Castellanos Stacy, Cooke Alexis, Koenders Sedona, Joshi Neena, Miaskowski Christine, Kushel Margot, Knight Kelly Ray
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.
Department of Community Health Systems, School of Nursing, University of California - San Francisco, 2 Koret Way, N505, San Francisco, CA, 94143-0608, United States.
SSM Ment Health. 2023 Nov 15;4. doi: 10.1016/j.ssmmh.2023.100243. Epub 2023 Jul 7.
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.
虽然流行病学文献认可慢性非癌性疼痛（CNCP）、阿片类物质使用障碍（OUD）以及源于身体、情感、性虐待或忽视的人际创伤之间的关联，但CNCP人群中人际创伤和结构性创伤之间复杂的病因及相互作用尚未得到充分研究。研究记录了经历多种童年不良经历（ACEs）与成年后患OUD可能性之间的关系。然而，ACEs框架因未能指出塑造家庭中ACEs易感性的社会和结构背景而受到批评。社会科学理论和人种志方法提供了有用的途径，以探索人际和结构性产生的创伤如何影响同时出现的CNCP、物质使用和心理健康体验。我们报告了一项对48名在安全网环境中接受治疗的CNCP患者及其23名初级保健提供者进行的定性和人种志纵向队列研究的结果。我们在2018年至2020年期间进行了半结构化访谈以及临床和家庭参与观察。在此，我们将分析重点放在患者和提供者如何解释以及定位患者创伤在减少阿片类药物处方这一更大临床背景中的作用，以突出美国阿片类药物过量危机的政治格局及其对临床互动的影响。研究结果揭示了结构性产生的、种族化的创伤对CNCP、物质使用和心理健康症状造成的不成比例的负担，这种负担塑造了患者对疼痛和物质使用的具体体验，以及他们与提供者的情感体验。创伤经历影响了临床护理轨迹，但提供者和患者表示补救选择有限。我们主张调整创伤知情护理方法，将创伤的结构决定因素及其与人际经历的相互作用置于背景中，以改善临床护理结果。
