Spotlight - Theresa Mallick-Searle

"Pain is common, pregnancy is common, and the overlap between the two can be challenging for both clinician and patient. Some women may even forgo having a child for the fear of unmanageable pain during the course of pregnancy.”

—Tracey Mallick-Searle

 

Long time PAINWeek and PAINWeekEnd presenter Theresa (Tracey) Mallick-Searle, MS, PMGT-BC, ANP-BC, Stanford Health Care, Division Pain Medicine, Redwood City, California, has been a registered nurse for over 25 years and a nurse practitioner in pain management for over 20 years, caring for patients with chronic and acute pain during pregnancy. Her book, Holistic Pain Management in Pregnancy: What RNs, APRNs, Midwives and Mental Health Professionals Need to Know, offers practical, clinical approaches and tips on treatment.

Weekend Dose: What lit the fire in you to write this book?

Theresa Mallick-Searle: It was really during my time on the acute pain consult service at Stanford that I recognized the need for additional clinician education about safe and practical pain management during pregnancy. As pain management experts, we knew about multimodal pain management, and high risk obstetricians knew about overall safe and practical care of mother and fetus. What was needed was a broader appreciation for multidisciplinary care in this patient population, especially in the acute care setting. I then started to reflect more on the patients that I was seeing in the ambulatory chronic pain clinic and recognized that there was an overreliance on opioids (consistent with the national trend) and a general discomfort amongst my colleagues to care for these patients.

WD: When did you start the book?

TMS: I started lecturing on this topic over 5 years ago at regional and national conferences. It was after one of these lectures that I was approached by an international publishing house (Springer) to create a book on the subject matter for the nursing audience. As anyone knows who has published a book, or even an article for that matter, the publication process is a lengthy one. The completed manuscript went though many drafts over the period of a year, but it was during the COVID-19 “shut down” when I found the time (while not traveling) to complete the book😊.

WD: Are there other books that cover this topic?

TMS: When starting my research for this book, I recognized the lack of available resources on this topic, especially texts that provided insights to a multimodal treatment approach. Most academic texts written for clinicians devote a paragraph or maybe a few pages on the subject. There are quite a few books with a focus on physical therapy, and quite a few articles focusing on pharmaceutical considerations. What this book offers is a well-rounded focus on multimodal pain management in pregnancy starting with statement of the need, an overview of basic pain assessment, and a focus on the most common pain complaints that worsen or present during pregnancy. The tone of the book is one of a holistic focus on this patient population, and real-life case scenarios are presented.

WD: What was your objective in writing the book?

My objective was to provide the reader with the most up-to-date clinical information available on assessment and management of pain during pregnancy, applying a nurturing and holistic approach to the patient. An overview to the scope of the need, including a discussion on the use of opioids and the incidence of opioid use disorder is covered. Things that you can do to help your patient in preparation for a healthy pregnancy is reviewed, including optimization of diet, nutrition, fitness, mental health, and stabilization of chronic pain conditions. A few of the most common pain conditions that can present or worsen with pregnancy—including low back pain, pelvic girdle pain, migraine, and fibromyalgia—are presented in an approach to the diagnosis and treatment of these common painful conditions.

 

—IN A RECENT STUDY, which included a cohort of more than 500,000 pregnant women in the United States, it was discovered that 6% of women received opioids throughout all three trimesters and 14% of women filled an opioid prescription at least once during the antepartum period.[1] Another study involving over a million pregnant women discovered that almost one in five of them received prescribed opioids during pregnancy.[2]

 

WD: “Women are not small men.” Is pregnancy research lagging because men don’t give birth? Is it just assumed that being pregnant and giving birth is “natural” and therefore, if it hurts, that’s just how it is?

TMS: This is an interesting question, and you raise two points. Firstly, pregnancy research is lacking because of the ethics involved with doing research on pregnant females (and their unborn infants). This is a difficult research consideration to overcome. I think that the pharmaceutical industry and FDA have offered excellent resources for clinicians by setting up “pregnancy registries”—a way of obtaining information about medication exposures, as well as giving avenues for patients and their providers to share information about their experiences using certain medications during pregnancy.[3] Unfortunately, many clinicians or patients are not familiar with these registries and the valuable information that can be obtained. This is information that was VERY important for me to educate my readers about in this book.

The second point is the idea that, “being pregnant and giving birth is ‘natural’ and therefore, if it hurts, that’s just how it is.” Unfortunately, I think that many clinicians (both male and female) have this opinion. It is not that clinicians are uncaring, but they do not have the experience or understanding about how to manage chronic pain in this patient population. This is another issue that I address in the book, that women do NOT need to unnecessarily suffer for the sake of a healthy pregnancy. When a woman is supported physically, psychologically, and spiritually during her pregnancy the best possible outcomes will ensue.

WD: Can you tell us about a specific occurrence in dealing with a pregnant patient in chronic pain that has stayed with you?

TMS: Yes, and this is a very recent example. Before I met this particular patient, she was counseled by her treating providers during her first pregnancy to stop all migraine preventative treatments and was told she could use sumatriptan when needed. She struggled throughout her pregnancy with very poorly managed migraines. When it came to her second pregnancy, she approached her then-treating provider about considering a different treatment approach. She was told that sumatriptan was the only option. When she came to me, she had done her own research and presented the published pregnancy registry data on the use of Botox™ and wanted to have a discussion on risks and benefits. Her chronic migraines were very well controlled by receiving Botox injections every 12 weeks. The main takeaway from this scenario is that clinicians need to be open to having the discussion with patients about known risks, create a partnership with the patient that involves informed consent, and be willing to explore treatment options best for both patients—the mother and the fetus.

WD: Where would you like to see pregnancy care headed in the next decade?

TMS: Simply put, I would like to see more education available to clinicians about the need for effective pain management options during pregnancy, more focus on counseling women with chronic pain about their options, and optimization of their pain conditions early on. Finally, I would like to see more collaboration within the interdisciplines that manage patients with pain and pregnancy, including primary care, obstetrics, pain management, nursing, physical therapy, psychology, and pharmacy.

WD: What is your take home message?

TMS: This is a very underserved patient population, as many clinicians are fearful of taking on the responsibility of caring for this vulnerable population. With adequate education and knowledge of resources, caring for a woman with chronic or acute pain during her pregnancy can be the most rewarding professional experience a healthcare provider can have because it truly embodies the meaning of the patient-provider partnership of care, as well as the multimodal treatment model.

 

—BETWEEN 1999 AND 2010, death from opioid pain relievers increased fivefold in the United States.[4] Therefore, it was vital that Holistic Pain Management in Pregnancy: What RNs, APRNs, Midwives and Mental Health Professionals Need to Know provides more multimodal balanced pain management strategies.

 

WD: When you’re not working, how do you like to spend your time?

TMS: I love this question! When I am not “working”—seeing patients in my clinical practice, providing consults on the acute pain service, lecturing nationally, or writing—you will probably find me on a tandem bicycle with my husband, touring or hiking in the mountains.

 

At PAINWeek 2022, Mallick-Searle will be presenting Green Acres: Pregnancy & Pain in Rural Communities and co-presenting Duck Soup: Multidisciplinary Pain Management in 2022.

References

1. Bateman, Hernandez-Diaz, Rathmell, et al. Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States. Anesthesiology. 2014;120(5):1216-1224.
2. Desai, Hernandez-Diaz, Bateman, et al. Increase in prescription opioid use during pregnancy among medicaid-enrolled women. Obstet Gynecol., 2014;123(5):997-1002.
3. U.S. Food & Drug Administration. Pregnancy registries. www.fda.gov/science-research/womens-health-research/pregnancy-registries.
4. Mack, Jones, Paulozzi. Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999–2010. MMWR. 2013;62(26):537-542.