Tackling the complexities of chronic pain and mental health
A new CAMH study is improving care by unraveling and responding to the complexities of chronic pain in women with mental health and substance use issues.
Cheryl Rolin-Gilman, Advanced Practice Clinical Leader in Nursing in CAMH’s Acute Care Program, led the study, published in June 2017 in the journal Pain Management Nursing.
She and other health-care professionals providing care in a women’s inpatient unit at CAMH had observed that many clients experienced chronic physical pain. “Working on the unit, I noticed that health-care professionals were struggling with how to effectively help our clients with chronic pain who have mental health and substance use issues, in addition to having experienced trauma in their lives,” says Rolin-Gilman. These complexities pointed to the need to better understand clients’ experiences, she says.
Another driver for the study was an opportunity that arose as CAMH sought to achieve designation as a Best Practice Spotlight Organization (BPSO) by the Registered Nurses Association of Ontario (RNAO). Part of this work involved implementing the BPSO’s evidence-based best practice guideline for assessing and managing pain.
“This particular best practice guideline had no information on the complexities of assessing and managing pain within a mental health and addiction setting, so it was important to ensure the best practices recommended in the guideline met the needs of our clients and our clinical team,” says CAMH Clinician Scientist Dr. Kristin Cleverley, also a researcher on the study. Dr. Cleverley is also the CAMH Chair in Mental Health Nursing Research at the University of Toronto. Under Dr. Cleverley’s supervision, Rolin-Gilman completed a six-month RNAO fellowship to evaluate and adapt the best practice guideline for CAMH’s patients.
Dr. Kristin Cleverley
Chronic pain can have detrimental effects on the lives of those involved, says Rolin-Gilman. This is compounded by misdiagnoses, mistreatment and misinterpretations of those symptoms. Further, stereotypes that depict women as being more emotional or having a lower pain tolerance than men may prevent proper pain management. Patients who have substance use issues may also receive inadequate pain management, because requesting medication to treat their pain may raise concerns among health-care professionals about substance dependence, says Rolin-Gilman.
Understanding the women’s perceptions of the assessment and management of their pain was the key focus of the study. Ten women, ranging from 18 to 55 years old and receiving care in the women’s inpatient unit, participated in focus groups between September 2013 and March 2014.
The research revealed four overarching themes: pain is complex, powerlessness, the therapeutic relationship and coping through self-management.
The role of trauma
For women who have experienced trauma, chronic pain can take on different dimensions. Rolin-Gilman explains that physical pain can remind patients of past trauma, like abuse, and, in turn, memories of trauma can bring about symptoms of pain. In some cases, this deeply layered pain can lead to feelings of despair or guilt, and people may cope by self-medicating with alcohol, opioid medications or other substances. One of the study participants, whose chronic pain made it difficult to work and earn an income, stressed that it was important to find a way to manage her pain “…so that I am not forced to go out and self-medicate again.” Another participant spoke of the interconnectivity of pain and the issues that come along with it: “Everything – they all fit together. What is the problem? Puzzle the pieces together.”
The research highlighted that more emphasis on treating all the roots of pain –physical and psychological – should be acknowledged. Some participants indicated that the treatment they received was lacking. “Working at a leading mental health hospital, we have the tendency to focus on treating mental illness,” says Rolin-Gilman. “But there also needs to be focus on the physical pain and the interconnectedness of the two.”
Validation of the patient’s experience was one of the most prominent issues that female participants discussed. Being understood and listened to was a key part of having a positive experience. One woman said, “I want someone that could understand me and understand what is going on with me if I was in pain.” When health-care professionals were more attuned with the needs of the patient, especially in cases of chronic pain, women described it as a relief.
Based on the results and insight from the focus groups, the research team implemented the RNAO best practice guideline to enhance current practices and improve patient care. For example, to give attention to pain at the earliest stage, staff in the inpatient unit began to complete an assessment of a woman’s pain as soon as she arrived on the unit. The researchers, in conjunction with CAMH’s Education team, also developed a staff training course on applying the best practice guideline for their patients. The researchers plan to conduct ongoing evaluation of pain management practices to bridge the gap even further.
“In order to achieve the best results, health-care professionals must involve the patient in understanding the risks and benefits of their choices and, in turn, listen to their beliefs, values and experiences,” says Rolin-Gilman. “It is a crucial partnership, where both the patient and clinician are effectively and productively communicating to meet the patient’s needs.”