Treating Pain on a Social Scale

Image © 1983, Wong-Baker FACES™ Foundation.  Used with permission.

Image © 1983, Wong-Baker FACES™ Foundation. Used with permission.

By Matt Wood

We hear a lot these days about online social networks, but the size and strength of a person’s real-life social network has major consequences for his or her health and quality of life. Studies have shown a statistical link between social interaction and mortality, and research has linked loneliness to a range of ailments and diseases, from high blood pressure and poor sleep to heart disease and breast cancer.

Older people are particularly sensitive to changes in their social networks. They often rely on others to help with everyday tasks such as shopping, cooking, cleaning or getting to medical appointments, and like everyone they benefit from the general sense of happiness and well-being that comes from having a robust network of family and friends.

Cognitive impairment from conditions such as dementia is known to limit a person’s social network, causing them to withdraw from the community and become more isolated. Another factor that contributes to social engagement, particularly among older people, is chronic pain. But how much of an impact a painful condition such as arthritis or a bad back can have on social engagement was the focus of a recent study by researchers at the University of Chicago Medicine, which found that chronic pain can affect social vulnerability just as much as cognitive impairment.

“In older adults, so much emphasis is on the physical impact of pain, particularly on functional disability, and the psychological impacts like depression, but not as much attention has been paid to how pain affects one’s socialization,” said Joseph Shega, MD, associate professor of medicine in the Section of Geriatrics and Palliative Medicine and lead author on the study. “More and more research has been done showing that social isolation is associated with worse health outcomes for older adults, so the opportunity came up to try to better understand if pain is associated with more social vulnerability or not.”

The Canadian Study of Health and Aging (CSHA) offered a unique opportunity to address this question by providing data on community-dwelling adults — people who live on their own, not in assisted living or nursing homes — over the age of 65. Shega, William Dale, MD, PhD, associate professor of medicine and chief of the Section of Geriatrics and Palliative Medicine, Kathleen Cagney, PhD, associate professor of sociology, and colleagues from the University of Pennsylvania, the University of Pittsburgh and Dalhousie University in Canada used a cross-sectional analysis of this data to understand the relationship of pain and cognitive impairment with social vulnerability. The study was published in the January issue of Pain Medicine.

The CSHA data included responses about pain levels, cognitive ability and a social vulnerability index, which comprises a variety of variables measuring important social factors. These variables included a person’s ability to engage in the wider community, their living situation, social support system, ability to maintain social ties and a sense of mastery over one’s life circumstances. Statistical analysis showed that moderate to severe pain increased the likelihood of being socially vulnerable just as strongly as moderate cognitive impairment.

Surprisingly, however, being in pain didn’t compound the effect of cognitive impairment on social vulnerability, or vice versa. “Our hypothesis was that they would,” Shega said. “We expected their social vulnerability to be greater than just the impact of the two separate conditions added together, but that ended up not being the case.”

Dale said the understanding that pain and cognitive impairment act similarly and independently to affect a person’s social vulnerability is important, because it puts more appropriate attention on pain management. “I think the big message is that pain is relatively neglected in the big scheme of things,” he said. “You’ll see tons of work on cognitive impairment and its negative impact on social engagement, but it’s fairly unusual to see some recognition of pain’s role being basically equivalent.”

Assessing pain’s impact on a patient can be difficult because different types of pain can affect people differently, regardless of its intensity. For example, severe arthritis in the hands is much more debilitating for someone who likes to play the piano than someone who likes to go hiking. Such pain might even take precedence over other health issues, such as high blood pressure, that don’t have noticeable symptoms that affect daily activities.

Shega said he hopes this study will change how physicians assess pain treatment. “Pain is an important construct for one’s overall health, which is their medical, physical, psychological, social and spiritual well-being,” he said. “It’s important to recognize that pain can impact social well-being, and when you’re assessing pain it should be one of the things that you’re also monitoring.”

Shega and Dale would like to continue their study of chronic pain’s ties to social engagement by working with longitudinal data from the National Social Life Health and Aging Project (NSHAP), a study by investigators from NORC and the University of Chicago that contains multiple waves of data over five to 10 years and rich social network data. Using this long-term data will allow them to assess whether pain leads to more social isolation, and how the structure of the relationship changes over time.

In the meantime, Shega and Dale want to focus on treating pain like any other medical condition. “My experience in the clinic is it’s getting harder and harder to treat pain, in part because it’s relatively neglected in the older population,” Dale said. “Patients will tell me they don’t want to get addicted to pain medicines, or they are very resistant to the idea of being treated for their pain, which they often consider part of ‘getting old.’ But they would never say they didn’t want to treat a medical condition.”

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Shega JW, Andrew M, Hemmerich J, Cagney KA, Ersek M, Weiner DK, & Dale W (2012). The Relationship of Pain and Cognitive Impairment with Social Vulnerability-An Analysis of the Canadian Study of Health and Aging. Pain medicine (Malden, Mass.) PMID: 22239723

About Matt Wood (465 Articles)
Matt Wood is a senior science writer for the University of Chicago Medicine and editor of the Science Life blog.

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