Consortium Against Pain InEquality (CAPE): The impact of adverse childhood experiences on chronic pain and responses to treatment

The World Health Organisation describes Adverse childhood experiences (ACEs) as the commonest and most intense childhood stressors. ACEs include physical and emotional abuse, neglect, and other challenging household circumstances. About half of us may endure at least one, but children exposed to several are likely to have more health problems later in life, including chronic pain. There are links between exposure to multiple ACEs and social deprivation.  The likelihood of ACE exposure is higher for boys, and for children of a young mother. Although there is good evidence that ACEs contribute to health inequalities, there is no widespread screening or generally accepted approach to reducing long term harms. Reasons for this include lack of understanding and inadequate assessment, with little consideration of other factors that might increase vulnerability.

The CAPE consortium brings together people from a wide range of backgrounds – such as scientists, people with lived experience of ACEs and chronic pain, clinical researchers, epidemiologists and psychologists. We are using an inclusive approach to integrate biological, psychological and social factors to understand the impact of ACE on chronic pain and how people respond to treatment. There are 5 related work packages:

1. We are developing a questionnaire-based assessment that captures ACEs by analysing existing approaches to see which ones work best. Alongside this we are capturing people’s first-hand accounts, to ensure that lived experiences of ACEs and chronic pain, are accurately reflected in our approach. Working with patient partners in the Chronic Pain Advisory Group we are bringing together this information to develop and test a new ACE questionnaire (the CAPE ACEQ). 
2. The CAPE ACEQ will be used to enrich pre-existing data in large scale population research datasets, (e.g. Generation Scotland). We will also collect data about pain and social interactions (adult relationships). We will link this to prescribing and health records (including mental health) to identify psychosocial factors that create vulnerability to chronic pain and negative responses to treatment in those exposed to ACEs. We will examine whether the increased burden of chronic pain, which disproportionately affects those exposed to multiple ACEs, leads to higher levels of prescribing opioid pain killers and associated adverse events that are more common in deprived communities.
3. We are also collecting data on pain, its impact (mood, sleep, fatigue etc), ACEs, health and social factors from a group of young patients suffering from a condition called juvenile idiopathic arthritis (JIA), who attend a specialist unit in London. We will use the data to understand what factors lead to different pain routes and outcomes in these young people.
4. We are using brain imaging data from existing population studies and new brain imaging from the JIA group, to establish whether there are changes in brain structure and/or function that may be associated with the development of poor pain and prescribing outcomes in those exposed to ACEs.
5. We are seeking biological markers of vulnerability or resilience to chronic pain and treatment in those exposed to multiple ACEs. For this we will study epigenetic factors, and test properties of brain cells, from donated samples. Participants in a population study called the Lothian Birth Cohort will be asked about their exposure to ACEs. Many of them have consented to donate brain tissue post-mortem and have already provided blood to produce stem cells. These stem cells will be differentiated to form brain cells, allowing us to better understand the effects of early life stress.

We anticipate that high quality evidence linking ACEs to chronic pain and treatment outcomes, combined with knowledge of mental health and social support, will provide a basis to develop individualised approaches to pain management and identify public health interventions to improve outcomes.