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Most health care professionals are aware that medical care in this country varies a great deal based on the patients’ race and ethnicity. We only have to look at the current coronavirus disease 2019 (COVID-19) crisis, in which Black individuals have been 

 both in number of infections and deaths as a result of a myriad of psychosocial, genetic, and environmental factors.

On top of unequal access, some individuals hold discriminatory beliefs about pain experienced by individuals of different racial and ethnic groups. In 1892, S. Weir Mitchell, MD, the father of American neurology, wrote about the experience of pain in White people of Northern European ancestry in comparison with Black and Native American people. He stated, “In our process of being civilized, we have won, I suspect, intensified capacity to suffer. The savage does not feel pain as we do.”

This view of pain was often used to rationalize the mistreatment of enslaved and Native American people: when violence was inflicted on them, they did not suffer as White people did. Pre-Civil War, 19th century New Orleans physician Samuel A. Cartwright, MD, said he identified “dysaesthesia Aethiopis,” an inherited disorder specific to Black individuals that made them insensitive to pain.

These views were perpetuated solely based on racism, without any science to support them. However, we now know that genetics can play a significant role in disease. Different races and ethnicities can be more at risk for certain diseases, such as sickle cell disease among Black people and Tay-Sachs disease among people of Ashkenazi Jewish ancestry. Thus, there is still the question of whether pain is experienced differently by individuals from different backgrounds.

A complicating factor in this discussion is how the experience of pain is affected by culture. It is readily apparent that it is more acceptable in some cultures and societies, often based on race or ethnicity, to complain about pain. How much of this is due to actual differences in the pain experience versus cultural acceptability of reporting pain—nature versus nurture—remains unclear.

 the effects of race and ethnicity on the care individuals received for chronic pain.

 The review identified trends in the effects of race and ethnicity on the experience of pain and how it is treated. Among the multitude of previous studies, one can find many different results, ranging from race and ethnicity playing significant roles to playing virtually no role.

Some studies have reported that Black individuals and people who belong to certain ethnic minority groups have higher pain thresholds, while other studies have 

 Minority patients, especially those from groups in which there are relatively small numbers of represented physicians, may have their level of pain underestimated by their caregivers.

Several studies have examined affects of race or ethnicity on the prescribing of opioids for pain. The most common finding was that Black patients were less likely to be prescribed opioids than White patients; however, it is worth noting that 

 patients were less likely to receive opioids than non-Hispanic White or non-Hispanic Black patients.

 Furthermore, some studies found that Black patients who were prescribed opioids were monitored more closely for misuse than White patients.

In light of the prescription epidemic in this country, resulting in rising rates of misuse and overdoses, it could be argued that more restrictive prescribing and closer monitoring might be a positive thing. If so, Black patients might accidentally benefit from these prescribing patterns. However, there is no indication that physicians are more carefully looking out for their Black patients than for their White patients. Even if the result is positive, there is no apparent intent. Furthermore, research has shown that Black patients and non-White Hispanic patients may have a more difficult time than White patients filling opioid prescriptions, as pharmacies in their neighborhoods may carry 

Unfortunately, there has been a tendency to have limited participation of non-English speakers and immigrants in studies of 

, and this may have resulted in an unrepresentative sample. Considering that pain is a subjective complaint that must be self-reported, limited language skills could impair patients’ ability to convey the presence and severity of pain, all important factors in determining proper treatment protocols.

The extent to which race, socioeconomic status, and 

 contribute to the apparent discrepancies in the management of pain remains unclear. The issue of poor access to health care may extend beyond just the pain itself and may also affect the identification and treatment of underlying disorders that may be causing or exacerbating the pain. This includes mental health issues, most notably depressive and anxiety disorders, which can play important roles in the development and maintenance of 

It is not too surprising that so many factors may explain variances in pain among different racial and ethnic groups. We know that there are many elements involved in the development of pain, especially chronic pain, including genetic, cultural, psychological, and environmental influences. The importance of each factor can vary from individual to individual.

The authors of the current study noted that there are no easy answers to pain management discrepancies, especially between Black and White individuals in the United States. More research is needed to identify the reasons for these discrepancies and the best methods for addressing them. Physicians should be aware of biases, including unconscious ones, and the methods for assessing and managing pain, especially among patients who may belong to different racial and ethnic groups than they do. Viewing all patients as complex individuals whose pain may involve many factors is crucial.

is in private practice in Philadelphia, Pennsylvania.

2. Cartwright SA. Report on the diseases and physical peculiarities of the negro race. In: Caplan AL, McCartney JJ, Sisti DA, eds. 

Health, Disease, and Illness: Concepts in Medicine

Racial and ethnic disparities in the treatment of chronic pain

4. Green CR, Hart-Johnson T. The impact of chronic pain on the health of black and white men. 

5. Hausmann LRM, Gao S, Lee ES, Kwoh KC. Racial disparities in the monitoring of patients on chronic opioid therapy. 

6. Nguyen M, Ugarte C, Fuller I, Haas G, Portenoy RK. 

Access to care for chronic pain: racial and ethnic differences

7. Bauer SR, Hitchner L, Harrison H, Gerstenberger J, Steiger S. 

Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting

8. Hollingshead NA, Vrany EA, Stewart JC, Hirsh AT. 

Differences in Mexican Americans’ prevalence of chronic pain and co-occurring analgesic medication and substance use relative to non-Hispanic white and black Americans: Results from NHANES 1999-2004

9. Becker WC, Starrels JL, Heo M, Li X, Weiner MG, Turner BJ. Racial differences in primary care opioid risk reduction strategies. 

10. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “

We don’t carry that”--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics

Pain as a cultural construct considers conscious and unconscious biases, as well as methods for assessing and managing pain in all patient populations, including those with mental health challenges.

Race, Ethnicity, and Chronic Pain

The association between smoking cigarettes and the risk of developing serious and potentially fatal health problems (most notably cardiovascular diseases, pulmonary diseases, and cancer), has long been accepted fact. However, an additional health problem that may also be associated with smoking has often been overlooked: pain.

Two recent papers indicate a strong association between smoking and pain.

 Among the review’s important findings is that those who suffer from chronic pain are substantially more likely to smoke than are those who do not suffer from chronic pain. Although smoking rates continue to decline in the latter group, this does not appear to be occurring in those with pain.

Cigarette smoking has been cited as a risk factor for a wide variety of painful conditions, including back pain, 

, and diabetic peripheral neuropathy. Smoking appears to be associated with both the development and severity of pain.

The second paper specifically studied the most likely locations of pain among individuals who smoke. The 

 examined data from a 2003 to 2004 National Health and Nutrition Examination Survey, which contained data from comprehensive bodily pain questionnaires in addition to questions on other health issues, including tobacco use.

 The study compared 1054 participants who smoked tobacco with 1316 participants who did not.

Those who smoked were found to be more likely to suffer chronic pain. Although the likelihood of pain was increased throughout the body, the study found that spine pain, and especially low back pain, had the strongest association with smoking. The second strongest association was between 

 and smoking. Smoking was also associated with both trunk pain, which included the chest and abdomen, and limb pain. (All statistical associations were drawn from Smuck et al.

This is an interesting and perhaps an unexpected finding. Because of the association between smoking and cardiovascular and cerebrovascular problems, it is easy to see why headaches would be fairly common among individuals who smoke. However, it might be reasonably expected that pain in the trunk and 

 would be more common than pain in the spine. The authors suggest that vascular factors may play a greater role in back pain than is often thought.

, which are becoming more popular, are any less associated with pain than traditional cigarettes remains an unanswered question.

From personal experience treating patients with chronic pain who also smoke, I know that helping them with smoking cessation attempts can be challenging. Although most patients are often well aware of the risks associated with smoking, their pain and its impact on their lives may make it more difficult for them to quit. Their pain may make them feel restricted, and their ability to participate in previously enjoyable activities is limited. Smoking is among the few such activities in which they can still indulge. They may also feel that smoking helps them cope with the pain.

 may have some analgesic effects, but abstaining from smoking may 

 individuals to suffer hyperalgesia, a lowering of the pain threshold.

 Thus, those who smoke may receive temporary relief from tobacco use, and their pain may get worse when they try to stop.

Additionally, depression and anxiety are frequent 

 among those with chronic pain, and their presence can also contribute to the challenge of getting patients to stop smoking.

Ultimately, all evidence points to the importance of convincing patients with chronic pain who also smoke that tobacco is not helpful. Indeed, tobacco may be significantly exacerbating their pain and adding to their misery.

The multitude of challenges can understandably make it difficult to persuade patients with chronic pain to stop using tobacco. Unfortunately, only a 

 of studies have sought to investigate the best treatments for attaining this goal.

Although no single optimal treatment has yet been identified, it appears that while nicotine replacement therapy can be useful, the 

 that are most successful are those that address both the pain and the smoking using psychotherapeutic interventions.

 In this way, treating tobacco use disorder and comorbid chronic pain is similar to the treatment of pain and iatrogenic opioid use disorder, where both problems must be managed together to be successful in treating either.

Of course, this raises the important issue of who treats pain and how it is treated. (For more information on psychiatry and pain, see 

Psychiatric TimesTM November 2020 Special Report

For the most part, the management of chronic pain has been under the aegis of anesthesiology, followed by physiatry and neurology, with psychiatry far down the list. However, the order of these specialties would be reversed if we asked which is best able to aid in smoking cessation. One doubts that there are many anesthesiologists, physiatrists, or neurologists who have expertise in treating patients with nicotine addiction.

As a result, it is difficult for patients with chronic pain who smoke to find health care professionals qualified to treat both issues. If it appears to patients that smoking and pain are 2 separate problems that require different medical specialties to treat them, it may make it more difficult to convince them that the issues are actually entangled. Nonetheless, the evidence suggests that managing 1 issue may aid in managing the other.

This article was posted ahead of print on November 11, 2020, and has since been updated. -Ed

Pain, nicotine, and tobacco smoking: current state of the science

2. Smuck M, Schneider BJ, Ehsanian R, et al. 

Smoking is associated with pain in all body regions, with greatest influence on spinal pain

Nicotine deprivation increases pain intensity, neurogenic inflammation, and mechanical hyperalgesia among daily tobacco smokers

Nicotine withdrawal and stress-induced changes in pain sensitivity: a cross-sectional investigation between abstinent smokers and nonsmokers

Anxiety and depression in bidirectional relations between pain and smoking: implications for smoking cessation

A reciprocal model of pain and substance use: transdiagnostic considerations, clinical implications, and future directions

7. Hooten WM, LaRowe LR, Ditre JW, et al. 

Effects of a brief pain and smoking cessation intervention in adults with chronic pain: a randomized controlled trial

Two recent papers look at the subtle and surprising links between smoking and pain in different parts of the body. 

Pain and Smoking: Is There an Association?

Chronic pain is a massive and costly health problem

 and among the main non-fatal causes of years lived with disability worldwide.

 In the United States alone, an estimated 50 million adults are suffering from chronic pain.

 Huge efforts have been made in past decades to better understand, prevent, and treat chronic pain. A common link between chronic pain and posttraumatic stress disorder (PTSD) has emerged as a result of this research. Many individuals with chronic pain suffer from PTSD due to the incidents that caused trauma-related distress, but chronic pain is also commonly found in individuals with PTSD as their primary disorder. Hence, a better understanding of this comorbidity may be important for the treatment of both disorders.

 vary notably due to differences in sampling and assessment tools. Of importance for the interpretation of prevalence rates, many studies rely on fulfillment of diagnostic criteria based on PTSD screening questionnaires. Two recent systematic reviews reported mean-possible PTSD prevalence rates of 11.7% to 19.1% in clinical pain populations, also noting large subgroup differences.

 Similarly, chronic pain complaints are common in patients with a primary diagnosis of PTSD, with prevalence rates estimated to be as high as 80%.

In a recent systematic review of studies on refugees with PTSD, chronic pain complaints were very common. In some studies, almost all participants reported such complaints.

 Furthermore, several studies have found that higher levels of PTSD symptomatology in patients with chronic pain are associated with higher levels of 

, raising the possibility that the conditions not merely coexist, but may influence one another negatively.

Several theoretical possibilities have been put forward to explain the comorbidity of PTSD and pain. These have mainly focused on shared, predisposing vulnerabilities, or on how the conditions may affect one another.

Asmundson et al suggest that underlying predisposing factors or traits cause the development of both PTSD and chronic pain.

 sensitivity (the tendency to respond with fear due to the assumption that [anxiety] symptoms are harmful), may amplify the intensity of the initial emotional response to a traumatic event, thereby increasing the risk of developing either condition.

 Also, other biological and psychological vulnerabilities have been suggested, such as a lowered physiological threshold for alarm responses and feelings of loss of control and unpredictability.

 Vulnerabilities, together with the circumstances of the traumatic event, affect the emotional responses in the encounter and initiate cascades of cognitive bias, hypervigilance, avoidance behavior, autonomic responses, and muscular responsivity.

 A number of vulnerabilities and processes, then, may make an individual more prone to develop the comorbidity following trauma.

Maybe the most-cited model in the field is the Mutual Maintenance Model.

 This model suggests that chronic pain and PTSD maintain and exacerbate one another through 7 mechanisms. Attentional and reasoning biases toward potentially threatening stimuli as well as catastrophizing are suggested to lead to heightened expectations, overestimations, and selective and negative interpretations of both pain-evoking and fear-evoking stimuli. Furthermore, pain may serve as a traumatic cue, evoking fear and PTSD intrusion and hyperarousal, and vice versa. Avoidant coping styles, depressive symptoms, and fatigue are also potentially intertwined and could lead to physical deconditioning, inactivity, disability—all preventing fear extinction. PTSD-related anxiety may also include pain perception directly. Finally, cognitive overload characterizes both conditions, and it leads to limited capacity to employ adaptive coping strategies.

 developed the Perpetual Avoidance Model, which suggests that PTSD symptomatology begins early post-trauma. Here, dysfunctional cognitions, intrusive symptoms, hyperarousal, avoidance behavior, and inactivity all fuel one another in a circular process. The model posits that pain may be initiated or increased as a function of hyperarousal, leading to reinforced fear-avoidance behavior and inactivity. In addition, Jenewein and colleagues argued that fear-learning deficits and impaired capacity to inhibit fear in PTSD may contribute to increased pain perception, pain sensitivity, and fear responses to painful stimuli.

 This idea builds on classical fear conditioning theory, in which fear-learning deficits cause an over-association of pain cues and prevent adaptive safety learning. Incorrect interpretations of bodily symptoms can lead to reinforcement and catastrophizing.

 As a final note, pain issues can also arise due to anxiety-related tensions.

 on pain sensitization, experimental studies find both increased and decreased pain perception, as well as unaltered pain perception.

 While these mechanisms are not fully understood yet, evidence shows that different pain profiles may be related to different PTSD symptoms and coping mechanisms. In a recent review

, PTSD hyperarousal has been associated with increased pain perception and dissociation with decreased pain perception. Also, the nature of the traumatic event may play a role in how PTSD affects pain sensitization. Combat-related PTSD was found to be associated with increased pain thresholds (the level at which a stimulus is experienced as pain), whereas accident-related PTSD was associated with decreased pain thresholds.

Different coping mechanisms may be related to dissociation and derealization. Whereas dissociation can lead to a reduction of conscious attention toward bodily sensations and incoming stimuli such as pain, anxiety and fearful appraisals may lead to attentional bias toward painful stimuli and thereby a decreased pain threshold. Hence, it seems that accident-related trauma is linked to an anxious and sensitizing reaction, whereas combat-related trauma may lead to a dissociative and habituative reaction. While differences in pain processing can be identified in experimental studies, subjective pain reporting most often points in the direction of a more severe symptom profile in relation to pain, disability, and distress when comorbid PTSD and pain persist.

The biological mechanisms behind pain sensitization and the development of chronic pain are complex but include regulatory mechanisms in the hypothalamic-pituitary-adrenal axis, inflammatory processes, immune system suppression, and fatigue.

Also, more complex interpersonal traumas such as physical and emotional abuse associated with war or sexual assault, for example, are of such a pervasive nature that the ability to trust others can be severely damaged, resulting in attachment insecurities that further increase the risk of developing long-term pain problems.

The high co-occurrence of chronic pain and PTSD and their possible entanglement underline the importance of conducting assessment for both PTSD and pain. Unfortunately, symptom overlap between pain and PTSD makes assessment a challenging task. In particular, symptoms related to the DSM-5 PTSD criterion D and criterion E (

) are also very common in individuals who have chronic pain but do nothave PTSD.

 contains items from the PTSD Checklist for DSM-5 (PCL-5) that are prone to misinterpretation. This exemplifies why screening can be a challenge, as individuals who misinterpret these items will sometimes unintentionally inflate their PTSD symptom scores. The key is to distinguish between the patients who feel upset about the consequences of traumatic pain and those who feel highly upset when thinking about the traumatic event itself. For example, negative beliefs about oneself (line 1) are often tied to a guilty conscience about being unable to fulfill one’s obligations due to pain. Loss of interest in activities and feeling cut off from individuals (lines 2 and 3) are often related to no longer being able to participate in sports and hobbies due to pain. Also, almost everyone with chronic pain at times feels irritable and has difficulty concentrating (lines 4 and 5). Similarly, chronic pain causes sleep problems (line 6). The problem is that intrusion symptoms like “feeling very upset when something reminded you of the stressful experience” (which are understood as unique PTSD symptomatology) are sometimes interpreted by patients as being upset when thinking about how pain hinders participating in activities, and not so much as being upset when thinking about the traumatic event itself.

Keeping the aforementioned challenges in mind, there are several PTSD-screening tools (

) that can easily be used. In accordance with the DSM-5, the PCL-5 covers all 20 PTSD symptoms assessed with the diagnostic interview CAPS-5. Also, there are 2 short-form versions (4 and 8 item) of the PCL-5. Another valid brief screening tool for chronic pain is the PTSD-8. The PTSD-8 includes 8 items covering the 3 PTSD symptom clusters of intrusion, avoidance, and hyperarousal (similar to the criteria of ICD-11) and has shown good overall accuracy when compared to a diagnostic interview in chronic pain.

Similarly, there are good and short instruments for pain complaints. Identification of psychological red flags in patients seeking care for musculoskeletal pain problems or PTSD can be useful in treatment planning, as these are often modifiable. 

 presents selected short screening tools for both pain-related problems and PTSD. The selected screening tools are brief, up-to-date, validated tools useful in the context of comorbid PTSD and pain. Of note, for some patient groups psychological disorders may be associated with stigma and may be more difficult to accept. This is important to recognize as it may have significant impact on what patients report to health care professionals, which is important as diagnostics in this area are highly reliant on self-report.

Case example: mutual maintenance mechanisms

“Jane” is a 38-year-old woman. Ever since a severe car crash, her life has not been the same. She has struggled with chronic pain, and she feels worn out and jumpy. Despite her physiotherapist’s best efforts, Jane continues to struggle to engage in the exercise intervention, and she complains about the exercises making her pain worse.

In psychotherapy, she starts to realize that being “worn out” and “jumpy” are related to the PTSD. Several examples of the integration of the conditions become clear to her:

- She often reports that talking about the trauma increases pain intensity.

- She realizes that her struggle to take on physiotherapeutic treatment was not only due to fear of pain and risk of re-injury, but that pain flare-ups return her to the trauma. In this way, her PTSD has made her highly hesitant to engage and made her feel overwhelmed.

- She begins to realize that both pain and PTSD affect her resources, which are split up between them. On days where PTSD symptoms are severe, she has fewer resources to handle pain, which in turn gets worse.

Interventions in these comorbid cases first and foremost need to be biopsychosocial in nature. Unfortunately, there are very few randomized controlled studies that target comorbid PTSD and pain, making it difficult to devise strong recommendations on best treatments for comorbid PTSD and chronic pain. Although there are good evidence-based treatments for each condition, it is still debated whether both conditions need to be targeted sequentially, in parallel, or by an integrated intervention.

If a sequential approach is chosen, it is important to take into consideration which disorder to treat first. As a rule of thumb, the primary disorder needs to be treated first. However, as previously outlined, the untreated disorder may worsen the other; and it is not always evident which disorder is the primary—particularly not in cases where both conditions developed in parallel.

The parallel approach also poses some challenges. If treated by different providers, collaboration and treatment planning can be difficult. Moreover, the clinicians for each disorder need to make sure that the patient has the resources to engage in both treatments. While an integrated intervention may overcome some of these challenges, there is no exact intervention guidelines for how to integrate the interventions.

Evidence points in the direction of integrating cognitive behavior therapy (CBT) techniques in the treatment of comorbid PTSD28 and chronic pain.

 However, one size may not fit all. The complexity of the trauma needs to be considered. In accident-related trauma (in which the primary symptoms may be musculoskeletal pain with elevated levels of arousal, catastrophizing, and pain-related fear avoidance beliefs), the vicious circle maintaining both pain and PTSD symptoms may be interrupted by interventions such as psychologically informed physiotherapy or an intervention with a cognitive behavioral focus on pain management and exposure to feared activities.

 Also, it has recently been shown that early interventions, including targeting PTSD hyperarousal symptoms and pain-related disability with a physiotherapist-led stress inoculation training intervention combined with physiotherapeutic exercise, was effective in reducing pain-related disability compared to exercises alone.

 For more complex interpersonal traumas, or when chronic pain and PTSD have persisted for years, specific and specialized intervention for both PTSD and chronic pain may be necessary for positive outcomes. With that said, the first step is to be aware of this prevalent co-occurrence of pain and PTSD, which requires a proper assessment of both conditions.

Of course, many other frequently comorbid disorders may further muddle the picture, both for assessment and treatment of both pain and PTSD. For example, many studies on PTSD and pain are conducted in military samples, who are also at increased risk of traumatic brain injuries (TBI) of varying severity. This phenomenon also is true for some type of accidents. There are some studies that show veterans with TBI and PTSD report more pain compared to veterans with either TBI or PTSD alone or neither of them.

Chronic pain and PTSD are also associated with suicidal ideation and violent impulses in veterans despite the presence of TBI.

 While this triad remains largely unexplored, some relevant narrative reviews exist, as well as reflections on treatment (eg, Otis and colleagues

Various psychopharmacological agents can be used to treat comorbid PTSD and chronic pain, but there is limited research. Since such a discussion is beyond the scope of this piece, clinicians are encouraged to investigate for themselves.

We hope this article has shed light on the complexity of the comorbidity of chronic pain and PTSD and sparked an interest in some readers to pursue gaining knowledge on this to the future benefit of patients. We encourage clinicians to always have the comorbidity of pain and PTSD in mind when seeing patients with either chronic pain or PTSD, and to be aware of symptom overlap when screening for possible PTSD in chronic pain. Finally, being aware of the nature of the traumatic event is important for treatment planning. If pain and PTSD is due to the same traumatic event, it may be relevant to consider an integrated or parallel treatment, while complex PTSD due to interpersonal trauma or events dating years back in time may require specific trauma-focused intervention in its own.

is assistant professor in a combined position at Department of Psychology, University of Southern Denmark, and at Specialized Hospital for Polio and Accident Victims. 

is associate professor at Department of Psychology, University of Southern Denmark.

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2. Barham L. Economic burden of chronic pain across Europe. 

3. Gaskin DJ, Richard P. The economic costs of pain in the United States. 

4. Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated factors in population-based studies. 

5. Phillips CJ. The cost and burden of chronic pain. 

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7. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults — United States. 

8. Siqveland J, Hussain A, Lindstrøm JC, Ruud T, Hauff E. Prevalence of Posttraumatic Stress Disorder in Persons with Chronic Pain: A Meta-analysis. 

9. Fishbain DA, Pulikal A, Lewis JE, Gao J. Chronic pain types differ in their reported prevalence of posttraumatic stress disorder (PTSD) and there is consistent evidence that chronic pain is associated with PTSD: An evidence-based structured systematic review. 

10.Otis JD, Keane TM, Kerns RD, Monson C, Scioli E. The development of an integrated treatment for veterans with comorbid chronic pain and posttraumatic stress disorder. 

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15. Pedler A, Sterling M. Patients with chronic whiplash can be subgrouped on the basis of symptoms of sensory hypersensitivity and posttraumatic stress. 

16. Ravn SL, Vaegter HB, Cardel T, Andersen TE. The role of posttraumatic stress symptoms on chronic pain outcomes in chronic pain patients referred to rehabilitation. 

17. Ruiz-Párraga GT, López-Martínez AE. The contribution of posttraumatic stress symptoms to chronic pain adjustment. 

18. Asmundson GJ, Katz J. Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the-art. 

19. Asmundson GJG, Abrams MP, Collimore KC. Pain and anxiety disorders. In: Zvolensky MJ, Smits JAJ, eds. 

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22. Jenewein J, Erni J, Moergeli H, et al. Altered pain perception and fear-learning deficits in subjects with posttraumatic stress disorder. 

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26. Bunzli S, Maujean A, Andersen TE, Sterling M. Whiplash Patients’ Responses on the Impact of Events Scale-R: Congruent With Pain or PTSD Symptoms? 

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The high co-occurrence of chronic pain and PTSD and their possible entanglement underline the importance of conducting assessment for both conditions. 

Exploring the Relationship Between Posttraumatic Stress and Chronic Pain 

If you were to poll physicians and ask which specialty usually takes the lead in the management of chronic pain, no doubt an overwhelming majority would say anesthesiology, with a smaller number saying neurology and physiatry. However, probably few would say psychiatry.

It is odd considering the recent revision of the 

 by the International Association for the Study of Pain, the leading worldwide organization for medical professionals involved in the field of pain: “Pain is always a subjective experience that is influenced to varying degrees by biological, psychological, and social factors.”

 This appears to be almost precisely with what psychiatry deals.

We already know that there is a high degree of comorbidity between 

 with chronic pain and, although it is commonly thought that the mental disorders are always secondary to the pain, research has shown that pain is a common presenting symptom of these disorders.

The papers in this Special Report discuss 2 other problems that frequently occur in those with chronic pain: 

 (PTSD). We have known about the relationship between sleep disorders and chronic pain for years; however, the relationship between pain and PTSD is a more recent finding.

As with depressive and anxiety disorders, it is usually thought that if a sleep disorder is present in a person with chronic pain, the sleep issue is always secondary to the pain. However, this oversimplifies the relationship. The interaction between pain and sleep disorders is often a 2-way street, with each exacerbating the other. Both the pain and the sleep disorder need to be addressed.

Of course, the presence of any type of pain can impair sleep. Patients with peripheral diabetic neuropathic pain often report worse pain in their lower extremities during the night when they are trying to sleep. Those who suffer from complex regional pain syndrome in their lower extremities may complain that it is it painful to have sheets touch their skin due to allodynia, in which stimuli that do not usually cause pain do so. Patients with back pain often report problems with sleep due to pain although, curiously, laying down is the position they usually find most comfortable. In fact, if the pain is worse lying down, it is considered a red flag indicative of serious underlying pathology.

Similarly, disruption in normal sleep cycles can cause pain. More than 45 years ago, research found disruptive sleep in some healthy individuals precipitated the symptoms of fibromyalgia and resulted in widespread pain.

There are few studies on the treatment of comorbid pain and sleep disorders. Although both are commonly treated with medications, there is limited research on using pharmacologic agents when both problems are present. Most of the studies have looked at pregabalin in patients with fibromyalgia.

Opioids and benzodiazepines, medications that are frequently prescribed for patients with chronic pain, may actually exacerbate pain because they can cause hyperalgesia (eg, lower pain threshold). These agents can also exacerbate sleep disorders because of their disruption of normal sleep architecture. Sadly, many lay people and medical professionals mistakenly believe that the sedative side effects of these medications mean they will be beneficial for sleep.

There is much less research on chronic pain and PTSD, although there has been a growing interest in the past few years. 

A limiting factor of the data is that much of the research involves veterans. Due to the nature of our recent wars, many veterans suffer from painful injuries caused by explosions. They frequently suffer from traumatic brain injuries (TBI) of varying severity. In fact, both pain and sleep disorders have both been associated with TBI.

 Of course, few civilians who suffer PTSD have similar experiences, so the role TBI may play in the development of comorbid PTSD and chronic pain remains to be determined. 

In addition, research has shown that PTSD may not only be associated with both pain and sleep disorders, but also play a role in acute pain becoming chronic pain.

Since we have yet to identify a markedly efficacious treatment for PTSD, adding chronic pain as a factor further complicates care decisions. Furthermore, although there has been much speculation as to which factors predispose people to develop PTSD and chronic pain separately, we still have no final answer, and we have limited ability to predict who is at increased likelihood for developing both.

For all 3 problems—PTSD, sleep disorders, and chronic pain—psychologically based therapies appear to be among the most promising treatments. They also do not carry the same risks of exacerbating another condition as do medications.

Since psychiatrists often treat PTSD and even sleep, there is little doubt they will see patients with comorbid chronic pain. Unless psychiatrists also are knowledgeable about pain and its management, we will not be able to provide optimal care for our patients.

 is in private practice in Philadelphia.

This article was originally posted on October 21, 2020, and has since been updated. Scroll down for the 

 of the full print issue in which it appeared. -Ed

Pain may not often be considered within the realm of psychiatry; however, chronic pain's relationships with sleep disorders and PTSD make it an issue psychiatrists can—and should—address.  

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