Richard L. Nahin

There are no nationally representative studies examining both the frequency and correlates of “undiagnosed pain”—pain without a formal diagnosis. To identify the magnitude of this healthcare gap, we performed cross-sectional secondary analyses of the Medical Expenditure Panel Survey (MEPS), 2016-2019 data. The primary study outcome is “being undiagnosed”: the absence of diagnoses for pain-related conditions among participants reporting pain-related interference (PRI). Pain-related interference was established using the SF36 pain question embedded in MEPS, with 10,954 individuals reporting any PRI within 4 weeks of the interview and 4,902 individuals reporting at least moderate PRI. Participants with PRI were assigned as “being undiagnosed” if the following conditions were met: (1) the participant did not have medical records for any pain-related conditions in both the previous and current year of the interview and (2) did not report having any pain-related priority conditions from a list provided during the MEPS interviews. Among those reporting any PRI, about 21.1 million people (9.3%; 95% confidence interval [CI], 8.6%-10.0%) were without diagnoses for either primary pain conditions identified using MEPS clinical classification codes or conditions where pain would be a secondary symptom (eg, hypertension and immunity disorders). From multivariable logistic regression modeling, we determined that younger and middle-aged adults, males, racial and ethnic minority groups, foreign-born populations, people without insurance, and people with better perceived health are more likely to have their pain undiagnosed. Our findings underscore the need for improved access to care and better patient-provider communications in those suffering from underdiagnosed pain.

Epidemiological research on chronic pain (pain lasting ≥3 months) and high-impact chronic pain (HICP) (chronic pain associated with substantial restrictions in life activities, including work, social, and self-care activities) in the US has increased substantially since the release of the Institute of Medicine (currently the National Academy of Medicine) report on pain in 2011¹ and the Department of Health and Human Services National Pain Strategy (NPS) in 2016.² These documents emphasized the need for epidemiological studies of pain in the US population, particularly in subpopulations that may be susceptible to the underreporting and/or undermanagement of pain. Since these publications, numerous nationally representative studies of US adults have described chronic pain and HICP prevalence, which varied depending on the operationalization of chronic pain and the survey year.^3-7 Far less is understood regarding the incidence of chronic pain in US adults because few longitudinal population-based studies contain high-quality information on pain. Current knowledge of chronic pain incidence in the US is limited to specific communities or groups or health care professionals^8-16 and/or specific age ranges^{8,9,11-13,15,17} and/or specific pain locations or conditions^8-13,15-20 and/or claims data or medical records.^10,17,19 Of these, a minority of studies^10,12,16,17 have presented incidence rates (IRs), defined as the number of new cases of chronic pain per person per year (ie, person-years [PY]) of follow-up among persons without chronic pain at baseline. Compared with cumulative incidence proportions, IRs more adequately account for the time at risk of developing an outcome that may occur in study participants during follow-up. We have not found any studies to date examining chronic pain incidence in a nationally representative sample of all adults.

This study assesses chronic pain prevalence among sexual minority U.S. adults who self-identify as gay/lesbian, bisexual, or “something else,” and examines the role of select covariates in the observed patterns. Analyses are based on 2013 to 2018 waves of the National Health Interview Survey, a leading cross-sectional survey representative of the U.S. population. General chronic pain and chronic pain in 3+ sites among adults aged 18 to 64 years (N = 134,266 and 95,675, respectively) are analyzed using robust Poisson regression and nonlinear decomposition; covariates include demographic, socioeconomic, healthcare, and psychological distress measures. We find large disparities for both pain outcomes. Americans who self-identify as bisexual or “something else” have the highest general chronic pain prevalence (23.7% and 27.0%, respectively), compared with 21.7% among gay/lesbian and 17.2% straight adults. For pain in 3+ sites, disparities are even larger: Age-adjusted prevalence is over twice as high among adults who self-identify as bisexual or “something else” and 50% higher among gay/lesbian, compared with straight adults. Psychological distress is the most salient correlate of the disparities, whereas socioeconomic status and healthcare variables explain only a modest proportion. Findings thus indicate that even in an era of meaningful social and political advances, sexual minority American adults have significantly more chronic pain than their straight counterparts. We call for data collection efforts to include information on perceived discrimination, prejudice, and stigma as potential key upstream factors that drive pain disparities among members of these minoritized groups.

The Institute of Medicine report “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” the US Department of Healt

Objective: Using a nationally representative sample of adults and pain definitions consistent with the United States National Pain Strategy, we examined the associations of pain and cognitive impairment (CI) with each other and with measures of health status, physical impairment, social impairment, health care utilization, and dissatisfaction with health care. Materials and Methods: Prevalence estimates and multivariable logistic regression analyses of the 2017 National Health Interview Survey were performed. Results: As the level of reported pain increased from “no pain” to high-impact chronic pain (HICP), there was an increase in the prevalence of CI from 2.99% in those with no pain to 18.19% in those with HICP. Similarly, as the level of CI increased from no impairment to substantial CI, the prevalence of any pain increased from 62.44% to 83.20%. As pain severity and CI increased, we found increased prevalence for all outcomes examined, with the highest prevalence seen in participants with HICP and substantial CI. While 4.15% of individuals without either pain or CI reported poor/fair health, this increased to 33.98% in those with substantial CI or “dementia” but no pain, to 52.22% in those with HICP but no CI, and to 81.8% in individuals reporting both HICP and substantial CI or “dementia.” Discussion: Our data suggest that individuals with comorbid chronic pain and CI are in a much higher state of self-reported disability than those with chronic pain or CI alone. Best practice guidelines are generally silent on multidisciplinary, integrated care for these comorbid conditions, increasing the potential for inadequate care.