Sociodemographic patterns of pain in an urban community sample: an examination of intersectional effects of sex, race, age, and poverty status

Sociodemographically Differential Patterns of Chronic Pain Progression Revealed by Analyzing the All of Us Research Program Data

The differential progression of ten chronic overlapping pain conditions (COPC) and four comorbid mental disorders across demographic groups have rarely been reported in the literature. To fill in this gap, we conducted retrospective cohort analyses using All of Us Research Program data from 1970 to 2023. Separate cohorts were created to assess the differential patterns across sex, race, and ethnicity. Logistic regression models, controlling for demographic variables and household income level, were employed to identify significant sociodemographic factors associated with the differential progression from one COPC or mental condition to another. Among the 139 frequent disease pairs, we identified group-specific patterns in 15 progression pathways. Black or African Americans with a COPC condition had a significantly increased association in progression to other COPCs (CLBP->IBS, CLBP->MHA, or IBS->MHA, OR≥1.25, adj.p≤4.0x10-3) or mental disorders (CLBP->anxiety, CLBP->depression, MHA->anxiety, MHA->depression, OR≥1.25, adj.p≤1.9x10-2) after developing a COPC. Females had an increased likelihood of chronic low back pain after anxiety and depression (OR≥1.12, adj.p≤1.5x10-2). Additionally, the lowest income bracket was associated with an increased risk of developing another COPC from a COPC (CLBP->MHA, IBS->MHA, MHA->CLBP, or MHA->IBS, OR≥1.44, adj.p≤2.6x10-2) or from a mental disorder (depression->MHA, depression->CLBP, anxiety->CLBP, or anxiety->IBS, OR≥1.50, adj.p≤2.0x10-2), as well as developing a mental disorder after a COPC (CLBP->depression, CBLP->anxiety, MHA->anxiety, OR=1.37, adj.p≤1.6x10-2). To our knowledge, this is the first study that unveils the sociodemographic influence on COPC progression. These findings suggest the importance of considering sociodemographic factors to achieve optimal prognostication and preemptive management of COPCs.

Problem of pain in the USA: evaluating the generalisability of high-impact chronic pain models over time using National Health Interview Survey (NHIS) data

Introduction

High-impact chronic pain (HICP) significantly affects the quality of life for millions of U.S. adults, imposing substantial economic/healthcare burdens. Disproportionate effects are observed among racial/ethnic minorities and older adults.

Methods

We leveraged the National Health Interview Survey (NHIS) from 2016 (n=32,980), 2017 (n=26,700), and 2021 (n=28,740) to validate and develop analytical models for HICP. Initial models (2016 NHIS data) identified correlates associated with HICP, including hospital stays, diagnosis of specific diseases, psychological symptoms, and employment status. We assessed the models' generalizability and drew comparisons across time. We constructed five validation scenarios to account for variations in the availability of predictor variables across datasets and different time frames for pain assessment questions. We used logistic regression with LASSO and random forest techniques. We assessed model discrimination, calibration, and overall performance using metrics such as area under the curve (AUC), calibration slope, and Brier score.

Results

Scenario 1, validating the NHIS 2016 model against 2017 data, demonstrated excellent discrimination with an AUC of 0.89 (95% CI: 0.88-0.90) for both LASSO and random forest models. Subgroup-specific performance varied, with the lowest AUC among adults aged ≥65 years (0.81, 95% CI: 0.78-0.82) and the highest among Hispanic respondents (0.91, 95% CI: 0.88-0.94). Model calibration was generally robust, although underfitting was observed for Hispanic respondents (calibration slope: 1.31). Scenario 3, testing the NHIS 2016 model on 2021 data, showed reduced discrimination (AUC: 0.82, 95% CI: 0.81-0.83) and overfitting (calibration slopes < 1). De novo models based on 2021 data showed comparable discrimination (AUC: 0.86, 95% CI: 0.85-0.87) but poorer calibration when validated against older datasets.

Conclusion

These findings underscore the potential of these models to guide personalized medicine strategies for HICP, aiming for more preventive rather than reactive healthcare. However, the model's broader applicability requires further validation in varied settings and global populations.

Exercise and Dietary Recommendations for Women with Chronic Pain: What's Weight and Race Got To Do with It?

Exercise and diet are beneficial for pain, yet many patients do not receive such recommendations from providers. This may be due to biases related to gender, race, and weight. We recruited medical students (N = 90) to view videos of women with chronic back pain performing a functional task; patients varied by weight (overweight/obese) and race (Black/White). For each woman patient, providers rated their likelihood of recommending exercises or dietary changes. Ratings significantly differed across recommendations (F(2.75, 244.72) = 6.19, P < .01) in that providers were more likely to recommend flexibility exercises than aerobic exercises and dietary changes and were more likely to recommend strength exercises than dietary changes. Results also indicated that women with obesity were more likely to receive aerobic (F(1,89) = 17.20, P < .01), strength (F(1,89) = 6.08, P = .02), and dietary recommendations (F(1,89) = 37.56, P < .01) than were women with overweight. Additionally, White women were more likely to receive a recommendation for flexibility exercises (F(1,89) = 4.92, P = .03) than Black women. Collectively, these findings suggest that providers' exercise and dietary recommendations for women with chronic pain are influenced by the weight status and racial identity of the patient. Future studies are needed to identify the reasons underlying these systematic differences, including the stereotypes and attitudes that may be driving these effects. PERSPECTIVE: This article presents results on how patient weight and race impact providers' exercise and diet recommendations for women with chronic back pain. Provider recommendations for these modalities may be systematically biased in a way that impedes care and impacts patient functioning.

Prevalence and associated factors of postoperative suxamethonium-induced myalgia in surgical patients at Debre Tabor Comprehensive Specialized Hospital Ethiopia: a cross-sectional study

Suxamethonium is considered by many to be the best drug for providing ideal intubating conditions, short surgical procedures, and rapid sequence induction. However, its usefulness is limited by the frequent occurrence of adverse effects like postoperative myalgia. Therefore this study aimed to assess the prevalence and associated factors of postoperative suxamethonium-induced myalgia. An institutional-based cross-sectional study was conducted on 210 patients who underwent surgery with general anesthesia. The data was collected by using structured and pretested questionnaires and analyzed using SPSS version 20.0. Logistic regression was conducted to identify significant predictors based on a P-value of less than 0.05 with a 95% confidence level. Among 210 patients the prevalence of suxamethonium-induced postoperative myalgia in the first 48 h was 88 (41.9%). Patients having previous anesthesia and surgical exposure (AOR 5.29, 95% CI 1.86-15.05), patients having a co-existing disease (AOR 2.69, 95% CI 1.08-6.67), patients that had not taken premedication (analgesia) (AOR 4.64, 95% CI 1.69-12.74), anesthesia maintenance using halothane (AOR 4.5 95% CI 1.7-11.4) and relaxation maintained with suxamethonium (AOR 3.1, 95% CI 1.2-8.1) were significantly associated with the prevalence of postoperative myalgia. The magnitude of suxamethonium-induced postoperative myalgia was high. So it is better to do with preventive techniques. As much as possible it is better to avoid using suxamethonium and necessary to use better to Premedicate with nonsteroidal anti-inflammatory drugs and non-depolarizing neuromuscular medications.

Attending to Marginalization in The Chronic Pain Literature: A Scoping Review

Background

There has been a recent and, for many within the chronic pain space, long-overdue increase in literature that focuses on equity, diversity, inclusion, and decolonization (EDI-D) to understand chronic pain among people who are historically and structurally marginalized.

Aims

In light of this growing attention in chronic pain research, we undertook a scoping review of studies that focus on people living with chronic pain and marginalization to map how these studies were carried out, how marginalization was conceptualized and operationalized by researchers, and identify suggestions for moving forward with marginalization and EDI-D in mind to better support people living with chronic pain.

Methods

We conducted this scoping review using critical analysis in a manner that aligns with dominant scoping review frameworks and recent developments made to scoping review methodology as well as reporting guidelines.

Results

Drawing on 67 studies, we begin with a descriptive review of the literature followed by a critical review that aims to identify fissures within the field through the following themes: (1) varying considerations of sociopolitical and socioeconomic contexts, (2) conceptual conflations between sex and gender, and (3) differing approaches to how people living with chronic pain and marginalization are described.

Conclusion

By identifying strengths and limitations in the research literature, we aim to highlight opportunities for researchers to contribute to a more comprehensive understanding of marginalization in chronic pain experiences.

Socioeconomic status, mental health, and nutrition are the principal traits for low back pain phenotyping: Data from the osteoarthritis initiative

Background

Low back pain (LBP) is a heterogeneous disease with biological, physical, and psychosocial etiologies. Models for predicting LBP severity and chronicity have not made a clinical impact, perhaps due to difficulty deciphering multidimensional phenotypes. In this study, our objective was to develop a computational framework to comprehensively screen metrics related to LBP severity and chronicity and identify the most influential.

Methods

We identified individuals from the observational, longitudinal Osteoarthritis Initiative cohort (N = 4796) who reported LBP at enrollment (N = 215). OAI descriptor variables (N = 1190) were used to cluster individuals via unsupervised learning and uncover latent LBP phenotypes. We also developed a dimensionality reduction algorithm to visualize clusters/phenotypes using Uniform Manifold Approximation and Projection (UMAP). Next, to predict chronicity, we identified those with acute LBP (N = 40) and persistent LBP over 8 years of follow-up (N = 66) and built logistic regression and supervised machine learning models.

Results

We identified three LBP phenotypes: a "high socioeconomic status, low pain severity group", a "low socioeconomic status, high pain severity group", and an intermediate group. Mental health and nutrition were also key clustering variables, while traditional biomedical factors (e.g., age, sex, BMI) were not. Those who developed chronic LBP were differentiated by higher pain interference and lower alcohol consumption (a correlate to poor physical fitness and lower soceioeconomic status). All models for predicting chronicity had satisfactory performance (accuracy 76%-78%).

Conclusions

We developed a computational pipeline capable of screening hundreds of variables and visualizing LBP cohorts. We found that socioeconomic status, mental health, nutrition, and pain interference were more influential in LBP than traditional biomedical descriptors like age, sex, and BMI.

Chronic Struggle: An Institutional Ethnography of Chronic Pain and Marginalization

There have been several recent calls to re-think chronic pain in response to the growing awareness of social inequities that impact the prevalence of chronic pain and its management. This in turn has resulted in new explorations of suffering as it relates to pain. While laudable, many of these clinically oriented accounts are abstract and often fail to offer a critical theoretical understanding of social and structural inequities. To truly rethink pain, we must also reconsider suffering, beginning in the everyday expert knowledge of people with chronic pain who can offer insights in relation to their bodies and also the organization of the social circumstances in which they live. Our team undertook a sociological approach known as institutional ethnography (IE) to explicate the work of people in managing lives beset by chronic pain and the inequities that stem from marginalization. In keeping with our critical paradigm, we describe participant accounts as situated, rather than lived, to de-emphasize the individual in favour of the social and relational. Through our analysis, we offer a new concept of chronic struggle to capture how pain, illness, economic deprivation, and suffering constitute a knot of experience that people living with chronic pain are obliged to simplify in order to fit existing logics of medicine. Our goal is to identify the social organization of chronic pain care which underpins experience in order to situate the social as political rather than medical or individual. PERSPECTIVE: This article explicates the health work of people living with chronic pain and marginalization, drawing on their situated experience. We offer the concept of chronic struggle as a conceptualization that allows us to bring into clear view the social organization of chronic pain in which the social is visible as political and structural rather than medical or individual.

Beyond Black vs White: racial/ethnic disparities in chronic pain including Hispanic, Asian, Native American, and multiracial US adults

ABSTRACT

Previous literature on race/ethnicity and pain has rarely included all major US racial groups or examined the sensitivity of findings to different pain operationalizations. Using data from the 2010 to 2018 National Health Interview Surveys on adults 18 years or older (N = 273,972), we calculated the weighted prevalence of 6 definitions of pain to provide a detailed description of chronic pain in White, Black, Hispanic, Asian, Native American, and multiracial groups. We also estimated modified Poisson models to obtain relative disparities, net of demographic and socioeconomic (SES) factors including educational attainment, family income, and home ownership; finally, we calculated average predicted probabilities to show prevalence disparities in absolute terms. We found that Asian Americans showed the lowest pain prevalence across all pain definitions and model specifications. By contrast, Native American and multiracial adults had the highest pain prevalence. This excess pain was due to the lower SES among Native Americans but remained significant and unexplained among multiracial adults. The pain prevalence in White, Black, and Hispanic adults fell in between the 2 extremes. In this trio, Hispanics showed the lowest prevalence, an advantage not attributable to immigrant status or SES. Although most previous research focuses on Black-White comparisons, these 2 groups differ relatively little. Blacks report lower prevalence of less severe pain definitions than Whites but slightly higher prevalence of severe pain. Net of SES, however, Blacks experienced significantly lower pain across all definitions. Overall, racial disparities are larger than previously recognized once all major racial groups are included, and these disparities are largely consistent across different operationalizations of pain.

Making Pain Research More Inclusive: Why and How

Current knowledge about mechanisms and interventions for pain has largely been derived from samples that are healthier, wealthier, younger, and more likely to be White than the general population. Failure to conduct inclusive pain research not only restricts generalizability and application of findings, but also hampers the discovery of mechanisms and the development of measures and interventions that are valid across population subgroups. Most of all, inclusive practices are critical to ensure that underrepresented groups derive equitable benefit from pain research. Here, we provide guidance for the pain research community on how to adopt inclusive research practices. We define "inclusion" to encompass a range of identities and characteristics, including racialized group/ethnicity, disability status, gender identity, sexual orientation, and age. We first describe principles relevant to promoting inclusion in pain research, including attention to: 1) stakeholder engagement; 2) structural factors underlying inequities; 3) the limitations of "disparity" research; 4) intersectionality; and 5) universal design. Next, we provide checklists with practical strategies for making studies more inclusive at each stage of the research process. We conclude by calling for system-level changes to ensure that the future of pain research is socially just, scientifically productive, and responsive to the needs of all people. PERSPECTIVE: This paper offers guidance on promoting inclusion of underrepresented groups in pain research. We describe principles relevant to conducting more inclusive research; eg, attention to stakeholder engagement, structural factors, and universal design. We provide checklists with practical strategies for inclusion at each stage of the research process.

Women’s experiences of navigating chronic pain within the context of living with an episodic disability

Objectives:

Of the 6.2 million Canadians aged 15 years or older who live with disability, 61% have disabilities that are not static or continuous. These dynamic conditions are known as episodic disabilities and many disproportionately experienced by women. Chronic pain is also a common feature associated with many episodic disabilities. The purpose of this article is to explore the experience of chronic pain for women living with episodic disabilities.

Methods:

This qualitative study draws on the tenets of interpretive description. Thirty women, with one or more episodic disabilities and chronic pain, participated in a semi-structured interview and answered questions about their chronic pain levels, using Von Korff et al.’s graded chronic pain scale.

Results:

Women experienced gendered treatment within the healthcare system and reported that they were frequently dismissed by their healthcare providers, most often physicians. Healthcare professionals’ practices around pain assessment were another common challenge for women. Women who were able to access financial support from government disability programs were more likely to access allied health professionals. Many of the holistic strategies that women researched and used to treat chronic pain were self-enacted. While diet, exercise, and other self-care activities are general health promotion strategies for all, they were seen as essential aspects of living that helped women have control over chronic pain and modifying the course of their episodic disability.

Conclusion:

Living with chronic pain and an episodic disability is complex. The findings of this study present the impact that gendered treatment in the healthcare system has on women who live with an episodic disability and experience chronic pain. It is evident that the current system did not meet the needs of the women in our study and system changes could result in better experiences, more disclosure of alternative therapies, and increase women’s agency in their care.

The impact of poverty and deprivation at the end of life: a critical review

This critical review interrogates what we know about how poverty and deprivation impact people at the end of life and what more we need to uncover. While we know that people in economically resource-rich countries who experience poverty and deprivation over the life course are likely to die younger, with increased co-morbidities, palliative care researchers are beginning to establish a full picture of the disproportionate impact of poverty on how, when and where we die. This is something the Covid-19 pandemic has further illustrated. Our article uses a critical social science lens to investigate an eclectic range of literature addressing health inequities and is focused on poverty and deprivation at the end of life. Our aim was to see if we could shed new light on the myriad ways in which experiences of poverty shape the end of people's lives. We start by exploring the definitions and language of poverty while acknowledging the multiple intersecting identities that produce privilege. We then discuss poverty and deprivation as a context for the nature of palliative care need and overall end-of-life circumstances. In particular, we explore: total pain; choice at the end of life; access to palliative care; and family caregiving. Overall, we argue that in addressing the effects of poverty and deprivation on end-of-life experiences, there is a need to recognise not just socio-economic injustice but also cultural and symbolic injustice. Too often, a deficit-based approach is adopted which both 'Others' those living with poverty and renders invisible the strategies and resilience they develop to support themselves, their families and communities. We conclude with some recommendations for future research, highlighting in particular the need to amplify the voices of people with lived experience of poverty regarding palliative and end-of-life care.

Complex sociodemographic inequalities in consultations for low back pain: lessons from multilevel intersectional analysis

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We found substantial individual heterogeneity in consultation for low back pain that could not be explained by combination of age, sex, education, income, and nativity.

Sociodemographic inequalities in the occurrence of low back pain (LBP) are well-studied. This study aimed to examine complex sociodemographic inequalities in the risk of LBP consultation in the population from a socioeconomical intersectional perspective. Using register data, we identified 458,852 individuals aged 35 to 75 years residing in Skåne in 2013, with no previous LBP consultation since 2006. We created 108 strata using categories of age, sex, education, income, and nativity. With individuals nested within strata, we modelled the absolute risk of LBP consultation during 2014 in a series of multilevel logistic regression models. We quantified discriminatory accuracy (DA) of these variables by computing the variance partition coefficient and area under the receiver operating characteristic curve (AUC). We identified 13,657 (3.0%) people with an LBP consultation. The absolute risk ranged from 2.1% (95% credible interval: 1.9%-2.3%) among young native men with high education and high income to 4.8% (4.3%-5.5%) among young foreign-born women with medium education and low income (2.3-fold relative difference). Discriminatory accuracy of intersectional strata was very low (variance partition coefficient 1.1% (0.7-1.6); and AUC 0.56 [0.55-0.56]). Sex (35.6%) and nativity (19.2%) had the largest contributions in explaining the initially small between-strata variation in risk of LBP. The low DA of the intersectional strata indicates the existence of limited intersectional inequalities in LBP consultation. Therefore, interventions to reduce LBP risk should be universal rather than targeted to specific socioeconomic groups with a higher average risk. Before planning targeted intervention, other risk factors with higher DA need to be identified.

Race Differences in Resilience Among Older Adults with Chronic Low Back Pain

INTRODUCTION

Racial minorities are disproportionally affected by pain. Compared to non-Hispanic Whites (NHWs), non-Hispanic Blacks (NHBs) report higher pain intensity, greater pain-related disability, and higher levels of mood disturbance. While risk factors contribute to these disparities, little is known regarding how sources of resilience influence these differences, despite the growing body of research supporting the protective role of resilience in pain and disability among older adults with chronic pain. The current study examined the association between psychological resilience and pain, and the moderating role of race across these relationships in older adults with chronic low back pain (cLBP).

METHODS

This is a secondary analysis of the Adaptability and Resilience in Aging Adults (ARIAA). Participants completed measures of resilience (ie, gratitude, trait resilience, emotional support), as well as a performance-based measure assessing lower-extremity function and movement-evoked pain.

RESULTS

There were 45 participants that identified as non-Hispanic White (NHW) and 15 participants that identified as non-Hispanic Black (NHB). Race was a significant correlate of pain outcomes with NHBs reporting greater movement-evoked pain (r = 0.27) than NHWs. After controlling for relevant sociodemographic characteristics, measures of movement-evoked pain were similar across both racial groups, F (1, 48) = 0.31, p = 0.57. Moderation analyses revealed that higher levels of gratitude (b = -1.23, p = 0.02) and trait resilience (b = -10.99, p = 0.02) were protective against movement-evoked pain in NHWs. In contrast, higher levels of gratitude were associated with lower functional performance in NHBs (b = -0.13, p =0.02).

DISCUSSION

These findings highlight racial differences in the relationship between resilience and pain-related outcomes among older adults with cLBP. Future studies should examine the potential benefits of targeted interventions that improve resilience and ameliorate pain disparities among racial minorities.

Greater mechanical temporal summation of pain in Latinx-Americans and the role of adverse life experiences

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Latinx-Americans showed greater temporal summation, adversity, and adversity correlates relative to non-Hispanic Whites. Discrimination and lifespan social status change inversely related to summation for Latinx-Americans.

Introduction:

Adverse life experiences disproportionately impact Latinx-Americans and are related to greater chronic pain rates. However, little is known about how adversities interact with central pain mechanisms for the development of later pain among Latinx-Americans.

Objectives:

The current study examined the relationship between adverse life experiences (eg, trauma and ethnic discrimination) and correlates (eg, social status) with mechanical temporal summation of pain (a proxy measure of central sensitization) between pain-free U.S. native Latinx (n = 65) and non-Hispanic White (NHW) (n = 51) adults.

Methods:

Participants completed self-report adverse life experience and correlational measures regarding childhood and adulthood and a mechanical temporal summation protocol.

Results:

Relative to NHWs, Latinx-Americans reported experiencing significantly greater trauma, discrimination, and lower social status during childhood and adulthood, along with greater temporal summation. Contrary to hypotheses, recent and lifetime experiences of ethnic discrimination significantly correlated with less temporal summation among Latinx-Americans. Decreases in objective and subjective social status across the lifespan (childhood to present day) correlated with greater temporal summation for Latinx-Americans. However, r-to-z transformation analyses confirmed that significant adversity and social status correlations observed among the Latinx group did not significantly differ from NHW participants.

Conclusions:

The present findings highlight the complex association between adverse experiences, adverse experience risk factors, and pain for Latinx-Americans. Given the disproportion of experienced pain and adversity among Latinx-Americans, the current findings suggest that a better understanding of the unique adversities for this sample may help elucidate the mechanisms underlying the relationship between adversities, adversity correlates, and pain risk for Latinx-Americans.