Toxic Stress Can Lead to Chronic Illness

By Dr. Lawson Wulsin  

COVID-19 taught most people that the line between tolerable and toxic stress – defined as persistent demands that lead to disease – varies widely. But some people will age faster and die younger from toxic stressors than others.

So how much stress is too much, and what can you do about it?

I’m a psychiatrist specializing in psychosomatic medicine, which is the study and treatment of people who have physical and mental illnesses. My research is focused on people who have psychological conditions and medical illnesses as well as those whose stress exacerbates their health issues.

I’ve spent my career studying mind-body questions and training physicians to treat mental illness in primary care settings. My forthcoming book is titled “Toxic Stress: How Stress is Killing Us and What We Can Do About It.”

A 2023 study of stress and aging over the life span – one of the first studies to confirm this piece of common wisdom – found that four measures of stress all speed up the pace of biological aging in midlife. It also found that persistent high stress ages people in a comparable way to the effects of smoking and low socioeconomic status, two well-established risk factors for accelerated aging.

Good Stress vs. Toxic Stress

Good stress – a demand or challenge you readily cope with – is good for your health. In fact, the rhythm of these daily challenges, including feeding yourself, cleaning up messes, communicating with one another and carrying out your job, helps to regulate your stress response system and keep you fit.

Toxic stress, on the other hand, wears down your stress response system in ways that have lasting effects, as psychiatrist and trauma expert Bessel van der Kolk explains in his bestselling book “The Body Keeps the Score.”

The earliest effects of toxic stress are often persistent symptoms such as headache, fatigue or abdominal pain that interfere with overall functioning. After months of initial symptoms, a full-blown illness with a life of its own – such as migraine headaches, asthma, diabetes or ulcerative colitis – may surface.

When we are healthy, our stress response systems are like an orchestra of organs that miraculously tune themselves and play in unison without our conscious effort – a process called self-regulation. But when we are sick, some parts of this orchestra struggle to regulate themselves, which causes a cascade of stress-related dysregulation that contributes to other conditions.

For instance, in the case of diabetes, the hormonal system struggles to regulate sugar. With obesity, the metabolic system has a difficult time regulating energy intake and consumption. With depression, the central nervous system develops an imbalance in its circuits and neurotransmitters that makes it difficult to regulate mood, thoughts and behaviors.

Though stress neuroscience in recent years has given researchers like me new ways to measure and understand stress, you may have noticed that in your doctor’s office, the management of stress isn’t typically part of your treatment plan.

Most doctors don’t assess the contribution of stress to a patient’s common chronic diseases such as diabetes, heart disease and obesity, partly because stress is complicated to measure and partly because it is difficult to treat. In general, doctors don’t treat what they can’t measure.

1 in 5 Americans Live with Toxic Stress

Stress neuroscience and epidemiology have also taught researchers recently that the chances of developing serious mental and physical illnesses in midlife rise dramatically when people are exposed to trauma or adverse events, especially during vulnerable periods such as childhood.

Over the past 40 years in the U.S., the alarming rise in rates of diabetes, obesity, depression, PTSD, suicide and addictions points to one contributing factor that these different illnesses share: toxic stress.

Toxic stress increases the risk for the onset, progression, complications or early death from these illnesses.

Because the definition of toxic stress varies from one person to another, it’s hard to know how many people struggle with it. One starting point is the fact that about 16% of adults report having been exposed to four or more adverse events in childhood. This is the threshold for higher risk for illnesses in adulthood.

Research dating back to before the COVID-19 pandemic also shows that about 19% of adults in the U.S. have four or more chronic illnesses. If you have even one chronic illness, you can imagine how stressful four must be.

And about 12% of the U.S. population lives in poverty, the epitome of a life in which demands exceed resources every day. For instance, if a person doesn’t know how they will get to work each day, or doesn’t have a way to fix a leaking water pipe or resolve a conflict with their partner, their stress response system can never rest. One or any combination of threats may keep them on high alert or shut them down in a way that prevents them from trying to cope at all.

Add to these overlapping groups all those who struggle with harassing relationships, homelessness, captivity, severe loneliness, living in high-crime neighborhoods or working in or around noise or air pollution. It seems conservative to estimate that about 20% of people in the U.S. live with the effects of toxic stress.

Recognizing and Managing Stress

The first step to managing stress is to recognize it and talk to your primary care clinician about it. The clinician may do an assessment involving a self-reported measure of stress.

The next step is treatment. Research shows that it is possible to retrain a dysregulated stress response system. This approach, called “lifestyle medicine,” focuses on improving health outcomes through changing high-risk health behaviors and adopting daily habits that help the stress response system self-regulate.

Adopting these lifestyle changes is not quick or easy, but it works.

The National Diabetes Prevention Program, the Ornish “UnDo” heart disease program and the U.S. Department of Veterans Affairs PTSD program, for example, all achieve a slowing or reversal of stress-related chronic conditions through weekly support groups and guided daily practice over six to nine months. These programs help teach people how to practice personal regimens of stress management, diet and exercise in ways that build and sustain their new habits.

There is now strong evidence that it is possible to treat toxic stress in ways that improve health outcomes for people with stress-related conditions. The next steps include finding ways to expand the recognition of toxic stress and, for those affected, to expand access to these new and effective approaches to treatment.

Lawson R. Wulsin, MD, is a Professor of Psychiatry and Family Medicine at University of Cincinnati. He also practices psychiatry in primary care settings, specializing in psychosomatic medicine.

This article originally appeared in The Conversation and is republished with permission.

The Trauma-Pain Connection Explored at For Grace’s Women In Pain Conference

By Cynthia Toussaint, PNN Columnist

Four years ago, I was wheeled into my pain management doctor’s office, not to talk about Complex Regional Pain Syndrome, but rather my newest and most dire diagnosis: Triple Negative Breast Cancer (TNBC). I knew I didn’t have a good chance at survival, but didn’t know why I had the most rare and aggressive form of the disease.

I asked Dr. Richeimer why this cancer would appear now, as my oncologist and genetic counselor were baffled. Without pause, he answered, “Cynthia, you’ve been trying to fix your dysfunctional family your entire life. The toll that’s taken on your body is why you have TNBC.”     

Thus began my trauma-informed journey.

I was already aware and intrigued that many researchers were identifying trauma as the main driver for chronic pain. Despite this, I passed on having trauma release treatment because I’d heard it could be triggering. But now that I was fighting for my very existence, I was all in.

In the midst of full-dose chemotherapy, no less, I took to reading and researching everything I could get my hands on about childhood trauma and how it leads to adult on-set chronic illness. On the trauma release front, I jumped into talk therapy and EMDR (Eye Movement Desensitization and Reprocessing), complimenting those treatments with big doses of music, writing, meditation, inner child work and ancestral healing.

I also started focusing my “For Grace” work on the trauma-pain connection. This included interviewing a boatload of experts and survivors as well as collecting and spotlighting lived experiences, all culminating in Friday’s 11th Annual Women In Pain Conference – “The Trauma-Pain Connection: A Path to Recovery and Growth.”

Radene Marie Cook

You see, I now understand that my 40+ years of pain and chronic illness are the result of serious and sustained trauma, suffered primarily during my early development. In short, trauma is not a piece of my chronic pain puzzle. It’s the whole puzzle.

I want to share all that I’ve learned with women in pain, during a day that I hope will launch your own trauma-informed journey, one that I promise will bring you healing and growth.

To start you on your way, our five-hour online seminar, beginning at 10am PT on November 17, will be broken into three sessions led by world-class speakers, panelists and breakout leaders, all who have survived trauma and volunteered their time.

• Session One will examine what trauma is, how it can be passed down generationally, and how it’s a driver for chronic pain.

• Session Two will highlight trauma release and the myriad of effective techniques, methods and strategies used to achieve that end, both practitioner-led and solo.

• Session Three will celebrate what I call the silver-lining of trauma, Post-Traumatic Growth, a process that paves the way for recovery, deeper meaning, new-found strength, and helping others.            

Themed throughout the conference will be the beauty, struggle and resilience of the Native American people. Because I’ve read time and again that this community suffers greatly from generational trauma, the day will be infused with stunning music and photography, compliments of one of our main speakers, Dr. Noshene Ranjbar, a leader of indigenous studies at the University of Arizona. It touched my heart that two of her students put in hours to gift us these sacred elements.

Perhaps the most poignant part of our event will be the extraordinary gift of intensely personal video vignettes sprinkled in from people who’ve traveled the dimly-lit trauma-pain tunnel, found healing through release, and moved on to the light of growth. The courage of these generous souls is a triumph of the spirit.      

This conference was For Grace’s heaviest lift to date. Coming from a chronic pain background, I didn’t know anyone in trauma and it took several years to build a critical mass of relationships. Also, because this conference is the first of its kind, our planning committee had to build it from whole cloth. Perhaps most difficult and most satisfying, was getting people to talk publicly about their deepest, darkest experiences. I know the challenge well because when I recorded my story, I was brought to tears more than once.

It was worth the sweat and tears because we struck gold.

This is the most important topic For Grace has covered. I’m certain that if you do the work, it will be a catalyst for healing and renewed wholeness. Remembering, facing and addressing our past traumas is our best hope to overcome the scourge of chronic pain.

Don’t wait to get a deadly disease to learn, to explore, to discover trauma’s place in your life. You’re braver than you think - and when you use that courage, you’ll be on the path to finding the last piece to your pain puzzle.

You can watch the conference for free at this link.

Cynthia Toussaint is the founder and spokesperson at For Grace, a non-profit dedicated to bettering the lives of women in pain. She has lived with Complex Regional Pain Syndrome (CRPS) and 19 co-morbidities for four decades, and has been battling cancer since 2020. Cynthia is the author of “Battle for Grace: A Memoir of Pain, Redemption and Impossible Love.”

Acetaminophen Better Than NSAIDs for Acute Trauma Pain

By Pat Anson, PNN Editor

Acetaminophen (Tylenol) is superior to non-steroidal anti-inflammatory drugs (NSAIDs) in treating acute pain in patients recovering from arm and leg trauma, according to new research published in the journal Academic Emergency Medicine. It’s the latest in a string of studies that recommend the use of non-opioid pain relievers for acute pain after discharge from a hospital.

The research is based on a study of 1,500 adults in the North African nation of Tunisia, nearly half of whom had bone fractures. Upon discharge from a hospital emergency department, the patients received either acetaminophen, a high-dose NSAID, or a combination of the two. Acetaminophen is commonly called paracetamol outside the United States.

After seven days, researchers found that nearly two-thirds (61.8%) of patients receiving paracetamol alone were “satisfied” or “very satisfied” with their pain relief. Only 11.4% required another oral pain reliever. The other two groups had similar satisfaction scores, but had lower rates of medication adherence. Side-effects such as vomiting and gastrointestinal pain were also more common in patients who received NSAIDs.  

“This study found that the combination of a high‐dose NSAID with paracetamol does not increase the analgesic effect compared to paracetamol alone. We also found that paracetamol alone is superior to high‐dose NSAID alone for post-traumatic extremity pain,” wrote lead author Mohamed Amine Msolli, MD, an emergency room physician at Fattouma Bourguiba University Hospital in Tunisia.

“Taking into account its superior efficacy and tolerability, paracetamol appears to be the most suitable first‐line therapy for managing mild to moderate posttraumatic extremity pain after discharge from the ED.”

Opioid analgesics are not widely available in Tunisia and most other Middle East countries, and were not included in the study. Nevertheless, the study findings are being cited as evidence that paracetamol is superior to both NSAIDs and opioids in treating acute trauma pain.

“The surprising efficacy of paracetamol over an NSAID, as shown by a 6.4% lower need for additional oral analgesics, may impact prescribing practices,” Andrew Chang, MD, a professor of emergency medicine at Albany Medical Center, said in a statement.

“Many ED patients who have a contraindication to NSAIDs but require analgesics upon ED discharge might be prescribed an opioid. Given the ongoing opioid epidemic, this study lends evidence to support the use of acetaminophen alone in such patients."

But the risk of long-term opioid use after an emergency room visit is actually quite low. A large 2017 study by the Mayo Clinic found that only about one percent of emergency room patients given an opioid prescription progressed to long term use.

Acetaminophen also has risks that are not acknowledged in the Tunisia study. Excessive use of acetaminophen can lead to liver, kidney, heart and blood pressure problems. Acetaminophen overdoses are involved in about 500 deaths and over 50,000 emergency room visits in the U.S. annually.

Finding Grace in Family-Induced Pain and Trauma

By Cynthia Toussaint, PNN Columnist

About 20 years ago, my mother called to share what felt like a disorientating thought.

“Cynthia, of all the members of our family, you’re the together one, the capable one and the successful one,” she said.

Though flattered, my thinking was, “How can that be? I’m the daughter with all the problems. The pain, the wheelchair, the one left childless without her show-biz career.”

I’m guessing now that my mother was intuitively letting me in on a secret -- a generations-long family secret. By telling me I had the right stuff, Mom was revealing that I’d broken the trauma cycle. She potently advised that I never let my family members hold me back, to “never not succeed because of them.”

That day I realized I’d done something exceptional, but I didn’t fully understand what it was. You’d think 38 years of chronic pain would have opened my eyes, but it took a cancer crisis for me to deeply examine what my mother was shedding light on.

I come from a profoundly dysfunctional family (domestic violence, divorce, mental illness, suicide, alcoholism, etc.), one so traumatizing my doctor believes that the toll of trying to fix my family, along with the inflammation of CRPS, was what gave me cancer. To have a chance at survival, I had to walk away from the toxic members of my family, which was the hardest and best decision of my life.

Unfortunately though, walking away might not be enough. Now that I’m in remission, I’m concerned that my inability to unlock from my frequent harmful thoughts about the trauma of past assaults will bring on a swift and more aggressive cancer recurrence.

Trauma Release

Enter EMDR (Eye Movement Desensitization & Repossessing). For the uninitiated, EMDR is a psychotherapy treatment designed to alleviate the distress associated with traumatic memories. For years studies have shown that people with serious adult-onset illnesses – including high-impact pain and cancer – experienced many adverse childhood events (ACE’s), as I did.

I’ve long considered doing EMDR for trauma release, but feared stirring up the debilitating depression that my family often sparks. I won’t lie to you. My EMDR plunge has been god-awful, as it’s brought on a ton of expected grieving and even rage. That being said, I’m sticking with it - and astonished by EMDR’s effectiveness and the insight it evokes.

My phenomenal practitioner, Kathy, has pointed out two major, life changing themes. The first, that family trauma is handed down over many generations, adversely changing our gene expression through what’s termed epigenetics. Sadly, I was born into the thick of this ever-rolling harm.

When I was seven, my dad jumped off a bridge due to severe mental illness. Much dysfunction led to his suicide, but this was the tipping point that my family of origin never recovered from.

After sharing what limited knowledge I had of my dad’s past, Kathy quickly assessed that, like me, he had a traumatic childhood. I was stunned to learn that his parent’s alcoholism, affairs and abandonments, along with all of the denial and covering-up, deeply wounded him. That insight gifted me great empathy for the person who shattered my world.

Mom’s side of the family was equally trauma-inducing. After her parent’s ugly divorce and Grandma having my loving grandfather committed to an institution, she had my mother kidnapped. Legend has it that this broke my aunt Grace’s heart, as her agonizing death from leukemia at age 20 soon followed.

To this day, even with advanced dementia, my mother describes her own grandmother as “a witch, the most evil person I ever met.” It goes on and on.

Healing My Inner Child

I finally understand that I have a family tree evergreen with trauma, the root of all my physical and psychological illness.

The second theme Kathy put forth is that to release my trauma we have to heal my “inner child.” I now understand that even as a fetus I took in the negative chemicals and vibe of my mother’s nightmarish situation – and it’s my inner child who’s carrying the greatest injury. The work is tricky because to reach her, we must maneuver around the many protective, life-preserving mechanisms she’s used for 60 years.

With Kathy’s guidance via Zoom, I’m slowly making friends with my inner child. While I want to protect her from the knowledge of a tragic future, ultimately I have to be vulnerable enough to let her spill the repressed memories of violence and dysfunction that host the lion’s share of our trauma.

My hope is that by healing my inner child I can end the cycle of excruciating harm I endure when I think about my family’s countless trespasses. If I can get to a strong landing point of understanding and release, my depression will turn to just sadness – and from there I can move on with better wellness.  

I want to be free.        

No matter the outcome, Mom was on to something. Thankfully, I’ve cracked the family code by asking why and doing the hard work. As Kathy reminds me, I choose “to think, not drink” - and because I don’t maintain the dysfunctional status quo, I’ve “jumped out of a sinking ship.”

All this time I thought my life had been upended by pain, but I now realize it was family trauma that caused every ounce of my misfortunate.    

This insight lovingly brings me to my aunt Grace who, by breaking the family trauma cycle, saved my mother. While I never met her, I see Grace as an angel and forever feel a deep connection, so much so I named my work for her goodness.

We’ve always been compared, and I now see that our similarity extends beyond looks and personality. A quote I continue to hear in my research about generational trauma is “The first born daughter often carries what remains unresolved in the mother.”

Grace and I were the eldest daughters and gave everything to save our broken families, an impossible task.

GRACE HAeRING

It cost my dear aunt her life – and I think she’s proud watching me fight for mine.

Cynthia Toussaint is the founder and spokesperson at For Grace, a non-profit dedicated to bettering the lives of women in pain. She has lived with Complex Regional Pain Syndrome (CRPS) and 15 co-morbidities for nearly four decades, and became a cancer survivor in 2020. Cynthia is the author of “Battle for Grace: A Memoir of Pain, Redemption and Impossible Love.”

Over-the-Counter Pain Meds and Gabapentin Recommended for Trauma Patients

By Pat Anson, PNN Editor

Over-the-counter pain medications and gabapentin are the best line of treatment for trauma patients suffering from acute short-term pain, according to new study at a Texas hospital that minimizes the use of opioids.

Researchers at the Red Duke Trauma Institute at Memorial Hermann-Texas Medical Center in Houston assessed two different combinations of non-opioid pain relievers in over 1,500 patients being treated for acute trauma, such as bone fractures and head injuries.

The treatment protocol that was deemed superior included a combination of inexpensive over-the-counter drugs such as acetaminophen and naproxen, with the nerve medication gabapentin (Neurontin). Opioids such as tramadol and oxycodone were only prescribed for breakthrough pain.

"Narcotics are not the mainstay of therapy for acute pain," said lead author John Harvin, MD, a trauma surgeon at the hospital and an associate professor at The University of Texas Health Science Center at Houston. "The research shows us that seriously injured people with acute pain can effectively be treated with an opioid-minimizing strategy."

The study findings, published in the Journal of American College of Surgeons, showed that a first-line pain regimen that used acetaminophen, ketorolac, naproxen, gabapentin or lidocaine patches reduced the use of opioids without a significant difference in pain scores. Only 62 percent of the patients were discharged with an opioid prescription.

"We used a generic pain regimen that is affordable at discharge. The discharge medications acetaminophen and naproxen can be bought over the counter. The only drug that requires a prescription is gabapentin and an as-needed opioid, if prescribed," Harvin explained.

The use of gabapentin as a treatment for acute pain is controversial, because recent studies show it has no significant analgesic effect and is increasingly being abused. In 2019, the Food and Drug Administration warned that serious breathing problems can occur in patients who take gabapentin with opioids or other drugs that depress the central nervous system.

But the use of gabapentin and over-the-counter pain relievers is now the standard treatment protocol for trauma patients at Memorial Hermann-Texas Medical Center, and physicians there are working to adapt it for the treatment of acute burn pain.

"The best way to decrease someone's risk for long-term (opioid) use is to minimize their exposure during hospitalization and at discharge, and we now know there are excellent non-opioid medications available that effectively treat pain,” said Harvin. “We know that culture change will take time and effort, but we're excited to be learning how to best leverage opioid-minimizing drugs to improve care, and to offer a new model that can be adopted by any trauma center."

The risk of long-term opioid use after an emergency room visit is actually quite low. A 2017 study by the Mayo Clinic found that only about one percent of emergency room patients given an opioid prescription progressed to long term use.

"Our paper lays to rest the notion that emergency physicians are handing out opioids like candy," said lead author Molly Moore Jeffery, PhD, a Mayo Clinic researcher. “Most opioid prescriptions written in the emergency department are for shorter duration, written for lower daily doses and less likely to be for long-acting formulations."

Teaching Children How to Cope with Pain

By Dr. Lynn Webster, PNN Columnist

Summer is upon us and so is trauma season. Emergency room visits for children with traumatic injuries can double during the summer. Potential injuries range from insect and animal bites to serious bicycle and ATV injuries.

This means parents will be on the front line, triaging each event to determine which injury needs medical treatment and which requires "only" emotional support.

A mother recently asked newspaper advice columnist Amy Dickinson about the best way to handle her toddler's pain. The mother was seeking suggestions from a stranger because she disagreed with her husband’s approach. She wanted to learn the "right" way to respond to her child's injuries.

The mother said she felt the need to provide the hurt child with ice packs and hugs, regardless of the extent of the injury, because that felt nurturing and productive.

On the other hand, the father thought his wife was making too big of a deal out of their child's pain. He believed that coddling children deprived them of the opportunity to grow into self-sufficient, resilient adults.

The columnist advised the mother that "tender gestures are an important part of parenting." Show your children that you care about their pain, Dickinson suggested, but don't turn each incident into a melodrama.

The mother's question grabbed my attention, because treating a child's pain is an omnipresent issue with far-reaching implications. By the time they reach age five, children have developed the way they will address adversity for the rest of their lives. Obviously, how a parent responds to a child’s injury -- their attitudes and behaviors -- is part of the culture that helps children form that foundation.

Options in Soothing a Child’s Pain

An overly doting, anxious parent can reinforce a hyperbolic response to pain that has little to do with the actual injury. A small "ouchie" can become a catastrophic event, and that may contribute to learned anxiety and the perception of greater pain.

On the other hand, ignoring an injury can lead to more aggressive attention-seeking behavior. Children need to know that an empathetic adult cares, even if the injury is relatively minor. Feeling safe positively influences a child's experience of adversity.

Children who have the emotional and cognitive ability to understand and determine their response to an injury generally suffer less. This is self-efficacy, and it allows the child to feel in control.

It's important to help children master their response to pain in age-appropriate ways. Of course, you comfort your pre-verbal children with a calm, measured voice and attitude. When children can communicate verbally, you can begin asking them whether their injury is a big one or small one. Then ask the children how they can make themselves feel better. This is how to nurture their resilience.

Accepting Pain

Experts who study why some people seem to handle pain better than others believe that acceptance plays a major role. There are two kinds of acceptance: acceptance with resignation and acceptance with resilience. 

Acceptance with resignation, or learned helplessness, steals hope more thoroughly than pain itself can do. A resigned person feels incapable of solving the problem and simply gives up.

Acceptance with resilience, on the other hand, makes it possible for a person to reinvent himself or herself to resolve the problem.

Children must learn how to accept pain with resilience so they can quickly, and without drama, move on from it. This requires a mutually caring relationship with the parent or guardian.

Big hurts, medium hurts, and small hurts may require different treatment, but not necessarily a different emotional response. Fundamentally, children must realize that everyday hurts are problems with solutions.

I recently watched my daughter instinctively demonstrate this behavior. My granddaughter, Gracie, fell and bumped her knee. The three-year-old began to cry. My daughter then asked Gracie: “is it a "big ouchie" or a "small ouchie?"

The question redirected Gracie’s attention. To my surprise, Gracie answered in a soft and shaky voice, “a small one.” Gracie received a hug from her mom and seemed to forget about the incident.

The Goal Is a Resilient Child

Pain is part of growing up. Parents cannot prevent injuries from occurring with their children, but they can model how to accept the injury with resilience.

To paraphrase Viktor Frankl, we have the power to choose our response to adversity. Relying on ourselves gives us control over our behaviors and happiness.

When parents can model self-efficacy without dismissing a child’s fears or insecurities; the result will be a resilient child who is able to experience pain as part of life, but not mistake it for life itself. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. Lynn is a former president of the American Academy of Pain Medicine, author of the award-winning book “The Painful Truth” and co-producer of the documentary “It Hurts Until You Die.”

You can find him on Twitter: @LynnRWebsterMD.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Genetic Variation Raises Risk of Post-Traumatic Pain

By Pat Anson, Editor

If you have chronic pain because of an accident, injury or assault, it could be because you have a genetic variation that makes you more likely to develop post-traumatic pain.

That’s the key finding behind a new study published in the Journal of Neuroscience. Researchers at the University of North Carolina studied over 1,500 people who were admitted to emergency rooms for trauma after a motor vehicle collision.

In addition to genotyping the patients, the researchers assessed their distress immediately after the accident, as well as their pain and post-traumatic stress symptoms six weeks later. Participants with a particular variant in the gene FKBP5 reported more severe pain and distress at follow up.

FKBP5 is a critical regulator of the stress response and affects how we respond to environmental stimuli. Previous studies have shown that certain variants of the gene play a role in the development of neuropsychiatric disorders such as post-traumatic stress disorder, depression, suicide risk and aggressive behavior.

UNC School of Medicine researchers were the first to show an association between FKBP5 and post-traumatic chronic pain. A 2013 study found that people with a particular variation of the gene are likely to experience more pain after exposure to trauma compared to people who don't have the variant.

The new study by the same research group builds on that discovery by showing that the variation inhibits the regulation of cortisol, a stress hormone that sensitizes peripheral nerves. People with high levels of cortisol are likely to experience more pain.

"In our current study, we showed that the reason this variant affects chronic pain outcomes is because it alters the ability of FKBP5 to be regulated by a microRNA called miR-320a," said lead author Sarah Linnstaedt, PhD, a professor of anesthesiology and an investigator in the UNC Institute for Trauma Recovery.

"In other words, it does not negatively regulate FKBP5, thus causing FKBP5 to be over-expressed. High levels of FKBP5 can be detrimental because it alters natural feedback mechanisms that control circulating cortisol levels."

Linnstaedt says the findings suggest there could be new therapeutic approaches to treating traumatic pain, such as medication that inhibits the activity of FKBP5 or gene editing that alters the variation.

Funding for the UNC study was provided by the National Institute of Arthritis, Musculoskeletal, and Skin Diseases, The Mayday Fund, a Future Leaders in Pain Grant from The American Pain Society, and the National Human Genome Research Institute.

The Link Between Trauma and Chronic Pain

Ann Marie Gaudon, Columnist

It has long been accepted in my field that chronic pain is a frequent outcome of trauma. There is extensive evidence to suggest that people suffering from post-traumatic stress disorder (PTSD) report chronic pain with striking frequency regardless of the nature of the traumatic experience. You don’t need to have been diagnosed with PTSD to be negatively and chronically affected by trauma.

One strong and commonly referred to theoretical model explaining the connection between trauma and chronic pain is known as the Mutual Maintenance Model. A person may respond to reminders of trauma through stress response, which may include avoidant coping (trying to avoid your distress by zoning out with video games or drinking to numb yourself), fatigue and lethargy associated with depression, pain perception elevated by anxiety, and intrusive memories of the trauma itself.

These considerable mental demands limit one’s capacity to control or decrease their physical pain and have the opposite effect of exacerbating and maintaining pain. To put it simply, experiencing pain prompts memories of the trauma, and memories of the trauma prompt experiences of pain.

The end result is that a person is trapped in a vicious cycle whereby the symptoms of trauma and chronic pain interact to produce self-perpetuating psychological distress and physical pain.

A second model, called the Shared Vulnerability Model, suggests that the interaction of trauma, psychological vulnerability (anxiety, loss of control over thoughts and feelings), and a lowered physiological threshold for alarm reactions all influence negative emotional responses, resulting in the development of PTSD and the co-occurrence of chronic pain.

This chronic arousal of the nervous system may be responsible for the symptoms of both PTSD and chronic pain. There is research which suggests that chronic pain and PTSD are not necessarily distinct from each other, but rather connected and overlapping. The fact that sympathetic activity (the gas pedal to your distress) is increased, and parasympathetic activity (the brake pedal to your distress) is decreased, both in general and in response to trauma-related stimuli, is one of the most robust findings within the PTSD literature.

Disastrous events can strike any of us, at any time in life, and no one is immune. Some events are relational such as a school shooting or a rape, while others are natural disasters like earthquakes or floods. After any distressing or life-threatening event, psychological trauma may set in. One may go on to develop extreme anxiety, depression, anger, or PTSD and may have ongoing problems with sleep, physical pain and even relationships.

Healthy ways of coping include getting support, avoiding alcohol and drugs, seeing loved ones, exercising, enhancing sleep habits, and other methods of self-care. Certainly not everyone with chronic pain has experienced trauma and vice versa. However, there is extensive research to show that PTSD and chronic pain are intimately connected.

Seek an experienced trauma therapist if you feel you are not coping well. Trauma therapy is highly specialized, takes place in healing stages at your pace, and works to re-wire what’s become maladaptive in your brain by laying down new and healthier neural pathways. Click here to see a YouTube video that explains that process.

The work will be hard and challenging, but the good news is that many people heal from trauma and go on to live rich and rewarding lives. Some offer inspiration to others who have also endured life-altering negative experiences.

People become sick and pained, and people also heal. Suffering can skyrocket, and suffering can also take a nosedive. You do the work as if your life depended on it, because experience tells us it often does.

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for 33 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Why Human Suffering Should Bother You

By Margaret Aranda, MD, Columnist

Patients go to doctors when they have pain and doctors can give them opioid medication to relieve that pain. That should not bother you, because it is a decision made between the physician and the patient.

No doctor has the right to strip a patient of dignity by minimizing or downplaying their pain. We can't become indifferent to the denial of pain, because pain is real. Pain hurts.

A recent column in The Conversation by Dr. Andrew Kolodny bothers me because of two sentences:

"They (opioids) are also helpful when used for a couple of days after major surgery or a serious accident. Unfortunately, the bulk of the opioid prescriptions in the U.S. are for common conditions, like back pain," wrote Kolodny, who is a psychiatrist, not a pain management doctor.

Let’s look at the different ways that Dr. Kolodny is minimizing pain:

Postoperative Pain: A large study recently found that long-term opioid use after surgery is rare. Yet some patients are now being denied opioids after major surgery because of fears they might become addicted. Patients should ask questions about how their postop pain will be treated before surgery and get another surgeon if no opioids are to be offered. Patients do not have to allow a surgeon to minimize their pain.

Trauma:  Serious accidents cause severe trauma. Severe trauma can take months, years or decades to alleviate, leaving patients with chronic pain through no fault of their own. Many are burned, disfigured, scarred, disabled, have a pain syndrome, use a wheelchair, and go on disability or Medicare. 

We cannot allow ourselves to minimize any degree of pain that leads to suffering, less zest for living, and lower quality of life.

Back Pain: Millions of people have low back pain and the added mental health stress that often comes with it, which costs the U.S. economy $100-200 billion in lost workdays and productivity annually. Don't minimize their pain, either!

Treating Pain:  No doctor who witnesses a patient suffering in an emergency room, operating room or intensive care unit should minimize their pain. I've worked in all three as a board certified anesthesiologist and intensive care unit doctor, and am a witness to how an Ivy League university, private clinic, free clinic, county hospital, women's hospital, and Veterans Administration hospitals treat severe pain that may never, ever get better. I'm also a witness as a rebel patient who was offered acetaminophen and ibuprofen for my postop pain.

Physician judgment: Many patients with chronic pain are disabled and legally protected from discrimination. They have failed other therapies and deserve opioid medication for quality of life. They are not bad people, and they have not done anything wrong. Nevertheless, they are often treated like "today's lepers," as Dr. Thomas Kline says. So don't minimize their pain.

Patient Perspective: While on opioids, many chronic pain patients can get out of bed, work a job and keep their families together. They aren't addicts, do not sell their pills, steal money from others to get more, are not estranged from their families for a “drug problem,” and have never had naloxone used on them.

If they are lucky enough to still get an opioid prescription, many are being treated like criminals with rigors that do not stand on evidence-based medicine. They are forced to sign pain contracts, undergo drug tests, and then deal with pharmacy restrictions. Even with pills in hand, it is often not enough. There is an epidemic of undertreated chronic pain, so don't minimize the patient.

Patient Outcome: Unilateral withdrawal or sudden tapering of opioid therapy leads to patient suffering, sleep loss and decreased quality of life. A patient can become bedridden, depressed, and some have committed suicide! It all starts with non-validation of pain.

The Doctor's Oath

No doctor has a right to label, stigmatize, minimize or abandon a patient, much less a patient in pain. To stay clear of this, every medical student is taught to preserve patient dignity and autonomy. Nevertheless, patients are being withdrawn from opioid therapy all over America today, and it is being done by doctors who minimize pain, break the physician-patient bond, and dishonor the Hippocratic Oath.

We've known for over 150 years that doctors commit suicide twice as often as other professions. I think the current situation truly bothers most compassionate doctors, who will be struggling even more in the years to come with physician burnout syndrome. We could see even more suicides by medical students and physicians. 

Doctors are supposed to save lives, and it is just as important to save quality of life. Without quality of life, it is entirely human to have moments when death seems to be the only option out of a life of suffering. Doctors need to keep patients away from having suicidal thoughts, especially if their illness is something that modern medicine can take care of and is severely undertreated, like pain.

It is important to the public in general, and to patients who are disabled in particular, that everyone understands that there are doctors who work night and day for patients who are in pain. We are passionate about it because doctors are healers and no one is ever going to change the meaning of being a real doctor.

I was reminded of this recently when I saw the revised version of the Hippocratic Oath by the World Medical Association. Two important sentences depict how doctors should be responding to pain and their patients:

“I WILL RESPECT the autonomy and dignity of my patient."

"I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat."

When we minimize pain, we minimize the patient. When we minimize the patient, the patient dies.

So go ahead and let human suffering bother you. It proves that you still have empathy and compassion. 

Dr. Margaret Aranda is a Stanford and Keck USC alumni in anesthesiology and critical care. She has dysautonomia and postural orthostatic tachycardia syndrome (POTS) after a car accident left her with traumatic brain injuries that changed her path in life to patient advocacy.

Margaret is a board member of the Invisible Disabilities Association. She has authored six books, the most recent is The Rebel Patient: Fight for Your Diagnosis. You can follow Margaret’s expert social media advice on Twitter, Google +, Blogspot, Wordpress. and LinkedIn.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.