To the organizers of the AAFP Adult Medicine Course…

To the organizers of the AAFP Adult Medicine Course,

I just attended the Adult Medicine Course in Phoenix Arizona, and wanted to take a moment to share some reflections and feedback with the organizers of this event. There was a lot of important, succinct, and relevant material that was presented in the four-day conference, and I am grateful for some of the clinical highlights I was able to take away from it.

However, I was disappointed with some core structural issues of the conference, and wanted to take the time to bring up my concerns, as well as provide some suggestions for things to consider in the future.

I think we are in a moment in society and in medicine, where there is an invitation and social responsibility to acknowledge the impact of structural oppression and inequity on health. We are in a time of greater wealth inequality than ever before, a time of climate change induced crises and migration patterns that are affecting health globally, a moment when movements for racial justice are drawing attention to the ongoing epidemic of daily police murders of people of color. We are living under a presidency that is assaulting our healthcare system, decimating the reproductive rights and access to reproductive choices of most women, and where millions of elderly, poor, and otherwise vulnerable Americans are facing the loss of health insurance.

I believe we are in a moment where it is no longer acceptable for large, well respected, healthcare leaders such as the AAFP to not only ignore these issues, but in fact reproduce the same oppressive dynamics that we are seeing under our current administration, and in the worst of our society at large.

In the entire four-day AAFP Adult Med conference, there were exclusively white, male, physician presenters. This is concerning for a number of reasons. There are growing numbers of female and people of color physicians and allied health professionals, and it is only appropriate to have presenters at a conference reflect the demographic of the field. Further, due to the socialization process within a society that systematically prioritizes men over women, white people over people of color, and educated and/or wealthy people- like physicians- over working class people, there are countless blinders and biases that white male physicians have been socialized to carry-albeit often unconsciously. This lack of awareness and lived experience from a diversity of identities creates gaps in knowledge of the presenters, and robs participants of a comprehensive educational experience.

I wanted to share just a few of the numerous examples of how the presenters reinforced oppressive dynamics and stereotypes throughout the conference.

  • One presenter made a joke about “you know…the obese woman stealing Halloween candy from her neighbor and then demanding thyroid replacement”. This exemplifies the unacceptable sexism and body shaming in western medicine, which reinforce negative stereotypes about women, and especially obese women. There were a number of body shaming remarks throughout the conference that exemplify the fatphobia physicians consistently enact on patients in ways that are both dehumanizing and oppressive.
  • In the hepatitis C case presentation, I noticed that the majority of the case studies were of African American patients. The over-representation of African American people in the hep C case studies reinforces negative stereotypes of African Americans through subtly implying that there are disproportionate Black IV drug users, as well as eliciting other narratives of anti-Black racism such as African Americans being “dirty” or “infected”, which have been inherited from generations of slavery, Jim Crow segregation and persistent manifestations of racism today.
  • One presenter continually referenced and projected his own Christian values. He made several comments such as referring offhandedly to “Jewish culture” when talking about religion, and telling the audience that, “everyone should just be monogamous because it’s safer and better”. This kind of Christian dogma from a presenter in a position of power is inappropriate at a medical conference that likely has participants from a variety of religious and spiritual backgrounds. Further, it is an unacceptable model for patient care in a time where non-Christian religions and especially Muslim people are being targeted and threatened at increasing rates.

From the AAFP website:

The American Academy of Family Physicians (AAFP) has a long history of supporting health equity and reducing health disparities in patient care. In fact, one of the key strategic objectives of the Academy is to “take a leadership role in addressing diversity and social determinants of health as they impact individuals, families, and communities across the lifespan and to strive for health equity.”

This ethic and commitment I see articulated on the Center for Diversity and Health Equity AAFP page was sorely lacking from the AAFP Adult Medicine Conference. Beyond the specific examples I provided, there was a consistent lack of analysis around this core understanding of social determinants of health and how they impact our patients. This was demonstrated repeatedly, as presenters would provide racial demographic information such as the risk differential between African American and white patients in regard to ASCVD risk without any context or acknowledgement of why African American males’ 10 year ASCVD risk is 6.1% as compared to 2.1% in a white female with the same risk factors. Without the appropriate framing of how social determinants of health impact health risk and outcomes, this information is implicitly interpreted as inherent or genetically driven, which is not only inaccurate but a missed opportunity to invite providers to better understand and address the social determinants of health and the health disparities that result in these risk differentials with our patients.

I am not suggesting that you make a superficial effort to “diversify” the presenter team by inviting in a token female or person of color presenter. Rather, I am inviting you all as leaders in family medicine education nationally to consider intentionally reflecting, evaluating and addressing these dynamics to improve the quality of your work and conferences in the future. People of color, women, LGBTQ and other marginalized people have a lot to offer the field of family medicine education. This might require asking the difficult questions such as; Why did we organize a conference with all white male presenters? What barriers exist that would keep qualified women, people of color or LGBTQ presenters from playing more leadership roles? What steps would we as an organization need to take to truly move towards our stated goal of addressing diversity and social determinants of health and strive for health equity? What kind of resources, time, money and support would be necessary to authentically work towards organizational transformation that addresses white male patriarchal standards and uplifts the voices and leadership of people of color, women and LGBTQ people?

As an organization that makes tremendous contributions to medical education and care Nationally, I hope that you are able to invest the appropriate time and resources to ask the difficult questions.

Sincerely,

Leah Jo Carnine

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Organizing against Trumpcare…

The summer monsoons have started, and after a month of temps hovering in the 110 range, I am again in love with Southern Arizona. I’m filled with appreciation for the resilience of the desert, amidst forest fires spreading rampant through the state. I’m trying to hold onto the monsoons when the world feels like the forest fires these days, on so many levels.

The Trumpcare bill in its’ various iterations is something I’ve been following closely in despair and fear. Reading the estimated impacts of the Trumpcare bill moving it’s way through the senate right now wakes me up in a panic, or hits me randomly throughout the day, moving me to tears. I think it’s something about being a human that cares about humans on the most basic level, and also something about being a healthcare provider and working with people who would be dead, or institutionalized, or in impossible medical debt without the programs that are under attack in this impending bill that’s hitting me super hard.

Most of my patients (and many friends in Arizona, for that matter) benefit from Medicaid expansion and/or Medicare. These programs fund most everything helpful I’ve ever been able to do for my patients. The defunding and dismantling of these programs is devastating beyond my imagination, and of course and as always, will disproportionately harm women, poor folks, people of color, disabled people and queer and trans folks.

I work with dozens of patients living with disabilities in their homes, within family and community, with Medicaid paying for the assistive devices, and home or family care to make it possible. Since the early version of Trumpcare, and the powerful disability rights & justice organizing against it, I have learned more about the history of disabled activists organizing for years to make it possible for disabled people to live at home, in community, instead of institutions. And I’ve learned about the real threat this legislation poses to undo those hard won battles.

I keep thinking about this undocumented/uninsured 15 year old boy I saw at the free clinic who had concerning cardiac symptoms, and an abnormal EKG suggestive of congenital heart disease, and how the state would have just let him die (turns out, we got him into a specialist and his heart is alright), or my friend’s mom in a state that opted out of Medicaid expansion who I am in almost daily contact with trying to help her navigate the system to rule out possible scary and life threatening illnesses without insurance coverage (nearly impossible). I think of the millions of undocumented folks that are already navigating this layer of exclusion and attrition policy, the death and pain and sickness and medical debt from ER visits that are yet another weight on a community that is already carrying so much.

Every day that I see patients, I click these diagnosis codes, which are generally diagnoses that are considered ‘pre-existing conditions’. This proposed bill eliminates mandatory coverage for many of these ‘pre-existing’ conditions, and doesn’t cap the amount that folks with ‘pre-existing conditions’ can be charged for insurance, and repeals protections for life time limits on healthcare costs that insurance will cover. In a comment on my facebook post, Aurora Levins Morales wrote about how oppression creates ‘pre-existing conditions’. And I keep thinking about how true and ironic that is. How state violence, capitalism, poverty and the chronic stress of living under white supremacy really actually create the social and economic context for pre-existing conditions to exist. And like everything this Government has and is doing, this bill targets most impacted and most vulnerable communities, via singling out folks with pre-existing conditions essentially created by state and structural violence. It feels like ‘A Handmaid’s Tale’ dystopian future mixed with Christian colonial logics, and real time anti-Black and white supremacist death policy.

We know how bad it is, and a lot of people are working really hard to stop this bill from getting through the US Senate. And while there are some real critiques of there being lots of white leadership and lots of new organizations leading the way, there is also some most impacted leadership, like seriously fierce disabled activists that have been participating in civil disobedience and putting their bodies on line.  There are groups like Public Health Awakened which are consistently centering a racial justice analysis, and tying the ACA repeal to the attack on migrant communities, and providing public health tools for racial and migrant justice, and Black women dreaming of Healthy Black Futures

I’ve been in my own journey of trying to figure out how to organize against the Trumpcare bill, doing my own weird professional healthcare advocacy with LTE’s and video collabs with a big hospital in town. I’ve been grateful to work at a Community Health Center that’s doing it’s own kind of advocacy, and linking up with some community groups to do visits to Senator Flake’s office with Medicare recipients, disabled folks and healthcare providers, making those calls to the Senator’s office, yelling on the street corner in the blazing sun. And while it feels like yelling at a wall, because it feels more like petitioning a power that doesn’t give AF about people, than building power in most impacted communities to win, it’s felt important to do something. And now, as this next round of the bill gears up for a senate vote as soon as next week, I’m excited to see a big mobilization in D.C. to shut down the senate, and my heart just wants to be there.

Beyond this next week, I want to be full on deep in this fight, and I want to do a different kind of organizing around healthcare. I want to work on our analysis to center most impacted communities, to tie the Trumpcare bill to the same logic that allows police officers to murder Black people with impunity. I want our talking points and actions to fight for Black lives and Black health. I want to work on getting these new-er white-er groups to show up in full force to support the struggles led by migrant folks and Native folks and Black folks and queer and trans people and poor people and sex workers and drug users- because these struggles are very much about staying alive, living with dignity, and of course health. I want to talk to poor or working class or middle class white folks impacted by this healthcare bill that might have voted for Trump about how this attack on basically everyone’s healthcare who is not rich, is working out. Not in a ‘serves them right’ shame-y sort of way but in a hey, maybe we can move together on this, and maybe that can be a step towards moving on to dealing with white supremacy way. I want to honor the wisdom of my comrade Diana Perez Ramirez, community organizer and public health genius in her invitation to use health as a lens for organizing, because it touches everything. I want to get inspired with people about autonomous health zones, and growing skills and knowledge together around health and body and food and herbs in a way that honors lineages of that knowledge that has been stolen from Native folks and communities of color, and gets them back into the right hands. I want to build healthcare infrastructure as a tool of organizing and connection, like the health fairs we did with migrant justice orgs in Phoenix, or healing days for most impacted leaders & organizers to get massages and acupuncture and stress relief tea, to just get taken care of for a day to regenerate. I want to follow the vision and strategies put forward from the healing justice track at the AMC, and the amazing mostly POC, mostly queer folks doing healing justice work.  I want to fight for a visionary universal healthcare plan that covers undocumented people, and reimburses healing modalities that actually work, like acupuncture and midwifery.

Right now, I am just trying to counter rage and despair with small actions, presence and grains of hope.

On navigating power dynamics and challenging white supremacy in medicine

I recently finished reading the brilliant ‘Structural Racism and Supporting Black Lives- The Role of Health Professionals’ published in this months New England Journal of Medicine, and am feeling gratitude for the mostly people of color doctors and public health folks putting out words like these, and leading efforts like #WhiteCoats4BlackLives. This article hits on some deep and core threads of white supremacy, impacts of systemic racism on health, and medicine’s collective failure at integrating any kind of analysis or praxis for addressing root causes of health disparities, or challenging systemic premature death experienced by communities of color. It lays out several recommendations for clinicians (and researchers) who want to do a better job, including; learning about and understanding the roots of structural racism in the U.S., understanding how racism has shaped our narrative about disparities, and naming and defining racism in health care and research.

As an organizer, I want to think through and talk about what we do as healthcare providers to work to challenge and dismantle white supremacy as part of larger social movements, how we organize and agitate and educate in medical schools and clinical institutions to implement this brilliant platform. But today, as a relatively new healthcare provider, I want to chew on what it looks like to do strive to do this work in my day-to-day as a clinician working with patients.

White supremacy is one system we continually interface with in medicine, as part of the intersecting web of oppressions including colonialism, ableism, classism, fatphobia, patriarchy and so on. There are so many layers of power we are constantly navigating (intentionally or subconsciously), depending on our personal location within this web, of course. And then there is this whole other layer of power dynamics in health care that exists between patient and healthcare provider, with a whole history of expertism and professionalization of medical knowledge out of the hands of everyday people, and medical injustices like medical experimentations and forced sterilizations. I think the practice of naming our location is a powerful step towards challenging racism and other systems of oppression. Especially for those of us experiencing layers of privilege as many healthcare professionals, this practice of seeing what we have been socialized not to see is necessary to dismantling systems of oppression. So, I want to start by locating myself as a white, settler, queer woman, able-bodied, class privileged, professional-classed medical professional.

When I first started at my job, I had just finished a visit with a man in his mid 40’s on dialysis, with bilateral amputations from diabetic complications and rheumatoid arthritis so severe he couldn’t inject his insulin. I had some tears in the bathroom from witnessing some of the late affects of colonialism on this persons’ body – including the severity of diabetic complications in Native folks linked to generations of forced displacement, land theft and separation from traditional farming practices, among other things. One of my colleagues caught up with me and gave me this misguided advice that I think is at the crux of how we consistently fail at this part, when she said, “Just remember, they did this to themselves”. This person is not a bigot, and she’s actually a tremendous healthcare provider that gives excellent individual care and is loved by her patients. I share this to show how much we as healthcare providers often fail at holding the larger picture of how systemic oppression (and all of the manifestations of it, including internalized oppression) affects people’s health. There is so much blaming patients that happens in medicine, so much rhetoric around “lifestyle choices” as if the way people eat or whether or not they exercise is a simple choice. In so much medical training, we are taught that health disparities exist for genetic reasons or lifestyle choices, without any acknowledgement of systemic injustice. So our day to day work seeing patients provides many opportunities to challenge our selves and each other on tendencies to blame and shame patients, to write off chronic illness as inevitable results of people’s bad lifestyle choices; to push to deepen analysis and hold these broader contexts of systemic injustices while striving to not victimize or pity the folks we work with.

For those of us working with marginalized folks, the call to learn about and understand the roots of structural racism (and other forms of oppression) is this real and tangible thing that we have the opportunity to do constantly in this work. How can we, for example, hold this broader context- of legacies of slavery and genocide, of medical experimentation, of eugenics and forced sterilizations, of lands stolen in exchange for Indian Health Services, of police murders and drug wars- in a clinical visit. To hold the violence and heaviness, and also the resilience of the folks we work with. One part of holding this bigger picture, I think, is to understand some of the mechanisms by which systems of oppression impact health. There is a tremendous amount of new research documenting what impacted communities have always known – that racism is bad for health – from racial profiling and chronic stress to the pathways of neighborhood segregation, discrimination, implicit bias, environmental racism and internalized oppression on health disparities, to how police killings are a public health epidemic. There’s also all the research coming out about the impacts of childhood trauma on health, and while to be more comprehensive and accurate, the Adverse Childhood Events checklist might also include experiences like policing and racial profiling in the neighborhood one grew up in, if we acknowledge that oppression is trauma, we can make the connections there.

I remember reading Dr. Gabor Mate’s book “When the Body Says No”, and piecing together how being on the short end of power can contribute to the development of certain chronic health conditions like autoimmune disease (i.e. lupus, rheumatoid arthritis). He explains how the immune system’s essential task is to distinguish self from non-self and protect self from things that can harm the body (viruses, bacteria, etc.). He goes on to explain, “Repressed anger will lead to disordered immunity. The inability to process and express feelings effectively, and the tendency to serve the needs of others before even considering one’s own, are common patterns in people who develop chronic illness”. For me, working with Native folks (who have the highest incidence of autoimmune conditions in the country according to the CDC), this framework resonated (women also have exceedingly higher rates of autoimmune disease than men, go figure). We can imagine how colonialism and the systemic disempowerment of Indigenous people could contribute to the immune system being misdirected and attacking self. This is just an example, but what I’m getting at is that using an anti-oppression framework can allow us to understand how oppression and power imbalance might be contributing to any number of health experiences our patients are coming to us with. And that providing good healthcare should include this parallel work around building an analysis around racism, anti-oppression and health.

Amidst my sporadic musings on how to integrate this analysis into patient care, I had the opportunity to interview Dr. Mate a while ago, and I asked him a question along the lines of “Within the limitations of a primary care medical visit, how can I talk to patients about the connections between colonialism and trauma and health in a way that is not disempowering?”. He responded by asking me questions until I could see that as a (white, settler) caregiver, bringing up colonialism could feel like an agenda. He encouraged me to think of ways of asking questions that help people identify the stresses in their lives, and see that dis-ease does not exist separately from their lives. He told me it sounds like I am speaking more than I listen, and I need to listen more. He talked about attunement, and agreed that the constant self work we can do, the nervous system regulation work we can do, allows us to be present and attuned, which is one of the greatest gifts we can provide. So in thinking about how we show up in an exam room, I think a lot about the conversation we had.

I continue sorting through these questions of how to show up with people one on one in an exam room, in a busy day, amidst all of the pressures of primary care work, and all of the stressors in people’s lives and the social determinants of health that are so much bigger than what I can address in a visit. When I’m at work, I’m often running from room to room, my nervous system dysregulated and frazzled, and it’s hard to be how I want to be with people. So I do my best, and try to be gentle with myself when I slip up, and try to slow down so I can learn how to be a different way, and then get swept up in the chaos of it all over again. I’m chewing on practices that I/we can cultivate to subvert power and meet people meaningfully in a clinic visit. And while so much of the context and analysis building around oppression, trauma and health feels like the necessary foundation from which to cultivate these practices, the moment to moment of it feels a lot like trying to be a decent human being. I think there’s something in the intersections, like praxis (theory and action), that I’m striving for. Like the analysis of a broader context of oppression allows for a container to better understand/imagine how people are where they are- with illness, addiction, pain, etc. And holding that bigger understanding I think allows us to shift from judgment, from some subtle “you did this to yourself” thinking, to empathy. And I think people feel the difference. So maybe with that, and with some practices is where the praxis is.

Here are some ideas, mostly things I want to do more of:

  • Asking more questions than talking
  • Never standing/hovering above someone
  • Taking a breath between exam rooms to energetically clean my filter
  • Ask for consent before a physical exam/touch
  • Give back options/power wherever possible “sit wherever is most comfortable to you”, “would you prefer my medical assistant to be present for the pap or that it’s just the two of us?”
  • Admitting not knowing
  • Not shaming people’s decisions/food choices/addictions/bodies/etc.
  • Trusting people’s intuition and expertise about their bodies
  • Not making assumptions
  • Talking to everyone about sex and practices in a normalizing way
  • Asking good questions, the kinds that help people make connections about stress, life, struggle to dis-ease/illness/pain, and about possible solutions
  • With addictions, or coping mechanisms, or other things that might harm people in some way, striving a balance between honoring those things and where they come from without shaming, and being supportive if/when someone wants to make changes (& practicing harm reduction)

I want to collectively be part of showing up for big justice-oriented transformations in our world and in healthcare. I want healthcare folks to increasingly be inspired by and participate in solidarity with the Movement for Black Lives, #NoDAPL, support Oak Flat and other Indigenous struggles, #Not1More and migrant justice efforts, combatting Islamaphobia and welcoming refugees because all of it is about public health, and I really believe that social movements are some form of preventative medicine. I want to be in daily struggle with myself to stay woke to the horrors of systemic racism and oppression, and bring more and more folks with me. I want medical (and PA and nursing schools) to teach about racism, capitalism and patriarchy as the threats to public health they are, and at the least integrate an awareness of social determinants of health into all levels of healthcare education. I want to see medical/PA/nursing schools subsidize people from impacted communities to become providers, so providers can serve the communities they come from. I want all the things, and in the meantime, I’m just going to try to stay open, stay in conversation, and try to work on these daily practices to do my job a little better.

 

 

 

 

 

 

 

 

on having a DEA#, chronic pain and addiction in primary care

I’ve been working as a PA doing primary care for just about 2 years now, and am still sorting through lots of big questions about my role in healthcare, medicine, power, how to support self-determination and wellness in this busted healthcare system, and so many things. I spend a lot of time working with people who are living with chronic pain, and have been thinking about how that links up with trauma, and where pain does and does not overlap with addiction.

I received very little training about chronic pain or the roots of chronic pain in my medical training. My training in addiction was equally limited, albeit more pathologizing, and I believe almost entirely inaccurate. Then I got my first job out of PA school on the Pascua Yaqui reservation, working with folks who have been impacted by colonialism and inter-generational trauma for hundreds of years. Here, I delved into a steep learning curve around many things, two significant ones being chronic pain and addiction. My analysis around colonialism and trauma gave me some preliminary context for the profound amount of suffering the patients I work with are dealing with on a daily basis due to the complications of diabetes, chronic pain, and addiction. The writings of Dr. Gabor Mate helped me develop an understanding that addiction is rooted in childhood trauma. He explains, and extensive scientific studies now shown a link between significant family trauma-such as family violence, addiction, incarceration, and sexual or emotional abuse- and addiction. Further, studies show that beyond individual experiences, entire communities with intergenerational and extreme trauma have higher rates of addiction, and that these are causally linked. For Native communities, this trauma is the result of colonial violence including sexual abuse in boarding schools, genocidal land theft and forced relocation. Dr. Mate helps link the systems of capitalism and colonialism as major contributors to traumatic events that can predispose people to addiction.

The research is out there on how child adversity/childhood trauma and higher ACE’s (adverse childhood events) scores are related to significantly higher rates of cancer, depression, autoimmune disease, heart disease, and addiction. The research demonstrates that chronic, toxic stress, and the environment one is raised in effect the expression of genes (epigenetics), brain connectivity and shape, resulting in these shifts in health. Dr. Gabor’s analysis, and my own experience providing healthcare with Native folks puts this in a broader context of how systemic oppression and the manifestations of wealth inequity, lack of power, police violence and incarceration are in themselves trauma, and inform trauma on the individual, familial, and community levels.

We are in a National moment with the chronic pain and “opioid epidemic” debate in healthcare. Everyday the news has headlines like, “The Opioid Crisis: Anatomy of a Doctor Driven Epidemic” and “Prescription addiction: Doctors must lead us out”, The rise of opioid prescribing is largely due to big pharma lobbying to increase medical prescriptions in the ‘90s, and 2000s. Among other things, this included the push for “pain as the 5th vital sign” wherein healthcare providers were encouraged to ask all patients about pain, and “treat” it by prescribing opioids widely and liberally. Now we are in a sharp turnaround in medicine, where government, state, healthcare agencies and media are in a frenzy about the “opioid epidemic”, and there is incredible pressure for ER docs, primary care providers, and even pain specialists to dramatically and rapidly decrease opioid prescriptions, and get as many people off of chronic opioid prescriptions as possible.

This frenzy is coming in the midst of some real public health concerns—including opioid overdose or poisoning, which is leading to an average of 44 deaths daily in the U.S. As it turns out, even back in the 90’s, people were overdosing or developing opioid poisoning. But it was just a much smaller number of people, so it went below the radar. The “opioid epidemic” topic intersects with an upsurge in heroin use, which may have some to do with people getting taken off their opioids for chronic pain, but seems to have a lot to do with the broader social and economic context we’re in. We are seeing staggering wealth inequity and poverty, a partial collapse of the white middle class, a rise (or perceived rise) in unemployment all of which are hitting lots of folks, and suffering, pain and isolation are major risk factors for addiction. Thing is, these are all getting smooshed together in a confusing mess of media and mixed messages, and being a healthcare provider in the midst of it has left me craving some politically grounded, harm reduction based insight and guidance for how to engage.

Some things I’ve gathered. Oppression is in itself trauma. Systemic oppression and childhood trauma and adversity impact many facets of health- including both addiction and chronic pain. Opioid dependence for people living with chronic pain, and people living with an opioid addiction have some areas of overlap but are by and large not the same.

I was able to participate in an online learning network called Project ECHO Pain that gave me some tools and framework for understanding chronic pain and better engaging patients who are living with chronic pain. We talk about three main types of chronic non-cancer pain (chronic pain from cancer is a whole different topic): nocioceptive (broken bones, stubbed toes, etc.), neuropathic pain (diabetic neuropathy), and what one of my teachers calls psychological pain—which I prefer to call chronic nervous system pain. All of this is experienced as pain in the body. There can be overlap between the different types of pain, but by and large they are unique etiologies. In medicine we often haven’t been trained to distinguish between the types of pain people are experiencing (or the root causes). And we have largely been prescribing opioids for any kind of pain, without performing appropriate evaluation to identify the actual cause.

There are a bunch of people living with chronic nervous system pain rooted in childhood adversity and trauma. For many, this pain is being managed by opioids, perhaps inappropriately. This does not mean that all people with chronic pain on opioids are addicts, although some of them might also be struggling with addiction. Many of these folks are dependent on opioids for relieving chronic pain that is psychological or nervous system pain, and therefore opioids are not ideal. When people are living with chronic nervous system pain, there is often a high level of nervous system dysregulation and stress, so opioid medications like oxycodone that soothe anxiety may make people experiencing this kind of psychological and nervous system pain feel better, but that doesn’t mean that it is the best treatment.

For me, the role of being a gatekeeper to opioids for a lot of folks who want them- whether for an opioid addiction or to soothe the psychological and nervous system pain of intergenerational trauma and colonialism- is a tension I struggle with daily.

Working with Native folks as a white settler healthcare provider in a legacy of colonization that created the very conditions for addiction, at a clinic where well meaning or indifferent healthcare providers have prescribed opioids indiscriminately for years, is not a simple thing. Mix in racial bias in prescribing opioids, by which I mean the research showing how people of color receive less opioids for acute pain and the internalized racial bias I am surely holding while prescribing opioids. And grappling with the daily experience of sitting face to face with a human being who is suffering, who is in significant and often debilitating pain. Sitting with someone who might be asking for a prescription of oxycodone, and whether or not opioids might be the best treatment route for that pain, looking at that person in pain and having the power to write that prescription or not is a complicated and often painful role to be in.

I know in primary care, especially for those of us working with marginalized folks, we are crunched with time, have too few resources and are engaging with problems that are much larger than any solution we can offer. But the reality is, we are the ones who need to be present and available to delve deeply and responsibly into chronic pain and addiction with our patients. It’s here I’ve been looking for resources, and while I haven’t figured out all the answers, here are some things I have found useful.

I’m in a learning process of how to engage in authentic conversation, loving investigation and accurate evaluation of chronic pain that is transforming my clinical practice. One of my teachers from Pain ECHO, Dr. Bennet Davis wrote an article, “the 9 Best Practices for evaluating and treating pain in primary care”, in which he breaks down a process for learning and getting to know your patient, including the psycho-social factors that impact their health and wellbeing, centering the patient in all decisions, orienting goals for pain treatment to how well someone is able to function in the ways they define as a priority. I started doing a more thorough intake for patients with chronic pain concerns, including the ACEs (Adverse Childhood Events) survey, a sleep evaluation, a brief pain inventory, and an opioid risk calculator. These forms give me tremendous information about the person I’m working with, their trauma history and risk for chronic nervous system pain, and how they are living, working, sleeping, existing in relation to their pain. I’m slowly learning how to ask questions to support people in making the links between their own difficult childhoods and their pain, and their ideas about how to heal. The next step is trying to get an integrative team on board, which means working with multiple providers to holistically address root causes of their chronic pain- including therapy, physical therapy, acupuncture, and whatever other resources are available (this could be another post: working with what’s reimbursed/affordable with patients when so many of the things that work and support healing are so expensive and inaccessible). I’m trying to learn how to really listen, how to be in tune with someone to know when it’s time to ask a question, or suggest a change or just sit in one brief moment of empathetic silence.

When addiction comes up, we need to have some more tools to offer—some framing around the learning-developmental, or the biopsychosocial model of addiction– which roots addiction in the environmental factors of one’s early life, as opposed to the medical ‘disease model’ of addiction (which pathologizes addicts as having brain chemistry disorder in a vacuum), or the ‘choice’ model (society’s approach to addiction where people are making a choice and have lack of willpower). We can counter the “tough love”/punishment approach to engaging with addicts rampant in our society and criminal justice system by being compassionate, available, empathetic, non-punitive and trauma informed in our approach. We can work to practice harm reduction and have relevant resources for addicts, including needle exchanges, free hep C testing, condoms and whatever else can help patients stay safer when using is a start. When patients want to talk treatment, offering up 12 step programs as one tool amidst many, including motivational enhancement therapy (an approach to therapy focusing on improving an individual’s motivation to change), acupuncture, medication therapy and/or methadone/suboxone maintenance therapy.

Because our nervous systems speak to each other, as an empath, I can mirror and take on pain in ways that are not helpful to myself or the people I’m working with. I am learning that how I am in my own nervous system is part of what I offer as a health care provider and as someone committed to social justice. My attempt to work on my own nervous system regulation for my own well being as well as for the care I can provide to my patients is requiring a tremendous amount of my own self-work, including somatic experiencing therapy (a body oriented approach to healing trauma and stress), slowing down, meditation and tonglen practice (Tibetan Buddhist practice of breathing in personal and collective suffering) and more.

There is so much suffering and pain in this world, and to have a DEA# and the ability to prescribe opioids amidst such a complicated mess of factors is a responsibility I couldn’t have imagined before stepping into it. So here we are, trying to make sense of chronic pain in a system that values profit over people, in a country unwilling to reckon with the legacies of injustice and the implications on our collective being. As healthcare providers we have this impossible role; we are asked to medicate and manage the manifestations of trauma and oppression on the body, without acknowledging root causes. Working with chronic pain is often something I want to turn away from, which is why the practice of turning towards it, engaging and going deeper feels necessary. While this work is so difficult, and I feel I have so few medical solutions offer, it’s also an opportunity to treat people who’ve been judged and shamed for their pain or addiction with dignity and respect, which is actually something well worth offering.