BY KAI KAROS. The current coronavirus pandemic has an impact on all of us. Still, some populations are arguably more affected than others. The various social measures to limit the spread of the coronavirus may disproportionately affect people with long-term painful conditions. Now that we are slowly trying to find the way to a post-pandemic future, it is important that these people don’t fall by the wayside.

Chronic pain has been labelled as a global epidemic, with 1 in 4 Americans and 1 in 5 Europeans suffering from it. People with chronic pain frequently experience social isolation, loneliness, and/or stigmatisation. Their pain is often not taken seriously, or worse, they are accused of malingering. In addition, there is discrimination in pain management based on socioeconomic status, gender, and race. For example, black patients frequently receive less adequate pain treatment by health-care professionals compared to white patients because of stereotypical beliefs that they experience less pain.

Fifteen cigarettes a day

We are beginning to understand such threats to the social needs of people are detrimental to health in general, and pain in particular.  For example, loneliness may be as lethal as smoking fifteen cigarettes a day! Similarly, social isolation and stigmatisation can actually worsen chronic pain. Moreover, early experiences of social trauma, such as bullying, can increase the risk to develop chronic pain later in life.

Pain management is a fundamental human right. Nevertheless, health systems worldwide currently prioritise the mitigation of COVID-19.

The current pandemic will likely increase the social threats for people with chronic pain. Physical distancing measures and travel restrictions increase social isolation, especially in vulnerable populations such as older adults or people with other chronic health conditions. Additionally, and paradoxically, being forced to stay at home and dealing with the increased stress of combining work and family life might increase interpersonal conflicts or feelings of guilt and being a burden to others. Critically, there are reports of increased domestic abuse because of the pandemic.

Pain management is a fundamental human right. Nevertheless, health systems worldwide currently prioritise the mitigation of COVID-19. Patients with complex medical conditions such as chronic pain, might be left behind as a result. Cancelled elective surgeries, closure of pain management services, and redeployment of clinicians to other areas of care all result in limited access to high-quality pain care. These developments in turn can widen inequities in relation to pain management for socially disadvantaged populations. One promising recent development is the rapid adaptation of telehealth interventions (e.g., online or via the phone), though empirical support for these new forms of treatment is scarce.

Social injustice

Finally, the COVID-19 pandemic exacerbates existing social injustices, also regarding pain. Those marginalised by social conditions (e.g. culture, race, sexual orientation, health, gender, socioeconomic status) have higher rates of chronic pain and comorbidities, as well as limited access to health care. This can lead to greater unmanaged pain and disability.

These communities are hit the hardest by the pandemic. COVID-19 has disproportionately affected socially disadvantaged groups, and the ensuing global economic fallout could magnify these inequalities in pain further. The concern is that those most economically disadvantaged also run a higher risk of getting COVID-19 (for instance because of poor sanitation or not having the possibility to effectively socially distance), are most susceptible to harm from it, and most likely to experience negative outcomes from it.

There is a real risk that the current pandemic and its associated social changes will lead to an increase in the prevalence, severity, and impact of chronic pain.

What does all this mean for someone living with chronic pain? Consider the example of a patient suffering from rheumatoid arthritis, Samantha. Samantha is 70 years old and lives in a long-term care facility. She experiences pain in several parts of her body on a daily basis, which causes great distress. Samantha started a pain management program earlier this year, which showed some promise. She learned skills to accept and manage her pain throughout the day, and to make time for activities that she really values, such as going for short walks with her family who visited about once a week. Samantha sees her therapist about once a week as well and enjoyed the regular social contact. She was also finally scheduled for a much-awaited knee surgery which promised to alleviate some of her suffering.

COVID-19 changed all this. Because of the strain put on hospitals, all non-essential medical procedures were postponed, and Samantha’s knee surgery was among them. Being considered especially vulnerable to COVID-19, the care facility where Samantha lives was placed under a rigid lockdown. Samantha was unable to attend her in-person weekly pain management sessions. Worst of all, her family, who had been her strongest source of social support, was prohibited from visiting her. She felt socially isolated and lonely. On top of the ever-present fear of contracting the virus, her pain also grew worse and she felt abandoned and forgotten. The only option left was a higher dosage of painkillers, which makes her feel like a zombie and does not seem to alleviate her pain significantly.

This fictional case of a patient during the pandemic likely resembles the experience of thousands of people living with long-term pain conditions and it demonstrates how the pandemic has cut so many vital lifelines of support in this population.

More resources

Taken together, there is a real risk that the current pandemic and its associated social changes will lead to an increase in the prevalence, severity, and impact of chronic pain. Luckily, the past months have already seen a fast and promising reaction from the scientific community to better understand the consequences of the pandemic for our health. The time seems right to follow this response and ultimately profit people who have been hit hardest by this pandemic, such as people with long-term pain conditions.

It is now paramount to further increase awareness of the interaction between social factors and health, and to invest more resources into research to better understand the interplay between biomedical, psychological, and social determinants of health.

Read more in the topical review ‘The social threats of COVID-19 for people with chronic pain‘ by Kai Karos et al., published in Pain.