Faculty Perspectives in Chronic Pain, Part 1 of 5
Socioeconomic Burden of Chronic Pain
Chronic pain is a debilitating condition that is associated with significant medical, emotional, and economic burdens. The International Association for the Study of Pain defined chronic pain as pain that persists past the normal time of healing, which may be less than 1 month, or more commonly, 3 months.1 However, there is no universally accepted standard definition of chronic pain. It may occur in the context of numerous illnesses and syndromes, including musculoskeletal disorders, joint pain, fibromyalgia, headaches, neuropathy, and pain after trauma and surgery.1
The experience of any pain, including chronic pain, is subjective and is influenced by various factors. According to the 2011 Institute of Medicine (IOM) report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, chronic pain is “influenced by genetics, early life experiences, mood and psychological state, coexisting medical conditions, and environments.”2 Despite the biological, cognitive, and emotional implications of chronic pain and several treatment strategies available for its management, chronic pain is underreported, underrecognized, and undertreated, with associated social and economic ramifications.2
This article will discuss the social and economic impact of chronic pain, existing barriers to pain management, and multiple strategies to overcome these barriers.
Prevalence of Chronic Pain
The IOM considers chronic noncancer pain a public health problem, partly because of its pervasive prevalence in the United States.2 According to the IOM, approximately 100 million US adults have some type of common chronic pain condition.2 An independent, cross-sectional, Internet-based survey asserted that self-reported chronic pain—defined as pain that is not fleeting or minor and lasting at least 6 months—occurred in 30.7% of the US population.3 Furthermore, 89% of the respondents with chronic pain had experienced the pain for at least 1 year, and 86% of individuals had experienced the pain at least 2 to 3 times weekly.3
The incidence rates for chronic pain are increasing and will likely continue to rise in the United States.2 The National Health and Nutrition Examination Survey (NHANES) data indicate that there was a significant increase in pain prevalence between 1999 and 2004, and this was apparent in different patient subpopulations of age, race, sex, and poverty level.2 In addition, data from the Department of Veterans Affairs showed a 4.8% annualized increase in the prevalence of low back pain between 2000 and 2007, which was more rapid than the prevalence of other conditions, including diabetes (4.4%), hypertension (4.1%), and depression (3.8%).4
Findings from the 2008 Medical Expenditure Panel Survey (MEPS) 2-year longitudinal data showed that the total number of adults with chronic back pain increased by an alarming 64% between 2000 and 2007.5 Increases in the prevalence of chronic pain may be attributed to multiple factors, including an aging population and the rising prevalence of chronic conditions, such as obesity and diabetes.2,5
Further epidemiologic analyses of the National Center for Health Statistics data revealed that musculoskeletal pain, particularly joint pain and back pain, is the single most common type of chronic pain, with 28.1% of US adults reporting low back pain.2 Other causes of chronic pain include knee pain (19.5%), severe headaches or migraine (16.1%), neck pain (15.1%), shoulder pain (9.0%), finger pain (7.6%), and hip pain (7.1%; Figure).2
Although the risk for developing chronic pain is universal, there are specific patient populations that are disproportionately vulnerable to, and undertreated for, pain.2 Increased vulnerability to pain is associated with numerous factors, some of which include sex, age, race and ethnicity, income and education, geographic location, and cognitive impairments.2
The prevalence of chronic pain is higher among women than among men—a trend that is apparent across different ethnicities and illnesses.6 Women are more likely than men to experience greater pain severity and to develop certain chronic pain conditions, including chronic fatigue syndrome, endometriosis, fibromyalgia, vulvodynia, and interstitial cystitis—many of which may occur concurrently.7,8
In addition, there is a marked disparity in the prevalence of several common types of musculoskeletal pain in women compared with that in men.2 For example, severe headaches were reported in 21.9% of women versus 10.1% of men; neck pain was reported in 17.5% of women versus 12.6% of men; and low back pain was reported in 30.1% of women versus 26.0% of men. Furthermore, chronic pain is found to be more common with increasing age; the prevalence of chronic pain among the elderly ranges from 18% to 57%. Poor socioeconomic status is also linked to higher prevalence of chronic pain.2
In the United States, the prevalence of chronic pain based on racial and ethnic categories has shown inconclusive results.9-11 Findings from the NHANES data (between 1999 and 2002) indicated that the reported rates for African Americans were similar to non-Hispanic whites for face/teeth, back, legs/feet, arms/hands, abdomen, and chest pain. In the same study, Mexican Americans had the lowest rates of chronic pain in the same pain locations compared with African Americans and non-Hispanic whites.11 In a study of experimental pain tolerance and adjustment to chronic pain in 337 patients with chronic pain, African Americans had higher levels of clinical pain, as well as greater pain-related disability compared with that of white participants.9 These results were substantiated by a quantitative review of 26 studies, in which African Americans demonstrated lower pain tolerance compared with non-Hispanic whites.10
A recent study that was based on the NHANES data between 2003 and 2004 postulated that socioeconomic differences may contribute to the apparent racial and ethnic disparities. In this study, individuals with the highest socioeconomic positions tended to experience less chronic pain compared with individuals in low socioeconomic positions.12
Population-based studies have similarly shown an inverse relationship between chronic pain prevalence and socioeconomic status, which is typically measured by education, employment, and poverty levels. For example, an individual without a high school diploma or a general equivalency degree was 1.33 times more likely to experience severe headaches and 1.28 times more likely to suffer from low back pain compared with an individual with at least some college education.2 In addition, an individual who was below 100% of the poverty level was 1.76 times more likely to experience severe headache or migraine and 1.48 times more likely to suffer from low back pain compared with an individual who was at least 400% of the poverty level (Table 1).2
It is important to note that the reports of disparate prevalence rates of chronic pain may be partly influenced by differences in the definition of chronic pain, disease severity, assessment, population characteristics, and physician management.2 Other factors that may contribute to differences in chronic pain may be attributed to greater pain sensitivity and lower pain tolerance among African Americans compared with other subgroups. For the Hispanic population, these differences may be attributable to cultural differences regarding the acceptability and expression of distress.2
Impact of Chronic Pain on Functional Impairment and Quality of Life
Current evidence indicates that approximately 22% to 25% of individuals experience moderate-to-severe chronic pain,3 and 10% of individuals experience severe disabling chronic pain.2 As may be expected, individuals with moderate-to-severe chronic pain also experience a marked decrease in their physical, psychological, and social well-being, more so than those with mild pain. Chronic pain can be so debilitating that it can affect every aspect of an individual’s quality of life (QoL), including the ability to perform daily activities, work, and maintain friendships and family relationships.2,13
Furthermore, chronic pain results in emotional distress and is consistently linked to an increased risk for depression and/or anxiety disorders.14 In 1 study, approximately 45% of 250 primary care patients with chronic musculoskeletal pain screened positive for at least 1 of the 5 most common anxiety disorders, including generalized anxiety, posttraumatic stress, social anxiety, panic, and obsessive-compulsive disorder.15 Compared with patients who screened negative for anxiety disorders, patients who screened positive reported significantly worse health-related QoL. In addition, the number of screen-positive anxiety conditions had an additive effect on psychological and pain-related functional impairment, regardless of the type of anxiety disorder.15
The emotional distress that is associated with chronic pain has detrimental effects on family relationships, home responsibilities, and friendships. Families of patients with chronic pain have reported “feeling powerless, alienated, emotionally distressed, and isolated.”16
The impact of chronic pain on everyday family life may be reflected in role reversals, where the patients’ responsibilities and duties are shifted to partners, children, or extended family members.16 Chronic pain may interfere with work and often results in the loss of employment, early retirement, and disability—all of which have a devastating impact on the family.16 One study that examined the transitions experienced by women with fibromyalgia reported significant relationship changes with family and friends, with notable changes in partner support and understanding, and role shifting in children.17
Disparities in caregivers’ assessment of individuals’ pain severity and disability have been reported; these disparities may lead to feelings of neglect or overprotective behaviors.16 Patients and their caregivers may also experience emotional turmoil, including frustration and anger as a result of their present situation, as well as self-blame and fear about their immediate future and potential pain resolution. Given the subjective and controversial nature of chronic pain, patients and their families frequently face social isolation that leads to further aggravation of their emotional distress.16
Socioeconomic Burden of Chronic Pain
The economic costs associated with the management of chronic pain, including direct healthcare costs and indirect costs, are astronomical in the United States. Using the 2008 MEPS data, the American Pain Society and the IOM estimated that the total national cost of pain ranged from $560 billion to $635 billion annually in direct treatment costs and lost productivity.2,18 Although the direct healthcare costs (eg, medication costs and hospital-based services) were considerable, the indirect costs that accounted for disability compensation and lost work productivity were even higher. It was estimated that the total incremental costs of medical expenditures ranged from $261 billion to $300 billion (Table 2).18 In addition, the indirect costs that were attributed to lost productivity based on the days of work missed, the annual hours of work lost, and lower hourly wages ranged from $299 billion to $335 billion. These estimates are considered to be conservative assessments and do not include (1) the costs associated with the care of institutionalized individuals, military personnel, and children aged ≤18 years; (2) the cost of pain to caregivers; (3) lost productivity of individuals aged <24 years and aged >65 years; (4) time lost for other nonwork-related activities; and (5) other indirect costs (eg, lost tax revenue, legal fees).18
Self-reported back and neck problems account for a large proportion of healthcare expenditures.19 Furthermore, total estimated spine-related expenditures increased by 65% between 1997 and 2005.19 A recent study based on the MEPS data reported an increase of 129% in inflation-adjusted (to 2010 dollars) biennial expenditures on ambulatory services for chronic back pain, increasing from $15.6 billion in 2000 to 2001 to $35.7 billion in 2006 to 2007.5
Compared with the general population, the expenditures of chronic pain are higher among certain high-risk patient populations, including women, the elderly, obese individuals, individuals with diabetes, and individuals experiencing severe pain.2 Using the 2008 MEPS of 20,214 individuals representing the US civilian noninstitutionalized population, it was estimated that annual healthcare expenditures were $4516 higher for individuals with moderate pain compared with those with no pain, and $3210 higher for individuals with severe pain compared with those with moderate pain.18 Specifically, individuals with joint pain and arthritis were found to have expenditures that were $4048 and $5838 higher, respectively, than for individuals without these conditions.18 Furthermore, healthcare spending rose with increased education, income, and health insurance status, and African Americans, Hispanics, and Asians were less likely than non-Hispanic whites to have healthcare expenditures.18
Unfortunately, undertreatment of pain has been well-documented in the overall population but more so in several groups at risk, including the elderly, women, ethnic and racial minorities, and individuals with low socioeconomic status.2 For example, 1 study that used data from the Health and Retirement Study to assess the need and receipt of hip or knee joint replacement surgery found that of the 14,807 adults who were assessed, African Americans were 53% less likely to have undergone surgery compared with white Americans.20 Similarly, another study showed that African Americans and Hispanics were less likely to receive an opioid drug as an analgesic compared with white individuals.21 In addition, individuals without a college education were 35% less likely to have undergone surgery. Interestingly, these differences could not be explained by factors such as employment status, access to medical care, family responsibilities, disability, or comorbidity.20
In addition to socioeconomic status, racial and ethnic disparities in pain treatment may be attributed to the differences in patient assertiveness, physician perception of the patient, and social distance.21 Undertreatment of pain in the elderly may be attributed to the underreporting of pain, presence of comorbidities that complicate diagnosis and treatment, higher rates of drug-related side effects and treatment complications, potential interactions with medications taken for other chronic conditions, and inadequate information regarding appropriate dosing.2,22
Although the financial costs associated with chronic pain may be quantified, the impact of chronic pain on QoL is difficult to measure with any degree of accuracy and is typically not accounted for in cost analyses.23
Barriers to the Effective Management of Pain and Strategies to Overcome Them
The IOM has identified several significant barriers to the optimal management of pain, including institutional, educational, organizational, and reimbursement-related barriers, all of which apply in the chronic pain setting.2 Foremost, there is considerable lack of awareness regarding the magnitude of the socioeconomic burden associated with chronic pain and the importance of pain management among patients, healthcare providers, employers, regulators, and payers—resulting in significant medical and emotional ramifications13; this provides the rationale for addressing the deficiencies in knowledge and awareness among all stakeholders.
At the healthcare provider level, there is an unmet need in several areas, including deficiencies in knowledge and competency; underestimation of pain prevalence; lack of awareness of pain’s impact on QoL and healthcare resources; and failure to implement well-validated, evidence-based guidelines for the assessment and management of pain. Deficiencies in these areas may hamper the delivery of high-quality care.2,13
In particular, there is confusion among providers regarding the proper clinical use of opioid medications and their potential for misuse, abuse, and diversion. In addition, many clinicians do not recommend interdisciplinary pain management services to their patients.2 Furthermore, current evidence indicates that there is a lack of implementation of, and nonadherence to, evidence-based guidelines among practitioners. In a cross-sectional study that used a mailed survey, the majority of primary care physicians who responded were found to be noncompliant with evidence-based Agency for Healthcare Research and Quality’s guidelines for the initial management of chronic low back pain.24 Clearly, there is an urgent need for education and training of healthcare providers, patients, and the public at large, in addition to collaboration among all stakeholders, including social service workers and policy makers, to address the gaps in knowledge and competencies in the care of individuals with chronic pain.
Cultural attitudes and geographic barriers may prevent patients from seeking help for pain relief, a problem that may be compounded by a lack of insurance coverage.2 Although self-management is integral for preventing flare-ups and reducing functional impairment, it is often not implemented by patients.2 Therefore, patient education and measures to increase public awareness are critical for pain management. Patient education should include several components, including the prevention of common types of pain, timing and methods of self-treatment, knowing the appropriate time to consult a physician, treatment goals, and access to other resources and support.13
Patient education has been shown to improve disability, pain, and QoL.25 However, available evidence indicates that past educational initiatives were often not high-quality programs and were ineffective for improving intermediate- or long-term effects on pain and disability compared with noneducational interventions.26 In particular, it was reported that mass media educational campaigns alone did not lead to positive and persisting behavioral changes.27 Taken together, these data indicate the need for innovative and effective approaches, including social marketing and policy changes, to improve public understanding and behavior.27
System-level barriers that are largely driven by reimbursement policies may limit frequent physician visits and restrict comprehensive assessments. The underuse of interdisciplinary management may also hinder patient-centered care. In addition, regulatory and law enforcement policies may constrain the appropriate use of opioid drugs.2
Overall, the current IOM recommendation is to identify and develop comprehensive approaches for overcoming existing barriers to pain care, particularly for high-risk patient populations and individuals who are undertreated for pain.2 Ideally, patients with chronic pain should have access to interdisciplinary care, including pharmacological therapy, physiotherapy, clinical psychology, surgery, invasive techniques, occupational therapy, and rehabilitation medicine.2
The IOM recommends that: (1) healthcare providers offer pain assessments that are consistent and complete; (2) pain specialty organizations work together to collaborate between pain specialists and primary care physicians, including referral to specialized pain centers when appropriate; and (3) payers and healthcare organizations revise reimbursement policies to provide optimal, evidence-based pain care.2
Given the important role of caregivers and family members in the effective management of patients with chronic pain, their support and inclusion in assessment, treatment, and rehabilitation programs are also required.16,17
Chronic pain is increasingly being recognized as a public health concern, with enormous clinical, social, and economic burdens. There are well-documented disparities in pain assessment and treatment in disadvantaged groups, including in the elderly and in racial and ethnic minorities. The urgency of coordinated management of this condition must be stressed among stakeholders. Because chronic pain is influenced by numerous interacting and contributing causes, as well as several effects, pain care must be tailored to each individual’s experience; this demands an interdisciplinary approach that includes a combination of physiological, cognitive, psychological, clinical, and self-care methods.
- International Association for the Study of Pain. Classification of Chronic Pain. Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2nd ed. Seattle, WA: IASP Press; 1994.
- Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011. http://books.nap.edu/openbook.php?record_id=13172&page=17. Accessed November 10, 2014.
- Johannes CB, Le TK, Zhou X, et al. The prevalence of chronic pain in United States adults: results of an Internet-based survey. J Pain. 2010;11:1230-1239.
- Sinnott P, Wagner TH. Low back pain in VA users. Arch Intern Med. 2009;169:1338-1339.
- Smith M, Davis MA, Stano M, Whedon JM. Aging baby boomers and the rising cost of chronic back pain: secular trend analysis of longitudinal Medical Expenditures Panel Survey data for years 2000 to 2007. J Manipulative Physiol Ther. 2013;36:2-11.
- Fillingim RB, King CD, Ribeiro-Dasilva MC. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10:447-485.
- End Women’s Pain. Chronic pain in women: neglect, dismissal, and discrimination. June 2011. www.endwomenspain.org/Common/file?id=24. Accessed November 10, 2014.
- Green CR, Hart-Johnson T, Loeffler DR. Cancer-related chronic pain: examining quality of life in diverse cancer survivors. Cancer. 2011;117:1994-2003.
- Edwards RR, Doleys DM, Fillingim RB, Lowery D. Ethnic differences in pain tolerance: clinical implications in a chronic pain population. Psychosom Med. 2001;63:316-323.
- Rahim-Williams B, Riley JL III, Williams AK, Fillingim RB. A quantitative review of ethnic group differences in experimental pain response: do biology, psychology, and culture matter? Pain Med. 2012;13:522-540.
- Hardt J, Jacobsen C, Goldberg J, et al. Prevalence of chronic pain in a representative sample in the United States. Pain Med. 2008;9:803-812.
- Riskowski JL. Associations of socioeconomic position and pain prevalence in the United States: findings from the National Health and Nutrition Examination Survey. Pain Med. 2014;15:1508-1521.
- Breivik H, Eisenberg E, O’Brien T; OPENMinds. The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care. BMC Public Health. 2013;13:1229.
- Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003;163:2433-2445.
- Kroenke K, Outcalt S, Krebs E. Association between anxiety, health-related quality of life and functional impairment in primary care patients with chronic pain. Gen Hosp Psychiatry. 2013;35:359-365.
- West C, Usher K, Foster K, Stewart L. Chronic pain and the family: the experience of the partners of people living with chronic pain. J Clin Nurs. 2012;21:3352-3360.
- Söderberg S, Lundman B. Transitions experienced by women with fibromyalgia. Health Care Women Int. 2001;22:617-631.
- Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13:715-724.
- Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299:656-664.
- Steel N, Clark A, Lang IA, et al. Racial disparities in receipt of hip and knee joint replacements are not explained by need: the Health and Retirement Study 1998-2004. J Gerontol A Biol Sci Med Sci. 2008;63:629-634.
- Tamayo-Sarver JH, Hinze SW, Cydulka RK, Baker DW. Racial and ethnic disparities in emergency department analgesic prescription. Am J Public Health. 2003;93:2067-2073.
- Barber JB, Gibson SJ. Treatment of chronic non-malignant pain in the elderly: safety considerations. Drug Saf. 2009;32:457-474.
- Phillips CJ, Harper C. The economics associated with persistent pain. Curr Opin Support Palliat Care. 2011;5:127-130.
- Webster BS, Courtney TK, Huang YH, et al. Physicians’ initial management of acute low back pain versus evidence-based guidelines. Influence of sciatica. J Gen Intern Med. 2005;20:1132-1135.
- Albaladejo C, Kovacs FM, Royuela A, et al. The efficacy of a short education program and a short physiotherapy program for treating low back pain in primary care: a cluster randomized trial. Spine (Phila Pa 1976). 2010;35:483-496.
- van Middelkoop M, Rubinstein SM, Kuijpers T, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J. 2011;20:19-39.
- Gross DP, Deshpande S, Werner EL, et al. Fostering change in back pain beliefs and behaviors: when public education is not enough. Spine J. 2012;12:979-988.
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