Chronic pain syndrome is an extremely complicated diagnosis and the treatment of its symptoms requires an interdisciplinary approach ranging from primary care physicians, physical therapists, anesthesiologists, and psychologists. Likewise, understanding the barriers to the treatment of chronic pain requires teasing out a similarly convoluted picture. Therefore, I’ve decided to write about the extremely complex and understudied relationship between poverty and pain. Not surprisingly, there are many components to this relationship because the American health care system is one that involves many players from the government, private sector, non-profits, and Medicare, Medicaid, TRICARE, Children’s Health Insurance Program, Social Security Administration, and the Veteran’s Administration, just to name a few. However my focus will be narrowed to concentrate on the relationship between living in poverty and efficacious treatment of chronic pain, the flip side of that relationship where individuals fall into poverty as a result of a life-altering, limiting, and costly diagnosis of chronic pain, and the stigma of poverty that consciously or unconsciously affects access to treatment for patients in pain. I am going to limit this entry to the first of these relationships and cover the latter in a subsequent post.
To understand how living in poverty affects access to successful pain management, I want to discuss a few studies that have been conducted and yielded strikingly similar conclusions. In the article, “Independent Associations of Socioeconomic Factors with Disability and Pain in Adults with Knee Osteoarthritis,” Cleveland et al. (2013) examined the correlation between lower socioeconomic status (SES) in both individual and community factors. In a study of 2,385 participants, the researchers found that individuals with lower SES, associated lower educational status, and exposure to occupational hazards were at a higher risk of developing disability and pain due to knee osteoarthritis. Therefore, they experienced pain at a higher incidence than their more affluent counterpart. Furthermore, as pain increased, these individuals did not have access to affordable service interventions or access to quality healthcare because of their socioeconomic status. At the community level, their study revealed that communities that had greater incidences of poverty also had higher levels of pain due to limited resources, fewer pain clinics, not having as many transportation alternatives, experiencing cracked sidewalks and unkempt streets, and few options within their community to exercise at affordable fitness centers. How strong is the relationship between lower socioeconomic status and pain? It turns out that the correlation is so strong that no matter what definition of socioeconomic disadvantage is used the results yielded are consistent as detailed through Ellen L Poleshuck and Carmen R. Green’s 2008 article “Disadvantage and Pain.” The authors found that lower socioeconomic status has routinely been correlated with almost every aspect of poor health indicators such as decreased life expectancy and morbidity (incidence rate of disease), and chronic pain was no different. Living in poverty increases an individual’s risk for pain on almost every level including musculoskeletal, sciatica, ulcer, and neuropathic. Poleshuck and Green suggest that an individual’s socioeconomic status permeates almost every level of why an individual may suffer with chronic pain including the ability to implement positive coping strategies, job type and satisfaction, access to quality health insurance, and even social support and interpersonal relationships.
Perhaps, it doesn’t come as much of a surprise that the link between living in poverty and experiencing greater amount of pain is strong when analyzing American communities. According to the UN’s 2012 Human Development Index, (a multifactorial statistical analysis of life expectancy, income, education, etc. that ranks countries accordingly) when adjusting for inequality the United States ranked 16 in the world. However, what was most astounding in my research for this post was a study that came out of Norway, a country that consistently ranked number 1 on the Human Development Index even after adjusting for inequality. The study performed by Mette Brekke, Per Hjortdahl, Tore K. Kvien (2002) found that even in an egalitarian country such as Norway, the individuals that lived in the less wealthy areas experienced very high levels of pain, disability, and depression related to chronic pain compared to the more affluent regions of the country.
Why are these studies important? For health care providers, the association between poverty and pain has major implications for treating this population according to their needs. For example, if an individual is discharged from aquatic therapy and told to follow their exercises accordingly but does not have access to a community center with a pool then the benefits of treatment decreases. Since communities with lower SES have a higher likelihood of comorbidity, patients walking a tightrope between health and finances often have to decide which disease they will treat medically and which one they will ignore. Having a pain disorder is life-altering but doesn’t carry the threat of life-ending. As a result, patients will choose to receive treatment for the life-threatening disease but ignore treatment for debilitating pain. Poleshuck and Green (2008) argue that it isn’t just practitioners that have to be aware of lower SES when thinking about approaches to pain. Researchers also need to be aware of the connection between living in poverty and pain. They argue that too often research on chronic pain is conducted in areas that have significant financial resources instead of places such as churches, homeless shelters, and community centers. There are other things to consider here. People that live in poverty and suffer from pain may not have access to primary care givers, analgesics or pharmacies that carry analgesics, and pain specialists. As the U.S. population ages and increasingly more people are diagnosed with pain disorders, those on the fringe will suffer most. Of course, there is a moral argument to be made here but there is an economic one too. According to an article that came out in Science Daily in 2012, health economists at Johns Hopkins estimated that chronic pain cost as much as $635 billion a year which they found was higher than heart disease, diabetes, and cancer. This was a conservative estimate. Therefore, one could argue that it is a public health interest to employ strategies of risk management, access, and multidisciplinary approaches to pain to vulnerable groups who suffer disabling pain at a higher number and magnitude.
For those interested
Cleveland et al. full study:
Poleshuck and Green’s study:
Science Daily’s summary: