Adverse Childhood Experiences: ACEs in Women and Chronic Pain

The National Women’s Health Week kicks off on Mother’s Day, May 12, and is celebrated through May 18, 2019. The U.S. Department of Health and Human Services’ Office on Women’s Health leads National Women’s Health Week. The event is intended to encourage all women to be as healthy as possible at each stage of life. In honor of this goal, May will be women’s health month at the CHP Blog and we’ll focus on topics of interest to IH clinicians.

When evaluating adult pain complaints, especially chronic pain problems, obtaining a careful and respectful history of adverse childhood experiences (ACEs) in the past may shed light on the nature of the current chronic pain condition.

The effects of ACEs on a variety of health outcomes in adult life began to be examined first in a population of Kaiser Permanente members in Southern California in the late 1990’s. This retrospective analysis found correlation between ACEs (which were defined as psychological, physical, and sexual abuse; violence, mental illness, and drug abuse in the household; and imprisonment) and later-in-life risk factors for death including alcoholism, drug abuse, depression, and suicide attempt. There was an associated 2- to 4-fold increase in smoking, poor self-rated health, ≥50 sexual intercourse partners, and sexually transmitted disease; and a 1.4- to 1.6-fold increase in physical inactivity and severe obesity.

This is of course a correlation, not a cause-and-effect explanation of these health risks. The initial study was limited to KP members (~1/2 female; 74.8% white; the average age 57; 75.2% had attended college; all had jobs and good health care) and was focused on just a few ACEs and associated health outcomes (obesity, substance abuse, risky sexual behavior, depression, heart disease, cancer, etc.).

Subsequent studies have investigated relationships in other populations with other kinds of ACEs and a variety of subsequent poor health outcomes in adults. These more recent studies have correlated pain, fibromyalgia, migraine headaches, depression, anxiety, and a self-image of poor health with adverse experiences in childhood, particularly physical and sexual abuse .

While both women and men are affected by ACEs such as sexual violence, women experience many ACEs from .25 to 10 times more often than men . Further, it is recognized that women generally report more pain and more chronic pain than men . These observations strongly suggest that clinical evaluation particularly of women (and men too) with chronic pain should prompt at least an initial screening for ACEs.

Patients are often reluctant to disclose ACEs. But prompting in an open, trusting, informed, and non-judgmental clinical relationship may facilitate the potentially sensitive and awkward conversation that reveals ACEs. While the appropriate interventions to address problems associated with ACEs have not fully been determined, from the perspective of Integrative Health (IH) it is essential to consider this aspect of a patient’s history in finding a treatment plan and setting treatment goals. Taking into account physical, psychosocial and spiritual factors is a hallmark of IH.

A model of when and how to screen patients for ACEs have been proposed by the Center for Health Care Strategies. Consensus recommendations include:
• Treatment setting and patient population should guide screening. Pain patients in IH primary care would seem to be appropriate .
• Screening should benefit the patient. Providers screening for ACEs must have a clear strategy in place for utilizing the information in a way that supports patients’ health, including an established referral network.
• Sharing results across treatment settings with appropriate privacy protections may help reduce rescreening and the potential for re-traumatization.
• Ample training should precede screening. Health care professionals should be proficient in trauma screening and conducting patient follow-up in a manner that is sensitive to cultural and ethnic characteristics.

A simple, open-ended question at intake can point to possible ACEs in the past and the need for in-depth evaluation with one of the several ACE scoring tools , .
• Is there anything else about you that you would like me to know?
• Have you ever been abused?