Researchers have found an increase in chronic pain among middle-aged people without a college degree. They attribute this to factors such as greater social isolation, less marriage, and falling wages.

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According to the Institute of Medicine, chronic pain affects around 100 million adults in the United States and costs its economy up to $635 billion per year in medical costs and lost productivity.

To investigate the relationship between chronic pain and age, health economists at Princeton University in New Jersey and the University of Southern California in Los Angeles pooled the results of multiple surveys in the U.S. and 20 other wealthy nations between 2006 and 2018.

They found that in the other wealthy countries, the prevalence of pain was higher among older adults — presumably as a result of accumulated injuries and an increasing burden of disease.

In the U.S., however, they discovered that older adults report less pain than people in midlife.

In a paper that appears in the Proceedings of the National Academy of Sciences, they call this counterintuitive finding “the mystery of American pain.”

The researchers analyzed data from four nationally representative, repeated health surveys in the U.S. and internationally. These were the:

They also drew upon two U.S. longitudinal surveys, which follow individuals over time. These were the Medical Expenditure Panel Survey and the Health and Retirement Study.

The scientists focused on adults aged 25–79 years of age. In the U.S., they restricted their sample to non-Hispanic Black people and non-Hispanic white people. The complete sample included responses from more than 2.5 million people.

Looking at the data as a “snapshot” of the different ages at a single point in time, they found that pain appeared to increase through adulthood until late middle age, when it started to decline.

This pattern held true in all the U.S. datasets and regardless of the definition of pain. However, it was not true of other wealthy nations.

That said, when the researchers re-analyzed the prevalence of chronic pain by year of birth and completion of a 4-year bachelor’s degree, a different picture emerged.

When they compared 52-year-olds with less education who were born in 1955, 1960, and 1965, for example, each successive birth group, or “cohort,” had a higher prevalence of pain. A total of 32% of those born in 1955 reported pain, whereas 40% of those born in 1965 reported pain.

Comparing cohorts born in 1950 and 1990, in other wealthy countries, there was an increase in pain prevalence of four percentage points among those without a degree. In other words, people without a degree who were born later experienced more pain than those born earlier.

By contrast, there was an increase of 21 percentage points between these cohorts among the two-thirds of U.S. adults who do not have a bachelor’s degree.

“The gap in pain between the more and less educated has widened in each successive birth cohort,” the study authors summarize.

In their paper, the authors conclude:

“The mystery of American pain can be resolved, not by looking at a snapshot, but by tracking the average prevalence of pain by birth cohort over time. For less educated Americans, pain prevalence has been rising by cohort over time, so that later-born cohorts are in more pain at every age than are earlier-born cohorts.”

This means that less educated U.S. adults who are currently in their middle years are experiencing more chronic pain than previous generations did at their age.

The authors say that if pain prevalence continues to increase with each successive generation, tomorrow’s older adults will be sicker than today’s.

“Pain undermines quality of life, and pain is getting worse for less educated Americans,” says study author Sir Angus Deaton. “This not only makes their lives worse but will pose long-term problems for a dysfunctional healthcare system that is not good at treating pain.”

In their paper, the researchers attribute the increasing prevalence of pain among less educated U.S. adults to the “ongoing erosion of working class life for those born after 1950.”

As possible causes, they point to changes such as:

  • greater social isolation
  • lower rates of marriage and higher rates of divorce
  • more children being raised without their parents being legally married
  • rising unemployment
  • falling wages

In parallel with the increasing prevalence of pain among less educated U.S. adults, say the researchers, there has been a rise in “deaths of despair” from suicide, drug overdose, and alcoholic liver disease.

They write:

“The epidemic of deaths of despair has barely touched more educated Americans and appears among the less educated only beginning around the cohort born in 1950 […]. The rising prevalence of pain is part of the deterioration of the social and economic conditions faced by less educated Americans.”

The authors also note that some people have used the rising prevalence of pain to justify the prescription of opioids in the U.S., contributing to the ongoing opioid epidemic. People also commonly use alcohol to dull pain.

In addition, some have implicated pain in suicide.

The researchers discuss some alternative explanations for the increasing prevalence of pain, including increasing body weight and people having to undertake more physically demanding work.

Focusing on lower back pain, however, the study authors calculate that increases in average body mass index (BMI) account for only about a quarter of the increase in pain prevalence among people without a bachelor’s degree.

Other research has ruled out the possibility that work has become more physically demanding for less educated U.S. adults. New types of employment may be worse in terms of job satisfaction, promotion possibilities, or earnings but not the risk of physical pain.

“Assembly lines or coal mines are more dangerous than call centers, fast food restaurants, or Amazon warehouses,” the researchers conclude.