracted from the medical records.
While most individuals in the sample reported at least one past nonviolent traumatic experience, 68 percent reported some form of past interpersonal violence and were on average 10 years older than those who did not report such a history. Roughly two-thirds of participants also reported having CP and daily opioid use. On average, each individual experienced approximately 2.76 (standard deviation, 1.63) types of interpersonal violence exposure such as physical or sexual assault; emotional abuse; childhood physical, sexual, or emotional abuse; or witnessing family or community violence. As predicted, interpersonal violence exposure correlated positively with reports of chronic pain and daily opioid use, and with a higher score for depression and anxiety symptoms. Additionally, interpersonal violence exposure increased the odds of having chronic pain nearly fivefold, and the odds of daily opiate use by more than five times. However, contrary to predictions, depression and anxiety symptoms were not significantly correlated with chronic pain or daily opioid use. Participants with interpersonal violence exposure experienced higher mean levels of depression symptoms (by 125%) compared to a 25 percent increase in anxiety symptoms.
It was surprising to find only one other report in the literature by the same group that suggested a correlation between a history of trauma and CP in SCD. In this study, embedding a licensed clinical social worker within the SCD clinic revealed that 22 (69%) of 71 patients screened self-disclosed at least one traumatic experience with a statistically significant relationship between CP and a history of trauma (p=0.001).3 While clinicians everywhere attest to the importance of identifying social determinants that pose barriers to optimal health and health care, it is a wonder that more astute investigation into the role of historical trauma of various types in the CP experience of SCD has not been widely adopted.
The study by Dr. Ford and colleagues reveals that adults with SCD experience multiple events of trauma in addition to multiple types of trauma, with one in three experiencing sexual abuse or assault. The cumulative impact of this polyvictimization can erode resilience and increase risk of physical, medical, and psychological problems.
There are some limitations to this study including its retrospective sequential sampling design, which may limit its broad generalization. Formal screening for post-traumatic stress disorder was not specifically measured, and authors were unable to deduce the sequence of psychological antecedents to CP and daily opioid use. We would benefit from future prospective, randomized studies that specifically address these barriers and elucidate the proposed sequence of events that lead to CP and ultimately daily opioid use.
The high rates of reported exposure to interpersonal violence in this SCD sample, including nearly one-third of the participants reporting past exposure to sexual abuse, underscore the need for an intentional and targeted multidisciplinary approach to both the medical and psychological needs of this vulnerable population. Regarding the patient described above who had experienced repeated interpersonal violence, she taught me to look deeper to uncover other potential etiologies for recurrent acute pain and CP in SCD – and hopefully be more sensitive to the recurrent trauma that amplifies pain for many of our patients.
Ms. Chen and Dr. Osunkwo indicated no relevant conflicts of interest.