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More Americans say they're in pain. It’s a fascinating and disturbing medical mystery.

Opioid painkillers may make us more sensitive to pain.

More than a third of Americans now experience chronic pain — more than those who have cancer, heart disease, and diabetes combined. And startling recent data shows that the severity of pain Americans report is increasing each year.

Chart showing that the number of Americans reporting chronic pain has increased from 1998 to 2010.

Pain is an incredibly complicated medical issue to diagnose, measure, and treat. Prescription painkillers meant to reduce the number of Americans living in pain have instead given rise to serious opioid addiction and an overdose epidemic.

But even as states (such as New Jersey) now try to curtail opioid abuse by limiting prescriptions, it’s critical that we see chronic pain as the serious public health issue it is, according to Hanna Grol-Prokopczyk, a medical sociologist at the University at Buffalo who’s doing some of the most interesting research on pain these days.

“We cannot forget people who are really suffering from chronic pain — which is a sizable minority of the US population,” said Grol-Prokopczyk.

In a paper published in 2016, Grol-Prokopczyk uncovered huge disparities in how Americans experience pain. Examining 12 years of data from the biennial Health and Retirement Study, she found that women were more likely to experience severe pain than men, and people without a high school degree were nearly four times as likely to experience severe pain as someone with a graduate degree.

Additionally, she found that pain predicted death. Americans who experienced severe pain had twice the odds of dying in the next two years; pain may even have a role in the recent uptick in mortality among middle-aged Americans.

I called up Grol-Prokopczyk to learn more about how chronic pain is increasing in America, how chronic pain is categorized, and how we can better treat people suffering from it. What follows is our conversation, edited for length and clarity.

Sarah Frostenson

Your finding that 37 percent of Americans reported chronic pain in 2010, up from 27 percent in 1998 — was this a surprise to you?

Hanna Grol-Prokopczyk

Yes. In fact, I didn’t find any evidence of pain plateauing. Rather, I saw pain levels go up linearly with age.

Chart showing that all age groups have experienced more chronic pain since 1998.

So I tried to understand why I was seeing something different than previous studies that found pain plateaued around age 60. It turns out there are two things at play.

One is that pain predicts death, and people who report more severe pain are more likely to die and disappear from the survey averages.

I’m not saying pain directly causes their death. But the research isn’t clear on whether there are health conditions that cause both pain and death or if there is something more direct going on, where pain — by either reducing the will to live or reducing the ability to exercise or socialize — increases one’s likelihood of dying.

The second thing is reported pain levels are going up each year, meaning that even for the same age group, people on average experienced more pain in 2010 than they did in 1998.

I knew that prescriptions for opioid analgesics had gone up dramatically during this same time period [1998 to 2010], so I assumed that more prescriptions for [them] would lead to less pain, not more pain. So to discover pain levels were going up even during a period of increased opioid prescriptions was very surprising to me.

Sarah Frostenson

Do we understand the underlying causes of chronic pain in the US and why a growing number of Americans are suffering from increasingly severe chronic pain?

Hanna Grol-Prokopczyk

For a lot of chronic pain conditions — for example, a lot of low back pain — no one knows exactly what’s underlying it.

But I can certainly try to put forward some hypotheses for why chronic pain’s prevalence is increasing in the US.

One is whether the high use of opioids themselves have led to a rise in levels of reported pain, given growing evidence that chronic opioid use can actually increase one’s sensitivity to pain.

A second thought is there might be something in the changing weight distribution of the US. If you’re heavier, for example, maybe you’re putting more pressure on your joints and this contributes to more mechanical causes of pain.

And as far as socioeconomic disparities we’ve observed, we can make lots of guesses about increased levels of chronic pain being related to occupation or quality of health care. But we definitely need more research to better understand these patterns.

Sarah Frostenson

Your paper examined many of the disparities when it comes to long-term pain in the US — whether it’s women being more likely than men to suffer from pain or those with less education being more susceptible. How did your findings challenge common perceptions?

Hanna Grol-Prokopczyk

Studies consistently find that women experience more chronic pain than men and that lower socioeconomic status is associated with more pain than higher socioeconomic status. But because most studies used just a yes/no response to measure pain, they didn’t pick up on the fact that these disparities are even bigger than we previously thought.

Women and people disadvantaged in education and wealth also experience more severe pain. And the differences are often really substantial in scale.

Chart showing that women and people with less education suffer from more severe pain.

For example, if you’re comparing educational groups, people who did not obtain a high school degree are about 4.5 times as likely to experience severe pain as people who obtained a graduate degree. If you put that into percentages, people who only graduated high school have about a 370 percent higher chance of experiencing severe pain.

My findings also confirm what other studies have shown, which is that once you control for socioeconomic status, racial and ethnic minorities actually seem to fare better than whites when it comes to pain.

This is one of those rare health problems where you see that pattern.

But when I looked at the different severity of pain reported, I saw it’s a somewhat more complicated picture. African Americans don’t report more pain than whites, but they do report more severe pain.

Sarah Frostenson

So when we look at disparity of pain by race and ethnicity, it’s more so that African Americans only experience less pain than whites when the pain is not acute or severe? Otherwise this “advantage” disappears?

Hanna Grol-Prokopczyk

Yes, so if you’re just looking at severe pain, that’s right. You would see bigger differences between whites and racial and ethnic minorities, with whites reporting less severe pain.

Chart showing that black people experience more severe pain than white people

Sarah Frostenson

Is this true of Hispanic Americans as well?

Hanna Grol-Prokopczyk

So Hispanics also report more severe pain than whites, but what’s tricky in that case is they appear to report pain differently than both black and white Americans.

It seems as if Hispanics have a more expressive rating style, which means they are more inclined to use the word “severe” as opposed to “moderate” or “mild” to describe their pain. And so it’s difficult to compare their reporting of severe pain to white respondents’ reporting of severe pain.

Sarah Frostenson

Given just how difficult it can be to diagnose pain and how inconsistent people are in rating pain, what are some improvements to make the data more comparable?

Hanna Grol-Prokopczyk

That’s a great question. I don’t think we have a perfect way of getting objective, comparable measures of pain across different people or different groups, in part because chronic pain epidemiology is a fairly new field. People are still figuring out how to measure pain and how to avoid biases.

Sarah Frostenson

There’s a growing body of evidence that suggests we don’t really understand if opioids are at all effective in treating chronic long-term pain. One unfortunate consequence of this is that the number of drug overdose deaths from opioid addiction has skyrocketed in the last 15 years.

So how do we effectively treat people living with real and persistent pain?

Hanna Grol-Prokopczyk

If there were a fantastic, super-effective and super-safe substitute for opioids, I think everyone would already know about it.

Dennis Turk and colleagues, who periodically review the effectiveness of various strategies for managing pain, found in a 2011 paper that current treatments provide “modest improvements” in managing pain and “minimum improvements” to one’s physical and emotional well-being.

Basically, they’re saying we don’t have particularly good pain treatments available.

So if we’re going to cut down dramatically on opioid prescriptions, which we’re already doing, we cannot forget people who are really suffering from chronic pain — which is a sizable minority of the US population.

Map showing which states have passed legislation to limit opioid prescriptions to 7 days or less.
There is growing momentum among state legislatures to restrict the number of days a doctor can prescribe a patient opioids.

Let’s recognize that we need to invest in either figuring out how to prevent chronic pain or treat[ing] it in a way that doesn’t have all the deleterious effects of opioids. Unfortunately, I don’t have a great answer for what the alternative is, but I want to make sure that we don’t just think, “Okay, let’s limit opioid prescriptions, and we’re all done.” Because the problem of chronic pain is going to remain.

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