How Pain Disproportionately Affects Vulnerable Populations

Chronic pain has been referred to as the invisible epidemic, but just because it cannot be seen does not mean it shouldn’t be taken seriously. Not only does chronic pain take an emotional toll, it is costly to countries and individuals. In 2017, The University of Michigan found that chronic pain results in annual losses of $635 billion in the U.S. alone. This includes the cost of treatments and lost productivity.

Nowhere are these losses felt more keenly than in America’s most vulnerable populations. While the exact definition of vulnerable population is up for some debate, it generally implies “the disadvantaged sub-segment of the community” and commonly includes “the economically disadvantaged, racial and ethnic minorities, the uninsured, low-income children, the elderly, the homeless, those with human immunodeficiency virus (HIV), and those with other chronic health conditions, including severe mental illness.”

There are social determinants that make chronic pain a more likely occurrence among these vulnerable populations. The Office of Disease Prevention and Health Promotion defines social determinants as conditions around people that have an impact on their health. While this may seem simple, social determinants can be as abstract as “culture” or “social support.”

In “Adjusting the Lens on Chronic Illness,” an episode of the Life Effects podcast from Teva Pharmaceuticals, the social determinants that play a role in chronic disease are discussed. The examples that are given can help make social determinants a little more concrete. To open the podcast, Gabriel Cortez, an educator in San Francisco, tells a story about visiting his grandfather. He says his grandfather would joke, “If you love me, you’ll bring me a cookie,” and they would eat cookies and spend time together. He remembers it fondly as bonding, but also realizes that this was an instance of social norms and attitudes as a social determinant, perpetuating chronic disease. His grandfather was later diagnosed with diabetes.

Cortez also talks about how, as immigrants, his parents would focus on buying an abundance of sugary drinks because it was a sign that they could afford to live the American lifestyle, a cultural social determinant. While a study from the Migration Policy Institute shows that adapting to American eating habits may not be what increases obesity rates, what Cortez says next might be.

He tells another story about how he watched his younger brother chug juice boxes at the beach, each of which contained 40 grams of sugar. But, as he points out, 40 means nothing out of context. If you don’t know the recommended daily allowance for sugar, 40 grams might seem reasonable. And how can you expect a child to know how much a gram is anyway? It might as well say 40 granules, and that’s the problem. At least in migrant populations, when numbers are given out of context like this people may not realize exactly what ingredients are in their food and in what amounts. This is an example of language/health literacy as a social determinant, and it’s a big barrier to being healthy. The Migration Policy Institute also found that children of non-English-speaking parents are at higher risk of being obese. It concludes that a reason for this might be that, “Many immigrants originate from countries in which food insecurity and stunting pose significant health risks to children, so they may be unaccustomed to protecting children from the opposite problem that comes from overeating.”

These statistics are important because according to the Harvard School of Public Health, two out of three adults and one out of three children in the U.S. are obese. The association between joint pain and obesity has been well documented, but research shows that other types of pain can also be associated with excessive weight. A study on the relationship between body mass index and fibromyalgia showed that over 60 percent of women who had fibromyalgia were overweight and 32.3 percent were obese. Obesity is a factor that often plays a role in chronic pain conditions, whether the pain results from obesity or causes it and is then exacerbated by it.

As too often happens with many lifestyle diseases, some people take this as an excuse to blame chronic pain sufferers for their conditions. This is counterproductive because not only does it shame people and prevent them from seeking help without offering any better alternatives, it is not true. Again, there are several social determinants contributing to weight gain, such as public safety. While the common advice of “eat better/less, move more” is often touted as the gold standard, not everyone has that option. Lack of safe public space can be a problem, particularly in low income neighborhoods. Many people in low income neighborhoods also do not have easy access to healthy food sources, meaning they would need to take time away from working to go buy healthy food that they would then need to take more time to cook and prepare. When a person is already working two jobs just to get by, it’s easy to see how this could feel like a non-option.

Even people who are not low income may not be able to follow this advice. Often, those who suffer from chronic pain end up gaining weight as a result of the pain they experience with simple movements. This added weight causes more pain, making people want to move less, and the cycle continues. To blame those suffering is to shirk the responsibility we have to help them.

There have been studies done that show that even within low income communities, there may be a solution for vulnerable population groups. One treatment that’s been found to help is cognitive behavioral therapy. According to the Annals of Internal Medicine “simplified group CBT and EDU [pain education] interventions delivered at low-income clinics significantly improved pain and physical function compared with usual care.” Other studies have shown that CBT and mindfulness-based therapies are one of the more cost effective ways to manage pain, compared with usual care.

As medical professionals, we need to be sure that when we are treating patients, we are keeping all these complex issues in mind. No two cases are the same, and they should not be treated as such. At ReclaimAbility, we make it a priority to take the time to discuss our patients’ goals and lifestyles with them. This is an important first step so we can come up with customized treatment plans for each of our patients and help them come up with realistic options to help relieve their pain.