Sociology of Chronic Pain

Abstract

Chronic pain is a common, costly, and consequential health problem. However, despite some important analytic contributions, sociological research on pain has not yet coalesced into a unified subfield. We present three interrelated bodies of evidence and illustrative new empirical findings using 2010 to 2018 National Health Interview Survey data to argue that pain should have a central role in sociological investigations of health. Specifically, we contend that (1) pain is a sensitive barometer of population health and well-being, (2) pain is emblematic of many contested and/or chronic conditions, and (3) pain and pain treatment reflect and have wide-ranging implications for public policy. Overall, whether pain is analyzed quantitatively or qualitatively—focusing on its distribution in the population, its social causes and consequences, or its subjective meanings for individuals—pain reflects social conditions, sociopolitical context, and health-related beliefs of a society. Pain is thus an important frontier for future sociological research.

Chronic pain is extremely common, costly, and enormously consequential for health, well-being, and productive functioning. It is also, as this article argues in detail, intricately shaped by and reflective of social factors, from the most micro to the most macro levels. Nonetheless, although chronic pain (often abbreviated below as pain for parsimony) has been studied extensively in the biomedical and psychological sciences, sociological research on pain—despite important analytic contributions—has not yet coalesced into a unified subfield. We posit that pain should have a central role in sociological investigations of health, that medical sociology needs to contribute to interdisciplinary scholarship on chronic pain, and that examining pain will enrich both the theoretical frameworks and empirical knowledge base within medical sociology.

Our arguments unfold in six sections. The first and second sections motivate the sociological study of chronic pain and present brief background on, definitions of, and theories of pain. The third through fifth parts present our core arguments in support of increased sociological attention to pain: that chronic pain is a holistic, sensitive measure of health and well-being; that it is emblematic of contemporary contested and/or chronic conditions; and that it is a litmus test of public policy, reflecting the political-economic orientations and health of a society and its health care system. The final section suggests directions for future research. Due to word constraints, many valuable sources could not be cited. However, throughout the article, we highlight scholarly contributions from sociology (including our own new estimates of pain’s prevalence, correlates, and association with mortality among U.S. adults); we also draw on interdisciplinary scholarship from biomedical, clinical, psychological, and other disciplines.

MEDICAL SOCIOLOGY AND CHRONIC PAIN

Sociologists have produced an innovative but relatively modest body of research on chronic pain, including early examinations of ethnic and gender differences in pain experiences and expression (Bendelow 1993; Zola 1966). Important more recent developments include qualitative examinations of the experiences of women with painful conditions such as fibromyalgia and migraine (Barker 2005; Kempner 2014; Pryma 2017) as well as studies published in the Journal of Health and Social Behavior that link early life course disadvantage to adult pain (Goosby 2013) and analyze pain management disparities at safety-net hospitals (Rubin et al. 2018). Nonetheless—and despite previous explicit calls for a “sociology of pain” (Bendelow and Williams 1995)—our field has given short shrift to the topic. Web of Science lists over 166,000 articles, published 2000 to 2020, with pain in their title, but only 140 are classified under sociology, and many of those use the word figuratively.

Sociological research on pain is, however, imperative. Social conditions shape the causes of chronic pain, its consequences, and even the very experience of pain. Micro-, meso-, and macro-level conditions affect risk factors for pain-inducing conditions or injuries and the likelihood of pain becoming chronic; they shape pain’s psychological, social, and financial consequences; they influence how pain patients are treated by the health care and social welfare systems and society at large; and, most intimately, they shape intrapersonal perceptions and understandings of pain. Whereas chronic pain is subjective and personal, sociologists are best positioned to illuminate the role of social issues—economic insecurity, discrimination, violence, and so on—in the ostensibly personal pain “troubles” (Mills 1959). Applying a sociological lens to the study of pain thus expands the range of “independent variables” and moderators in the (literal or metaphorical) “regression equations” to include previously understudied demographic, socioeconomic, and public policy factors. Moreover, pain is itself an “independent variable.” Chronic pain impacts individual and societal outcomes, including population-level health and mortality patterns; macro-level policies, including disability benefits; and the orientation toward the opioid epidemic from medical, public health, and criminal justice lenses.

Sociologists are arguably at a watershed moment for the sociological study of pain. In 2019, the World Health Organization (WHO) released the 11^th International Classification of Disease (ICD-11), which for the first time classifies chronic pain as a disease (WHO 2019). This may unleash a flood of biomedical research on the “new” condition—research that would be strengthened by sociological insight. Prominent econometricians have begun analyzing chronic pain (Case and Deaton 2020); we can complement their work from a sociological perspective. The hardships of the COVID-19 pandemic may exacerbate pain worldwide, given the tight links between social conditions and pain. And finally, the opioid epidemic—with inherent, if fraught, ties to pain—continues to rage in the United States and elsewhere; intense interdisciplinary effort is needed to guide policies to conquer it.

CHRONIC PAIN: SELECT BACKGROUND CONCEPTS IN BRIEF

Defining Pain

Defining pain is no easy task. The pioneering pain scholar Margo McCaffery defined pain as “whatever the experiencing person says it is, existing whenever and wherever the person says it does” (Boddice 2017:45). The International Association of the Study of Pain (IASP) formulation, which is effectively the official definition in biomedicine, describes pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (Raja et al. 2020:1). Various definitions, however, share the emphasis on the subjective components of pain over the role of underlying physical damage.

Acute Versus Chronic Pain: Adaptive Versus Maladaptive

Acute and chronic pain are often distinguished based on duration, specifically, as less than versus more than three months. These two classes of pain, however, are profoundly different phenomena (Basbaum et al. 2009).

Acute pain is a life-saving neural alarm system, which alerts one to noxious stimuli—injury or inflammation—such as a broken bone or appendicitis. It is necessary for survival. Chronic pain, in contrast, persists well past expected healing time or even emerges without any evident injury to the tissues. It is increasingly understood as a maladaptive source of suffering and disability, often decoupled from initial physical damage—if there was any—and caused or exacerbated by abnormal functioning of the nervous system (Woolf 2004). The distinction between acute and chronic pain is evident in brain imaging studies where the two activate different areas in the brain (Reckziegel et al. 2019). Chronic pain, moreover, causes large-scale anatomical and metabolic changes in the brain, especially in emotion-related brain circuitry (Hashmi et al. 2013).

The acute–chronic distinction is central also to the question of whether pain is just a symptom of one of countless diagnoses or a condition in its own right (or whether it can be both). If pain is largely a symptom of a disease or injury, as is acute pain, then research should focus on the underlying disease. For much of the twentieth century, in fact, medicine viewed pain largely as a symptom, causing a vicious circle: Pain was viewed as secondary, research was limited, and the understanding of pain lagged (Raffaeli and Arnaudo 2017). Fortunately, with gradual appreciation of the distinct nature of chronic pain, medical research now views at least some pain as an independent condition (Siddall 2013), a notion supported by chronic pain’s addition to the ICD-11 (WHO 2019). The complex classifications and typologies of pain notwithstanding, sociological research is justified in examining chronic pain as an entity in itself, based on its common social causes, consequences, and contexts, as discussed in later sections.

Historical and Current Pain Frameworks

Scholars have theorized pain since antiquity. Early understanding of chronic pain was holistic and metaphysical or spiritual. In medieval Europe dominated by the Christian worldview, pain was accepted as punishment for sins (pain, penalty, and punishment share the same Latin root) and even sought as evidence of one’s piety (Boddice 2017). In the mid-seventeenth century, Descartes overthrew millennia-old notions and defined pain as a sensation transmitted directly from a point of injury in the body to the brain. This mechanistic view underpinned Western understanding of pain for the next three centuries. It is evident across all early modern theories of pain developed in the nineteenth and early twentieth centuries, including the influential specificity theory, which posited, incorrectly, that a dedicated “pain center” in the brain processes stimuli from specific pain receptors (Moayedi and Davis 2013).

By the mid-twentieth century, this Cartesian understanding was increasingly recognized as inadequate and was finally superseded by the paradigm-shifting gate control theory (Melzack and Wall 1965). The theory postulates that structures in the spinal cord act as a “gate” that can modulate the ascending pain signals while the brain itself has pain-regulating mechanisms that shape the pain sensation. Further elaborations, such as neuromatrix theory (Melzack 1999), gave the brain an even more central role in the production of the pain experience. The emphasis of the role of the central nervous system as not only in passively perceiving but also actually generating pain paved the way for the current biopsychosocial model.

The biopsychosocial model has dominated pain research for four decades (Turk, Wilson, Swanson, et al. 2011). This model expands Melzack’s view of the central role of the brain and recognizes a broad array of “psychosocial” mechanisms affecting chronic pain. Unfortunately, the expansion into psychosocial factors stopped in the department of psychology. Thus the social part of the model’s name is better understood as “social–psychological” factors: interpersonal, affective (emotional), and cognitive inputs, including social support, beliefs, attitudes, self-efficacy, cognition, and coping, and affects, including distress, depression, and anxiety (Gatchel et al. 2007). Even if social forces or social determinants are specifically mentioned in this literature, they still refer largely to interpersonal social–psychological factors (Craig and Fashler 2013).

Thus, the currently predominant model of pain neglects the role of structural inequalities that shape who experiences pain, how they experience it, and how others view their pain, let alone upstream, fundamental driving factors such as public policy, the medical–industrial complex including pharmaceutical and health insurance industries, and the sociopolitical context that underlies all these factors and their interrelationships (Montez 2020; Wailoo 2014). To ignore these upstream determinants is to have an incomplete understanding of pain, just as Phelan, Link, and Tehranifar (2010) have warned regarding overall health. Medical sociology as a field can and must rebalance the lopsided biomedically focused pain models with our expertise on the social context and appreciation of its profound effect on pain if we are to understand the profound impact of pain on society and the way in which the structure of societies influence pain.

PAIN AS A BAROMETER OF POPULATION HEALTH

Chronic pain is a sensitive barometer of population health and well-being. In this section, we review characteristics that jointly support this claim. We show that pain has enormous health and social consequences; is universal, that is, relevant to all and affecting many; at the same time is unequally distributed in society, reflecting existing structural inequities; and is inextricably linked with multiple dimensions of physical and mental health and well-being.

Population-health scholarship often relies on holistic indicators of health, such as self-rated health. Pain, as a broad construct with a multitude of possible causes and correlates, can serve a similar role but with the added strength of direct clinical and policy implications. Another strength of chronic pain for population-health research is its inherently subjective nature: Its “gold standard” measurement is a person’s own assessment (Boddice 2017), unlike for many other health measures (e.g., chronic conditions) for which medical records are considered the gold standard. Additionally, major population-health surveys collect information about pain, sometimes longitudinally or in repeat cross-section, typically in one of two forms. Global pain questions (e.g., in the Health and Retirement Survey) ask, “Are you often troubled with pain?” A positive answer can be followed with questions about pain intensity and/or interference with daily activities. A site-specific approach (as in the National Health Interview Survey) asks a series of questions with respect to particular body sites, such as low back, neck, or joints.

The Far-Reaching Consequences of Pain

Chronic pain exacts a heavy price from affected individuals, their families, and society at large. For individuals, pain is a major “biographical disruption” (Bury 1982) that can destroy “the self” (Charmaz 1983) and derail all aspects of life trajectory. Pain interferes with work and daily activities and is the leading cause of disability (Zimmer and Rubin 2020), which can cascade to subsequent social, occupational, and economic problems. Pain disrupts sleep, increases fatigue, compromises cognitive function (Turk et al. 2016), and doubles the risk of suicide (Racine 2018).

Beyond the individual, pain affects the entire family, workplace, and other social structures where the sufferer is embedded. Pain reduces productivity and increases absenteeism, which can have repercussions for others in the workplace (Dueñas et al. 2016). Pain impedes the ability to carry out social roles, such as those of a parent or a partner, leading to feelings of loss, stress, anger, resentment, and helplessness across the family unit (Strunin and Boden 2004). Family and friends struggle watching their loved one in pain but also may feel burdened by the needed caregiving (Dueñas et al. 2016).

At the national level, such consequences are multiplied by the 100 million Americans who are estimated to be affected by chronic pain (Institute of Medicine 2011). The prevalence estimates range from about 10% for high-impact pain to upward of 40% using broader definitions of pain (Dahlhamer et al. 2018; Zajacova, Grol-Prokopczyk, and Zimmer 2021), and costs in the United States exceed $300 billion annually in lost productivity alone, with an additional $300 billion for health care, dwarfing the costs of all other leading causes of morbidity and mortality (Gaskin and Richard 2012).

Moreover, pain prevalence is increasing steeply across all studied population groups in the United States (Zajacova et al. 2021; Zimmer and Zajacova 2020) and other countries (Rice, Smith, and Blyth 2016; Zimmer, Zajacova, and Grol-Prokopczyk 2020). Experts expect chronic pain to increase further in the aftermath of the COVID-19 pandemic (Clauw et al. 2020), due in small part to postviral pain syndromes but primarily due to economic collapse, social stressors, anxiety, social isolation, reduced physical activity, and unavailable medical care. The combination of pain’s high prevalence and continued increase lends urgency to medical sociologists’ task to better understand and help reverse these distressing trends.

Pain Disparities

Although pain affects people from all walks of life, its prevalence differs markedly across population groups. By far, the most widely studied pain disparities, especially in biomedical research, are gender/sex differences. However, even in population-health scholarship, gender differences have been studied extensively, and findings are consistent: Nearly universally, women report higher prevalence of pain than men (Jay et al. 2019; Kennedy et al. 2014).

Much less research exists on other disparities. Lower socioeconomic status (SES), whether operationalized with education, income, or other measures, is generally found correlated with higher pain prevalence (Dahlhamer et al. 2018; Goosby 2013; Janevic et al. 2017). Findings for racial and ethnic disparities are less consistent. Some research shows that black and Hispanic respondents report less pain than their white counterparts (Kennedy et al. 2014; Zajacova et al. 2020), but other studies—especially if taking into account pain intensity and respondents’ SES—show comparable (Janevic et al. 2017) or higher (Grol-Prokopczyk 2017) prevalence in nonwhite adults.

Figure 1 illustrates disparities in severe pain in a representative sample of U.S. adults (for methods and approach for all Figures), see the Appendix in the online version of the article). About 10% of men and 13% of women report severe pain. Whereas 11% of non-Hispanic white and Hispanic Americans report severe pain, the proportion is more than 15% for black and only 8% of “Other” respondents. These demographic disparities are important and sizeable, yet socioeconomic gradients are staggering in comparison. Fewer than 7% of college graduates report severe pain, whereas among Americans without a high school diploma, the percentage is nearly triple: 19%. And similarly, by family income, only 6% of the highest income group, but 19% of the lowest income group, report severe pain. An interesting exception to the monotonic SES gradient pertains to adults with some higher education, who have slightly more severe pain than adults with a high school diploma, an anomaly examined elsewhere (Zajacova et al. 2020). Our illustration thus shows that the amply studied gender differences pale in comparison with the larger race and massive socioeconomic disparities. The results provide justification for social science research on this surprisingly understudied area.

Figure 1. Predicted Probability of Severe Pain in U.S. Adults Aged 30 to 84.

Note: For detail, see the Appendix in the online version of the article.

Source: National Health Interview Survey, 2010–2018.

Pain and Other Health Dimensions

Pain is closely connected with effectively all dimensions of physical and mental health. Figure 2 illustrates these strong correlations. Pain is tightly coupled with self-rated health; dimensions of mental health such as depression, fatigue, and anxiety; and functional limitations, such as arthritis. Such correlations at the population level were described previously (Nahin 2015; Rubin and Zimmer 2015). Pain, like other chronic conditions, tends toward comorbidity: Experiencing pain goes hand in hand with other conditions (Patel et al. 2013), especially those that are pain-related, such as arthritis, but also those with little evident pain component, such as hypertension (Zajacova et al. 2021). In this sense, pain is both a unique condition in its own right as well as a cause and an effect of other conditions.

Figure 2. Correlations between Pain Severity and Other Health Measures, U.S. Adults Aged 30 to 84.

Note: For detail, see the Appendix in the online version of the article. SRH = self-rated health.

Source: National Health Interview Survey, 2010–2018.

Pain is particularly intimately linked with disablement—they often co-occur (Zimmer and Rubin 2020). Respondents who were “often troubled with pain” had six times the odds of functional limitations and eight times the odds of ambulatory difficulty compared with respondents without pain (Smith et al. 2018). Yet despite the inextricable connection, pain is given short shrift in widely used models of health disability (Verbrugge and Jette 1994; WHO 2013). The seminal Verbrugge and Jette (1994) formulation of the disablement process, for instance, mentions pain only parenthetically. This is quite puzzling—after all, people limit activities most often because they experience pain (Zimmer and Rubin 2020). Thus, pain—its presence and severity—should be a central component of any disablement framework.

The strong links between pain and mental health have been documented extensively, especially for depression and anxiety (Goosby 2013; Gureje et al. 2008), but also anger (Greenwood et al. 2003) and suicidal ideation or suicide (Racine 2018). Even relative to a host of social and medical correlates, psychological distress is a highly salient predictor of pain levels and trends (Zajacova et al. 2021). The links are complex and certainly bidirectional and reciprocal, so that distressed mental states exacerbate pain and the presence of pain exacerbates distress (Viana et al. 2018). Mounting evidence reveals that social pain, such as social exclusion or discrimination, shares neural mechanisms with those processing physical pain, particularly its affective component (Eisenberger 2015). Thus, factors that increase exposure or vulnerability to social pain may also increase exposure and vulnerability to physical pain and vice versa.

Finally, pain, particularly severe pain, likely also predicts mortality. Figure 3 shows that moderate and especially severe pain are associated with substantially lower survival compared with no or mild pain even after controlling for a host of sociodemographic variables in a sample of U.S. adults. This illustrative finding corroborates the rapidly evolving literature on pain and mortality. Seven years ago, a systematic review on pain and mortality found only 10 articles suitable for inclusion; the authors concluded that pain was associated with only modestly higher mortality (Smith et al. 2014). Just three years later, the prominent epidemiologist of pain Gary Macfarlane (Macfarlane, Barnish, and Jones 2017:1815) declared that the “evidence is now clear” that pain, at least severe/widespread pain, is associated with excess mortality. Explanations for the association are not well understood, but possible mechanisms include pain medication (Cleveland, Nelson, and Callahan 2019) and pain’s potential to increase allostatic load, suppress the immune system, and impair tissue repair (Gatchel et al. 2007).

Figure 3. Predicted Probability of Survival by Pain Severity, U.S. Adults Aged 30 to 84.

Note: For detail, see the Appendix in the online version of the article.

Source: National Health Interview Survey, 2010–2014, linked to mortality follow-up through 2015.

INVISIBLE, CONTESTED, AND INTRACTABLE

Chronic diseases have been the leading causes of death and disability in the United States since the mid-twentieth century. A large number of chronic health problems feature psychiatric or physical symptoms for which no biological explanation can be found: Roughly 50% of medical consultations feature such “medically unexplained symptoms” (O’Leary 2018). Whereas sociological focus on pain would be warranted by pain’s high prevalence and profound consequences alone, pain’s frequent unverifiability, inexplicability, and long duration also make it a telling test case for how individuals and institutions contend with contested, intractable conditions in general. These disease characteristics strongly shape illness experiences;patient–provider relations; the invocation of gender, racial, and other stereotypes; and pain treatment and research.

Pain’s Profound Invisibility and Its Consequences

Qualitative social scientists have shown a consistent fascination with what Baszanger (1992:181) calls the “fragile factuality” of pain (i.e., its invisibility and unverifiability; e.g., Barker 2005; Jackson 2011). Although some authors refer to conditions such as diabetes and lupus as “invisible” because they cannot be seen directly (Joachim and Acorn 2000), often these conditions can be diagnosed and verified by medical professionals through the tools of biomedicine. Pain, however, cannot achieve such “mediated visibility” but retains a “profound invisibility” (Grol-Prokopczyk 2013:12): No instrument, blood draw, or biopsy can quantify it. Scientists have long pursued objective measures of pain, such as through brain imaging, but as a recent National Institutes of Health sponsored consensus statement attests, the candidate measures are only “potential pain biomarkers” and remain infrequent in clinical trials or practice (Davis et al. 2020:386, emphasis added).

Furthermore, although some health conditions can be verified and measured by quantifying their underlying cause (e.g., hemophilia can be diagnosed and graded via the quantity of clotting factors in the blood), pain remains elusive here as well because the correlation between observed physical pathologies and experienced pain is surprisingly weak. One can experience great pain with no perceptible cause, as in fibromyalgia (Barker 2005), or no pain in the presence of documented pathology, such as degenerative spinal discs (Emch and Modic 2011). Lacking objective measures, clinicians and researchers must rely primarily on patients’ subjective self-reports to assess pain.

Unsurprisingly, self-reports are a problematic basis for pain measurement and verification. As trenchantly expressed by Scarry (1985:7), “[t]o have great pain is to have certainty; to hear that another person has pain is to have doubt.” Doubt surrounding claims of pain is, indeed, rampant. Studies report with remarkable consistency that pain patients experience skepticism and accusations of malingering or hypochondria from family, friends, employers, health care providers, and so on (Crowe et al. 2017; Glenton 2003; Jackson 2011; Pryma 2017). Pain patients report “feeling disrespected and distrusted, suspected of drug-seeking, and having their symptoms dismissed as trivial and/or not warranting medical care” (Upshur, Bacigalupe, and Luckmann 2010:1791). These feelings appear to be justified: Doctors often do doubt the credibility of their pain patients’ complaints (e.g., Matthias et al. 2010), and conditions featuring pain are all too well represented among “contested illnesses” (Barker 2011). Many people with pain report that invalidation and stigmatization damage their social lives and sense of identity. Such experiences contribute to “biographical disruption” (Bury 1982) and have led to theories of pain as “an assault on the self” (Smith and Osborn 2007) or “a threat to the social self” (Karos et al. 2018).

Pain’s unverifiability and poorly understood etiology give health care providers much leeway in deciding how much pain a patient is “really” experiencing. The pain patient becomes a blank slate onto which others project stereotypes of exaggeration or stoicism, physical or psychological weakness, drugseeking behavior, and so on—stereotypes strongly related to gender, race-ethnicity, and class. Kempner (2016:1048) traces medical and literary depictions of migraine sufferers as weak, neurotic women back to at least the eighteenth century, and notions of “stoic men” and “sensitive” or “hysterical” women remain pervasive in twentieth-century medicine (Samulowitz et al. 2018). These notions, importantly, shape treatment: Men with pain are more likely to be offered surgery or opioids, whereas women are substantially more likely to be prescribed psychotropic medications for depression and anxiety (Thernstrom 2010).

Similarly, false beliefs about blacks’ lesser pain sensitivity vis-à-vis whites combined with racialized stereotypes of drug addiction and diversion shape contemporary pain treatment (Hoffman et al. 2016). Minorities, especially men, are less likely to be prescribed analgesics than whites, and if they are prescribed opioids, they are more likely to be given urine tests or substance abuse assessments (Hausmann et al. 2013). The limited evidence on social class disparities indicates that class interacts with sex and race in shaping perceptions and treatment of pain patients (Rubin et al. 2018). Although health conditions need not be invisible and unverifiable to be subject to gender, racial-ethnic, or other stereotypes, these characteristics make resistance to stereotypes appreciably more difficult.

Pain’s Therapeutic Intractability and Its Consequences

Pain often lasts or recurs for years. Over 70% of people with back pain, for instance, continue to experience symptoms four years later (Smith et al. 2004), and 85% of people with widespread pain (in three or more bodily locations) still experience it 12 years later (Andersson 2004). Pain intensity may wax and wane over the course of weeks, days, or hours, and these patterns may shape pain’s psychological and social consequences. For example, back pain sufferers report that having “good days,” during which they can perform normal tasks, harms their credibility on bad days when pain disables them (Glenton 2003).

Pain’s frequent long duration reflects the limits of the modern medical armamentarium. Review articles on chronic pain treatment are, by their own admission, “sobering,” concluding that “present treatment options result in modest improvements at best” for pain itself and “minimum improvements in physical and emotional functioning” (Turk, Wilson, and Cahana 2011:2226, 2232). Baszanger’s (1992) ethnography of French pain clinics described a schism between doctors who expected to cure chronic pain and those who aspired only to manage it. At present, however, the vast majority of pain specialists fall into the latter, more pessimistic camp, likening pain to lifelong, incurable conditions such as diabetes, which can be managed but not cured (Grol-Prokopczyk 2013).

Pain’s therapeutic intractability is a problem for both pain patients and those who treat them. The prominent late-nineteenth-century physician Sir William Osler quipped, “When I see [pain patients] coming in the front door, I leave by the back door”; over a century later, clinicians still view pain treatment as “frustrating and challenging” (Graf 2010:1976). For medical researchers, the difficulty of treating pain itself (i.e., pain intensity) has led many to refocus their work on a varied set of putatively more treatable outcomes, such as pain-related disability. As one researcher explained, “Pain is really a secondary outcome of interest, since there is no guarantee that pain can be cured or reduced, but we know we can help people improve functionally despite the pain” (Grol-Prokopczyk 2013:83). This shift from pain intensity to other outcomes may make pain a more “do-able” problem (Fujimura 1996) for clinicians and researchers—but it may also put them at odds with patients, who frequently hold out hope for curing the pain itself. Pain doctors describe how substantial “expectations management” is required to “talk people out of the ‘cure’ belief”—if they succeed in doing so at all (Grol-Prokopczyk 2013:85).

Together, pain’s invisibility and intractability, clinicians’ skepticism, the limited efficacy of existing treatments, and the tension between cure and management as treatment goals make patient–provider interactions deeply fraught. Physicians’ role as gatekeepers controlling access to disability benefits and high-risk medications, including opioids, creates further tensions (Pryma 2017; Rubin et al. 2018). Pain patients are often highly disappointed with the quality of their care (Hadi et al. 2017), and “[r]elations between pain patients and health care deliverers” have been deemed “the worst in medicine” (Jackson 2011:378).

Scholars note that Parsons’s (1951) formulation of the “sick role”—that is, the responsibilities, exemptions, and benefits that society affords to a sick person—is based on an acute disease model in which sickness is verifiable, curable via medical experts’ advice or intervention, and of limited duration (Crossley 1998; Glenton 2003). It appears that alternative models to incorporate the chronically ill—especially those with unverifiable conditions— are lacking. Thus, like square pegs in a round hole, chronic pain patients attempt to emulate Parsons’s ideal-typical patient, seeking out concrete physical diagnoses and effective biomedical treatments—and experiencing delegitimation and stigma when the diagnoses and/or treatments cannot be found (Glenton 2003).

Commonalities and Variability in the Pain Experience

Certain themes in research on the chronic pain experience recur so frequently that they appear nearly universal. A review of diverse chronic pain conditions reports several consistent “meta-themes” related to topics mentioned previously, including “invisible but real” and “disrupted sense of self” (Crowe et al. 2017:1004). At the same time, sociological research highlights variability in pain experiences, as shaped by characteristics including gender and race. Studies document how gender stereotypes and structural inequalities negatively affect women’s experiences of chronic pain conditions (e.g., Barker 2005; Kempner 2014). Pryma (2017) finds that black and white U.S. women with fibromyalgia frame their claims of pain differently due to highly racialized discourses regarding morality, worthiness, and disability. Scholarship on sickle-cell anemia, which in the United States predominantly afflicts black Americans, also underscores how the pain experience is inextricably grounded in specific historical, political, and cultural contexts (e.g., Rouse 2009).

Future research could enrich the understanding of pain by exploring heterogeneity not only across sociodemographic groups but also across disease characteristics and institutional contexts. How are pain experiences shaped by pain severity/interference, duration, or stage of the “disease course” (Yang and Grol-Prokopczyk 2020)? How are they shaped by national- or state-level health insurance or disability benefit programs? The salience of policy contexts is addressed in the next section.

PAIN, POLICY, AND OPIOIDS

Chronic pain presents a paradox: It is a deeply personal subjective experience, yet it is also inextricably interwoven with politics and policy up to national or even global levels. Some argue that questions of whose pain is legitimate and what relief they deserve lie at the core of much political discourse and decision-making about the U.S. welfare state since the mid-twentieth century (Wailoo 2014). Similar questions motivate global institutional initiatives, such as the WHO’s and IASP’s advocacy of pain management as a human right (Brennan, Carr, and Cousins 2007). Policies particularly relevant to pain include the social welfare systems that shape overall well-being and socioeconomic contexts; regulation of the development, marketing, and prescribing of analgesic pharmaceuticals; health insurance coverage (or noncoverage) of specific pain treatments; and disability insurance policies.

For example, the Social Security Disability Insurance (SSDI) is critical for many with pain severe enough to interfere with work. Yet the SSDI requires a proof of underlying “medically determinable impairment,” which must be documented by “clinical or laboratory diagnostic techniques” such as X-rays or MRIs (Social Security Administration 2017:1). Given the low correlation between observable physical damage and experienced pain, this requirement is problematic (Case and Deaton 2020; Pryma 2017) and may lead to a vicious downward spiral of pain, economic loss, and distress for many Americans.

Complex policy influences are also evident in the opioid epidemic, which over the last 20 years killed almost half a million Americans (Centers for Disease Control and Prevention 2020). On one hand, opioids are a lifesaver (metaphorically, but also literally) to some pain patients (Thernstrom 2010). On the other hand, there is astonishingly little evidence of opioids’ effectiveness in long-term use (Chou et al. 2015) in contrast to well-documented adverse side effects and outcomes including depression and reduced immune function (Grol-Prokopczyk 2019). Indeed, opioids may actually worsen chronic pain over time because they increase sensitivity to pain (Green-Fulgham et al. 2019).

Given this fraught portrait, why are opioids the most widely prescribed medication class in the United States (Volkow and McLellan 2016) and the primary treatment for chronic pain sufferers (Jones et al. 2018)? The answer, again, is grounded in historical political, medical, and pharmaceutical developments.

For much of the twentieth century, medicine had a strong aversion to opioids, buttressed by criminal legislation and an anti-opioid culture; even severe terminal cancer pain was often undertreated. This changed in the 1980s and 1990s: A misinterpreted 1980 letter to the editor of JAMA incorrectly assuaged doctors’ fears of opioid dependence and addiction, hospital-accrediting organizations began promoting aggressive pain treatment to increase patient satisfaction, and changing health care reimbursement models led to widespread closures of interdisciplinary pain clinics, leaving pharmacological treatments as the most feasible option for time-strapped providers. Concurrently, pharmaceutical companies developed supposedly addiction-proof analgesics, most notoriously Oxycontin, and because of inadequate government oversight, marketed them aggressively and sometimes deceptively to physicians and patients alike (e.g., Jones et al. 2018). Over time, low-income Medicaid enrollees came to disproportionately rely—and overdose—on opioids, reflecting Medicaid’s coverage of opioids but not many alternative pain treatments (Grol-Prokopczyk 2019).

These developments occurred in the context of a disintegrating social safety net, mounting economic stresses, and “despair” among many Americans (Case and Deaton 2020), increasing their susceptibility to pain and demand for opioids. In recent years, the pendulum swung back toward more restrictions on opioid prescribing (Chiarello 2015), leaving many patients stranded and struggling to manage their pain.

In sum, policies including welfare state retrenchment, inadequate government regulation of a profit-hungry pharmaceutical industry, and health insurance coverage policies conspired to produce skyrocketing increases in long-term opioid use. More broadly, pain’s prevalence, disparities, consequences, and treatments reflect and shape intersecting political–economic forces in medical, commercial, legal, and ethical realms.

NEW RESEARCH DIRECTIONS/OPEN QUESTIONS

As previous sections have shown, social factors at every level of analysis shape who experiences pain, how pain is experienced, and how pain is treated in health care and society. In the following, we identify particularly promising and important directions for further investigation in support of a full-fledged sociology of chronic pain.

Causes of Pain

Pain prevalence is increasing in the United States and elsewhere, and it is important to understand why. Might it be related to breakdown of the social and economic fabric for all but the most advantaged Americans (Case and Deaton 2020)? If so, what mechanisms link this contextual deterioration to pain? What is the role of changing employment patterns, increasing obesity (Stokes et al. 2020), pervasive opioid use, psychological distress, or even changing expectations and thus reporting of pain?

In addition, pain prevalence varies markedly across groups. We must explore the intersections of age, gender, race-ethnicity, and SES because they each have unique and interactive impacts on life trajectories and, correspondingly, on pain. Moving “upstream” from individual characteristics, why do rural areas (Johannes et al. 2010) and states in the South, West, and Appalachia (Case and Deaton 2020) suffer disproportionately high pain burden? Comparison of U.S. states can highlight the role of sociopolitical contexts (Montez 2020): How do state government policies, health care systems, or cultural expectations affect the burden of pain in the United States?

Sociology has two unique strengths in answering such questions. First, medical pain specialists, who dominate current pain research, tend to see the most severe and intractable pain cases and often focus on particular pain diagnoses. Quantitative sociologists, in contrast, rely on representative, general population samples, which provide a more comprehensive and balanced picture of pain’s severity, causes, and consequences. Second, unlike biomedical approaches that focus on proximal causes, medical sociologists better grasp sociopolitical structures as upstream “causes of causes” (Galea and Vaughan 2018). This broader picture is necessary for a full understanding of pain and for effective interventions.

Consequences of Pain

We need to better understand the far-reaching consequences of pain on individuals, families, and social systems. How does chronic pain influence the economic well-being of affected individuals and their families? How do pain sufferers navigate the workplace, especially for the precariously employed? And what is pain’s impact on spousal, parental, and caregiving relationships as well as friendships and other social ties? Beyond these micro- and meso-level consequences, what is the sociocultural, economic, and political impact of pain at national and global levels?

Important open questions remain also about the health consequence of pain. Quantitative studies could further explore how and under what circumstances pain influences mortality, the role of pain in the disablement process, and pain’s contributions to cognitive aging (Moriarty, McGuire, and Finn 2011). Qualitative sociological studies could explore the parallels between pain and other chronic, invisible health conditions and could help interrogate and suggest alternatives to common models of health problems as verifiable, treatable, and temporary.

Institutions, Sociopolitical Context, and Pain

Sociological scholarship on pain has often explored patient experiences. This is an essential perspective, but much can be gained by exploring the roles of other actors, both individual and institutional, in shaping pain. How is the way we conceptualize and address pain shaped by the science, medicine, business, and politics of pain?

Even the most foundational facts about pain—including its definition and classification—are produced within social institutions. Whelan (2009), for instance, documented the sometimes tense international, interdisciplinary negotiations involved in creating the influential Classification of Chronic Pain. Future research, informed by sociology of science and of the professions, could unpack the professional “black boxes” in which pain-related norms and standards are created and could assess which stakeholders’ interests are prioritized in the process.

Institutional cultures may compete with each other, as when physicians and pharmacists face clashing medical versus legal frameworks in deciding who should be treated with opioids or, more broadly, when medical, criminal justice, public health, and pain advocates’ imperatives collide (Chiarello 2015, 2018; Thernstrom 2010). More research is needed to understand how this wide range of actors and structures jointly shapes the experience of pain and pain management. Such research can also use pain as a case study to examine how institutions, professions, and social movements interact when they navigate a shared social space.

Politics and corporations are also critical players in pain. Commercial interests help shape ideas about pain and its treatment. The role of pharmaceutical marketing in the opioid epidemic is blatant, but corporate self-interest can have more subtle and nuanced effects. Barker (2011), for instance, describes how the approval and marketing of a new medication for fibromyalgia contributed to legitimation of the condition but also created unrealistic expectations of patient function and recovery. Political discourse, pain-related policies, and regulations are also crucial: Pain is deeply political because it is central to debates and framing of suffering, morality, and social welfare in the context of health insurance or disability benefits (Wailoo 2014). Interdisciplinary research should explore how politics and the corporate pursuit of profits (Montez 2020) impact pain in the United States and elsewhere. Such approaches can illuminate the core beliefs of a country’s politics, culture, and society.

Finally, a global perspective in the form of international comparisons is powerful in making the influence of national cultures, norms, and policies visible and should be applied in research on pain and pain policy. For instance, despite roughly comparable chronic pain prevalence in Western Europe and the United States, opioid overdoses are seven times more common in the United States (Meyer, LeClair, and McDonald 2020). To what degree do legal and medical norms and regulations explain this difference? Overall, the rich institutional and sociopolitical landscape at local, national, and international levels is ripe for sociological examination.

Foundational Concepts in Medical Sociology and Chronic Pain

Research on chronic pain could help advance foundational concepts in medical sociology—and vice versa. The life course perspective, for instance, has been successfully used to uncover important insights about health over the life span. This concept is mirrored by the “disease course” of chronic pain (Yang and Grol-Prokopczyk 2020:10), which considers how pain’s duration, trajectory, and severity shape intrapersonal and interpersonal outcomes. Many concepts from life course sociology, including “turning points,” “critical periods,” and “linked lives,” could be fruitfully applied to pain research. For instance, the pivotal transition process from acute to chronic pain appears to be sensitive to social inputs; sociologists could clarify how social factors across the life course shape the risk of pain chronification.

Another foundational concept from the origin of medical sociology is the sick role (Parsons 1951), which lays out social norms for patients and doctors. The invisibility of chronic pain and its sometimes contested nature, however, undermine patient efforts at legitimation in ways unforeseen by Parsons (1951). Moreover, pain physicians may also struggle to meet Parsonian ideals, such as of doctors as omnipotent authorities. Sociological studies could examine implications of such tensions (e.g., Might doctors’ prescription of opioids reflect a social pressure to “do something” for patients?) and, more broadly, could expand theories of patient and provider roles in unverifiable, difficult-to-treat conditions.

Other sociological concepts that may contribute fruitfully to pain-related research include hegemonic masculinity (or gender roles in general), the loss and reconstruction of self in chronic illness, and medicalization. A decade ago, a prominent scholar and critic of medicalization concluded that medicalization of pain, unlike for many other conditions, was beneficial because it legitimized pain treatment and research (Conrad & Muñoz 2010). In the wake of the opioid epidemic, exposés of pharmaceutical companies’ profiteering, and the new “chronic pain” classification in the ICD-11, a careful assessment of benefits versus harms of pain medicalization may be warranted. Overall, seminal sociological concepts, theories, and models could enrich studies of chronic pain and could in turn be refined for today’s health landscape by considering the unique and complex phenomenon of chronic pain.

CONCLUSION

Chronic pain is a sensitive barometer of health at the individual, population, and institutional levels. A rapidly evolving population-health scholarship on social aspects of chronic pain has recently generated compelling findings on pain prevalence, trends, and disparities. An important if modest body of sociological inquiry has examined pain’s meanings, framings, and consequences to individuals as well as society. These contributions can serve as a foundation for deeper sociological study.

Among common chronic physical health conditions, pain has a particularly strong association with psychological health problems. In part for this reason, pain may be particularly sensitive to the health of social welfare systems, health care systems, and Western medical paradigms. Because pain is a biopsychosocial and often intractable health problem, addressing it effectively depends on a social system that focuses on prevention and well-being, treats patients holistically, and can accommodate chronic, disabling health conditions. Presently, the United States does none of these well. U.S. health care currently focuses on reimbursement of individual procedures and quick pharmacological solutions rather than on integrative long-term approaches focused on patient selfmanagement (Rubin et al. 2018).

In the late-nineteenth century, Durkheim launched empirical sociology by showing how a seemingly private act—suicide—reflected social forces, in particular the upheaval in the wake of the Industrial Revolution. In the twenty-first century’s postindustrial, neoliberal United States, we may likewise gain important new insights into the impact of social forces, structures, policies, and contexts by examining an ostensibly private experience: pain. Overall, we hope to show that sociological approaches are poised to make important contributions to understanding chronic pain and that pain, in turn, sheds light on many phenomena of interest to sociologists. The sociology of chronic pain is an important frontier for future sociological research.

Biography

Anna Zajacova is an associate professor of sociology at the University of Western Ontario. Drawing on interdisciplinary sociology, demography, and social epidemiology scholarship, Zajacova studies population health over the adult life course. In particular, she examines social causes and consequences of chronic pain; she also explores how differentiation in higher education is reflected in health disparities among adults in the United States and Canada. Her work, funded by the National Institutes of Health and the Canadian Social Sciences and Humanities Research Council, has appeared in outlets such as Demography, Journal of Health and Social Behavior, and The Journal of Pain.

Hanna Grol-Prokopczyk is a medical sociologist and demographer. Much of her research focuses on chronic pain: its measurement, its social distribution, and its predictors and consequences. She is principal investigator on a National Institute on Aging-funded project on “The Demography of Chronic Pain: A Population Approach to Pain Trends, Pain Disparities, and Pain-Related Disability and Death” (1R01 AG065351; 2020-2025). She also conducts research on how surveys can best generate interpersonally and internationally comparable measures of subjective health conditions and on U.S. counterterrorism policy. She is an associate professor of sociology at the University at Buffalo, SUNY.

Zachary Zimmer is professor of family studies and gerontology and Canada Research Chair in Global Aging and Community at Mount Saint Vincent University in Canada. His research concerns a range of topics related to the health and welfare of older persons from global and demographic perspectives. Recent endeavors include investigating implications of religiosity and spirituality among older adults worldwide, effects of early-life wartime trauma on later-life health, population trends in chronic pain, and intergenerational relationships in societies undergoing sociodemographic change. His work has been published in journals that cross disciplines, such as gerontology, sociology, demography, public health, medicine, and epidemiology.