Why Americans Feel More Pain

“Tens of millions of Americans are suffering pain. But chronic pain is not just a result of car accidents and workplace injuries but is also linked to troubled childhoods, loneliness, job insecurity and a hundred other pressures on working families. [..]

[..] cluster of tightly woven problems that hold back our people and our country: childhood trauma, educational failure, addiction, mental health issues, homelessness, loneliness, family breakdown, unemployment — and, we increasingly recognize, physical pain.

“People’s lives are coming apart, and this leads to huge increases in physical pain,” said Angus Deaton, a Nobel Prize winner in economics who with Anne Case popularized the term “deaths of despair.” He, Case and Arthur A. Stone warn in a recent article that “the mystery of American pain reveals a warning for the future.” [..]

Medicines that work very well for acute pain, like opioids, were prescribed for many years for chronic pain [..], resulting in a tsunami of addiction that now claims more than 100,000 lives a year in overdoses alone — and leaving large numbers of pain sufferers dependent on pills that they now struggle to obtain. While opioids can provide relief, some experts also believe that opioids were never a sound choice for long-term pain. [..]

There is no single pain center in the brain, but chronic pain often reverberates in parts of the brain that can also be involved in emotions and traumatic memories [..]. As the title of a best-selling book by Bessel van der Kolk on how psychological trauma can manifest as physical pain, puts it, “The Body Keeps the Score.” [..]

Chronic pain is unusual among diseases of despair in that it disproportionately strikes women, who according to one study are 75 percent more likely than men to report severe pain. That apparently is because testosterone eases pain (boys and girls suffer pain equally until puberty).

The big factor in pain differences is class. One study found that poor Americans are more than three times as likely to report pain as wealthy Americans. Another found that just 2 percent of those with graduate degrees report severe pain, while almost 10 percent of high school dropouts do.

“Basically, if you’ve got a B.A., you’re vaccinated against all of this crap,” said Deaton, the economist. Deaton, Case and Stone found that each successive generation among less-educated Americans has reported more pain at any given age. [..]

America’s increasing chronic pain doesn’t come primarily from obesity or workplace injuries but may have something to do with the financial and social stresses in working-class America. When jobs are lost, pain increases. One international study found that a 3 percent increase in the unemployment rate is associated with a 1 percent increase in the number of people reporting pain.

Other studies have found that economic insecurity is associated with more pain. So is discrimination and unhappiness. Pain can lead to depression, causing further pain. “Loneliness strongly predicts the development of pain,” another study found. In effect, chronic pain is tightly woven into the bundle of diseases of despair, and causation probably runs in several directions. [..]

Dr. Daniel Clauw, director of the Chronic Pain and Fatigue Research Center at the University of Michigan, believes that we already have a toolbox of remedies that can help 80 percent or 90 percent of chronic pain sufferers but that our treatment system and insurance protocols betray those in need.

“We’ve really over-medicalized pain,” he told me. His first recommendation to patients with chronic pain is simple: Get more sleep and exercise. There’s no simple solution, he emphasized, and it takes work by patients to recover.

“I’m a huge advocate of physical therapy,” he added, and he also sees positive results from yoga, acupuncture, acupressure, cognitive behavioral therapy and meditation.

He mimics addressing a patient: “Mrs. Jones, I don’t know if acupuncture is going to work for you, or if it’s going to be physical therapy or chiropractic manipulation. But I do know that if you try three of these non-pharmacologic therapies, on average one of the three will work pretty well. And then the next year we’ll try two or three more, and you’ll get better yet.”

The demographic most vulnerable to chronic pain — unemployed middle-aged Americans with limited education — is less likely to have health insurance or the means to pay for treatment (much of which isn’t covered by insurance in any case). So these people suffer, or they may pay $5 for a fentanyl-laced pill to delay the suffering.

New approaches are emerging, but they are not necessarily more accessible. Virtual reality seems promising for alleviating chronic pain. Mindfulness training is sometimes helpful. Cannabis helps many people, with the most promising cannabinoids easing pain without producing a high, and researchers are investigating some encouraging indications that psilocybin (the hallucinogenic substance in “magic mushrooms”) may help as well.” [..]

Since pain and deaths of despair fall heavily on the poorly educated and unemployed, we might address educational gaps: getting everyone through high school and equipping graduates with a marketable skill. Before the pandemic caused setbacks, there was some progress in raising America’s pathetic high school graduation rate and in bolstering vocational training with initiatives like career academies.

Prevention also entails addressing broader social dysfunction. We’ve done a good job reducing workplace injuries, for example, but we haven’t shown the same determination to prevent the kinds of abuse that seared Wert and her sister. The foster care system is often a disaster that sets children up for diseases of despair. Home-visiting programs like Nurse-Family Partnership coach parents on everything from avoiding substance abuse and chipped lead paint to talking frequently with one’s child, and they have a remarkable record of improving outcomes for disadvantaged children. High-quality pre-K can similarly help get kids on track to success.

People recovering from addictions often talk about the importance of facing reality and accepting difficult truths. Here’s one for all of us to confront: Tens of millions of Americans are suffering in ways that lead to addiction, pain and a tangle of other pathologies and then transmit this misery to the next generation.

Maybe the brain’s pain alarm system is trying to tell us about how America heals: To ease our chronic pain, we must do better at addressing deeper wounds in our economy and society.”

Full editorial, N Kristof, New York Times, 2024.5.3