Pain in US corrections settings: the promise of digital solutions for better data and treatment access

The problem of pain

Estimates suggest that 50–100 million American adults live with ongoing pain—more than those affected by heart disease, diabetes, and cancer combined (see Table 1). Notably, these national prevalence estimates exclude the ∼5.5 million individuals incarcerated in jails and in state and United States (US) federal prisons, despite pain being common and impactful among individuals in corrections settings. Although pain prevalence literature is limited, some estimates suggest that up to 25% of individuals incarcerated in state and federal prisons have chronic pain. One study of 210 individuals in a county jail who were 55 years of age or older (of whom 60% were Black) revealed that 75% reported any current pain and 39% reported having frequent pain.¹ Multimorbidity, the increased aging of the corrections population, social isolation, and insufficient pain treatment further contribute to chronic pain in corrections settings.¹ Indeed, a Texas Department of Criminal Justice chronic cancer pain study (n = 102) found that 64% of individuals reported inadequate pain management.² Taken together, individual small studies suggest that pain prevalence in corrections settings mirrors that in the general population. Notably, higher-quality and broad-scale data on pain are needed across corrections settings, as are solutions that expand access to effective pain care.

Table 1.

Referenced Web links.

Document/source	Topic	Web link
National Pain Strategy (NPS; 2016)	US pain prevalence	https://www.iprcc.nih.gov/node/5/national-pain-strategy-report
Institute of Medicine Report on Relieving Pain in America (IOM; 2011)	US pain prevalence	https://www.ncbi.nlm.nih.gov/books/NBK91497/
Correctional Populations in the United States, 2021. Bureau of Justice Statistics	US census of incarcerated individuals	https://bjs.ojp.gov/document/cpus21st.pdf
Federal Bureau of Prisons Clinical Guidance, Pain Management of Inmates (2018)	Pain prevalence in incarcerated populations	https://www.bop.gov/resources/pdfs/pain_mgmt_inmates_cpg.pdf
National Institutes on Drug Abuse (NIDA) Criminal Justice Drug Facts	Substance use disorder and opioid use disorder in incarcerated populations	https://bjs.ojp.gov/content/pub/pdf/dudaspji0709.pdf .
National Alliance on Mental Illness (NAMI)	Mental health treatment while incarcerated	https://www.nami.org/Advocacy/Policy-Priorities/Improving-Health/Mental-Health-Treatment-While-Incarcerated
Survey of Prison Inmates, 2016. Bureau of Justice Statistics	Medical problems reported by incarcerated individuals	https://bjs.ojp.gov/library/publications/medical-problems-reported-prisoners-survey-prison-inmates-2016
CHOIR	CHOIR learning health system	https://choir.stanford.edu

Pain treatment in corrections settings

Although the 2018 Federal Bureau of Prisons Clinical Guidance for pain treatment in corrections settings includes the biopsychosocial model of care, implementation of this model is fraught with many of the same barriers experienced nationally in non-corrections settings. Federal guidance recommends a multidimensional pain treatment approach that addresses biological, psychological, behavioral, familial, vocational, social, and medico-legal factors, with the goals of (1) improving patient function and (2) ensuring appropriate use of pain medication. Pain management implementation varies by clinician team size and involves either medical management teams (smaller facilities/capacity) or multidisciplinary pain management teams, which include a range of disciplines and can include outside specialist consultants who develop and implement comprehensive pain care plans that largely apply an interdisciplinary pain rehabilitation treatment approach as best practice. Interdisciplinary pain rehabilitation integrates into medical management team or pain management team physical reconditioning with pain education, mental health education, activity modification, and psychological and behavioral treatments. Clinical psychologists often deliver psychological interventions, including imagery and distraction, relaxation response training, cognitive behavioral therapy (CBT), acceptance and commitment therapy, biofeedback, and hypnotic analgesia, with specialized clinician training required for many of these. Though aspirational, interdisciplinary pain rehabilitation data for patient access and outcomes are lacking for corrections settings. Outside of corrections settings, national shortages in pain psychologists and poor access to pain psychology services have impeded the implementation of integrated pain treatment.

Correction settings involve specific considerations and complexities. For instance, according to the National Alliance on Mental Illness, roughly 40% of incarcerated populations have mental health histories, compared with 20% of the general population. Among individuals with mental illness, 63% will receive no mental health services while incarcerated, thus leaving this risk factor untreated. Because mental health conditions are associated with a greater likelihood of chronic pain and poorer outcomes, patients could benefit from effective treatment that dually addresses pain and psychological symptoms via enhanced self-regulation. A second consideration pertains to corrections settings having a high percentage of patients with histories of substance use disorder or opioid use disorder. According to the National Institute on Drug Abuse, research shows that an estimated 65% of the US prison population has an active substance use disorder. Pain is a risk factor for the first use of illicit substances and the ongoing use of substances and contributes to substance use disorder / opioid use disorder relapse.³ As such, ensuring receipt of effective pain treatment during incarceration is crucial for optimizing patients’ care within the corrections setting, as well as their post-release health outcomes. Behavioral pain treatment is vital in this at-risk subgroup of patients, with the corrections setting being ideal for addressing both. However, psychologist staffing shortages remain a challenge and barrier to care; digital (mobile health [mHealth]) options might provide new avenues to expand access to behavioral pain treatment in corrections settings.

Digital health trends in corrections settings

The digitalization of prisons is a trend that offers opportunities to expand health care and social welfare services and increase the efficiency of prison processes.⁴ Though relatively nascent in corrections settings, digital therapeutic studies outside of pain have included CBT, mHealth interventions, telemedicine, and telehealth services.

In one innovative statewide study conducted during the COVID-19 pandemic, 2187 people with a history of methamphetamine use disorder who were incarcerated in Ohio participated in a digital CBT program called “Breaking Free from Substance Abuse.”⁵ The automated CBT program involves 12 evidence-based behavioral change techniques, skills building, cognition and emotion regulation, and action plans. Within-subject analysis revealed a dose–response effect wherein participants who had a higher engagement with the digital CBT program had more significant reductions in substance dependence, depression/anxiety, biopsychosocial impairment, and improvements in quality of life.⁵ The authors noted that digital programs are not meant to replace clinicians; rather, self-directed therapies can augment in-person support.

Another study surveyed 482 individuals incarcerated in North Carolina prisons about their comfort and satisfaction with telemedicine during the COVID-19 pandemic. Most respondents were male, 47% were Black, and 60% had no prior telehealth experience.⁶ The authors noted 3 potentially modifiable predictors of patient satisfaction with telemedicine: personal comfort with telemedicine, wait time, and clinician clarity in explaining the treatment. Notably, patient satisfaction with telemedicine was highest in those receiving telemedicine for the first time. A clear rationale and orientation to digital treatments, combined with on-demand options that eliminate wait times, could potentially support timely receipt of treatment and patient satisfaction.

As a preliminary index of the feasibility of digital interventions in corrections settings, authors of a cross-sectional Finland study of individuals incarcerated at 11 prisons (n = 225) showed that 63.2% of respondents rated digital services as easy to use, and most (69.8%) were confident in their ability to quickly use new digital services.⁴

The promise of digital solutions for better pain data and treatment access

The pressing need to better understand the significance of the health problems of chronic pain in correctional settings is also a core public health responsibility. The 2016 National Pain Strategy recommends steps to “a) increase the precision of information about chronic pain prevalence overall, for specific types of pain, and in specific population groups; b) develop the capacity to gather information electronically about pain treatments, their usage, costs, and effectiveness; and c) enable tracking changes in pain prevalence, impact, and treatment over time, allowing evaluation of population-level interventions and identification of emerging needs.”

Unfortunately, most population-level databases (eg, the National Health Interview Study) do not include people in correctional facilities. Most studies conducted in correctional facilities are observational and regional in nature. One national survey, the 2016 Survey of Prison Inmates (see Table 1), characterizes many health conditions, but not pain. Much as we did in the National Pain Strategy, we call for the Survey of Prison Inmates to include questions to characterize the prevalence and incidence of chronic pain and high-impact chronic pain.⁸ We also need to include questions to better understand the use, costs, effectiveness, and availability of pain treatments.

Population-level databases (eg, national and regional surveys) are limited in their phenotypic characterization of the individual with pain. These surveys are better at understanding population-level characteristics. As such, we also need local and regional digital health approaches to characterize incarcerated patients at the individual level. This need can be addressed by institution-level digital capture of data.

Understanding and better addressing the unmet needs of people in corrections settings requires better data and digital treatment approaches that transcend current health care staffing shortages. Effective in-house electronic data capture could transcend persistent limitations in corrections settings studies, such as small sample sizes, sampling bias, measurement limitations, and variability in the quality of facilitators.⁹

The absence of solid research evidence on the efficacy of various methods in anesthesia, perioperative care, and pain management presents obstacles to delivering consistent, high-quality care. Clinicians, lacking data to correlate a patient’s distinct profile with the relative success of different treatments, tend to default to practices they acquired during their education, often from their mentors, leading to unjustified inconsistencies in their approach. Historically, systems that allow health care providers to incorporate pertinent data and track patient outcomes effectively have been missing. The Institute of Medicine (now known as the National Academy of Medicine) advocated for the creation of learning health care systems (LHSs). These systems, as conceptualized by the Institute of Medicine, harness a unified digital framework to facilitate data-driven, coordinated care that is both patient centric and delivered “just in time” for health care providers. LHSs integrate science, informatics, incentives, and a culture conducive to ongoing enhancement and innovation, striving for continual betterment. When executed correctly, LHSs have the potential to refine and personalize care within correctional settings and the broader community.

Addressing the National Academy of Medicine’s initiative and the National Pain Strategy’s directives, one author (S.C.M.) established CHOIR (as detailed in Table 1) as a pioneering, open-source, adaptable, and cost-free LHS. CHOIR systematically gathers patient-reported outcomes at every clinic encounter, dynamically presents these outcomes in graphs to assist immediate clinical decision-making, monitors patient responses to treatments over time, and incrementally improves the delivery of health care, thereby informing personalized treatment strategies. Furthermore, CHOIR compiles data of a caliber suitable for research purposes, which can shed light on the variables that affect the severity and chronicity of pain; such data are pivotal for identifying modifiable factors and implementing the scalable, non-drug pain relief methods recommended by the Federal Bureau of Prisons (2018) and other entities.⁷

Recent developments in nonpharmacological pain treatment include brief, low-burden, effective behavioral interventions that can be received online (group telehealth) or in digital on-demand format—thus scaling patient access. For example, a 1-session online or in-person pain relief skills group intervention, Empowered Relief^®, was shown to provide pain relief and multidimensional symptom improvement (pain catastrophizing, pain interference, anxiety, depression, sleep disturbance) for chronic pain at 3 and 6 months after treatment,¹⁰ as well as to reduce pain and opioid use after surgery. Indeed, such cost-effective, efficient, and scalable nonpharmacological treatment options could reduce pain and suffering among patients in corrections settings, thus unburdening patients and clinicians alike. Future studies could explore whether digital treatments and on-demand supports reduce medical utilization and associated costs and enhance health outcomes after release.

Conclusion

Existing challenges impede a complete understanding of the problem of pain in corrections settings and in delivering high-quality pain care. Overcoming these challenges will require significant systems-level changes, and these are achievable. We need to better understand the problem of pain in corrections facilities at a population level through the future integration of pain questions into national surveys. At the local level, we can leverage advances in information technology systems to implement LHSs and other digital health platforms to better characterize the individual with pain and aid in delivering risk- and treatment-stratified care. These LHSs can also cost-effectively deliver evidence-based behavioral therapies to help augment the care provided by understaffed clinicians and delivery systems. Finally, such digital systems could optimize pain care for incarcerated individuals, reduce their vulnerabilities immediately after release, and support their health in the ensuing post-release years. Ultimately, effective digital solutions could reduce the impact of pain on those in correctional institutions, reduce health care utilization, and favorably impact society.

Funding

We acknowledge support from the National Institute on Drug Abuse (K24 DA053564 [B.D.D.] and K01 DA053391 [N.V.]) and the National Institute for Neurological Diseases and Stroke (K24 NS126781 [S.C.M.]).

Conflicts of interest: Stanford University receives revenue for continuing medical education on Empowered Relief (ER) instructor certification training provided to clinicians. B.D.D. is Chief Science Advisor at AppliedVR, and her consulting role with this company (personal fees) is unrelated to the present research. B.D.D. receives royalties for 4 pain treatment books she has authored or co-authored. She is the principal investigator for 2 pain research awards from the Patient-Centered Outcomes Research Institute, one of which is investigating the effectiveness of ER. B.D.D. is a principal investigator for two NIH grants investigating ER’s efficacy. B.D.D. serves on the Board of Directors for the American Academy of Pain Medicine, the Board of Directors for the Institute for Brain Potential, and the Medical Advisory Board for the Facial Pain Association. B.D.D. is a scientific member of the NIH Interagency Pain Research Coordinating Committee, a former member of the Centers for Disease Control and Prevention Opioid Workgroup (2020–2021), and a current member of the Pain Advisory Group of the American Psychological Association. S.C.M. receives research funding from the NIH, the Food and Drug Administration, and the Patient-Centered Outcomes Research Institute (administered through Stanford University). He is an unpaid advisor to both ACTTION (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks) on their oversight committee and the American Chronic Pain Association (ACPA) for their scientific oversight.

All co-authors have seen and agree with the article’s contents. We certify that the submission is original work and is not under review at any other publication.