Accounting for the interplay of interpersonal and structural trauma in the treatment of chronic non-cancer pain, opioid use disorder, and mental health in urban safety-net primary care clinics

Stacy Castellanos; Alexis Cooke; Sedona Koenders; Neena Joshi; Christine Miaskowski; Margot Kushel; Kelly Ray Knight

doi:10.1016/j.ssmmh.2023.100243

Accounting for the interplay of interpersonal and structural trauma in the treatment of chronic non-cancer pain, opioid use disorder, and mental health in urban safety-net primary care clinics

SSM Ment Health. 2023 Nov 15:4:100243. doi: 10.1016/j.ssmmh.2023.100243. Epub 2023 Jul 7.

Authors

Stacy Castellanos¹, Alexis Cooke², Sedona Koenders¹, Neena Joshi¹, Christine Miaskowski³, Margot Kushel⁴, Kelly Ray Knight¹

Affiliations

¹ Department of Humanities and Social Sciences, School of Medicine, University of California - San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA, 94143-0850, United States.
² Department of Community Health Systems, School of Nursing, University of California - San Francisco, 2 Koret Way, N505, San Francisco, CA, 94143-0608, United States.
³ Department of Physiological Nursing, School of Nursing, University of California - San Francisco, 2 Koret Way, 631, San Francisco, CA, 94143-0610, United States.
⁴ Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, Department of Medicine, School of Medicine, University of California -San Francisco, UCSF Box 1339, San Francisco, CA, 94143-0608, United States.

Abstract

While the epidemiological literature recognizes associations between chronic non-cancer pain (CNCP), opioid use disorder (OUD), and interpersonal trauma stemming from physical, emotional, sexual abuse or neglect, the complex etiologies and interplay between interpersonal and structural traumas in CNCP populations are underexamined. Research has documented the relationship between experiencing multiple adverse childhood experiences (ACEs) and the likelihood of developing an OUD as an adult. However, the ACEs framework is criticized for failing to name the social and structural contexts that shape ACE vulnerabilities in families. Social scientific theory and ethnographic methods offer useful approaches to explore how interpersonally- and structurally-produced traumas inform the experiences of co-occurring CNCP, substance use, and mental health. We report findings from a qualitative and ethnographic longitudinal cohort study of patients with CNCP (n = 48) who received care in safety-net settings and their primary care providers (n = 23). We conducted semi-structured interviews and clinical and home-based participant observation from 2018 to 2020. Here we focus our analyses on how patients and providers explained and situated the role of patient trauma in the larger clinical context of reductions in opioid prescribing to highlight the political landscape of the United States opioid overdose crisis and its impact on clinical interactions. Findings reveal the disproportionate burden structurally-produced, racialized trauma places on CNCP, substance use and mental health symptoms that shapes patients' embodied experiences of pain and substance use, as well as their emotional experiences with their providers. Experiences of trauma impacted clinical care trajectories, yet providers and patients expressed limited options for redress. We argue for an adaptation of trauma-informed care approaches that contextualize the structural determinants of trauma and their interplay with interpersonal experiences to improve clinical care outcomes.

Keywords: Chronic non-cancer pain; Opioids; Primary care; Safety-net; Structural factors; Trauma.

Grants and funding

R01 DA043631/DA/NIDA NIH HHS/United States