Abstract
Chronic pain (CP), or pain that persists for at least three months, is a common yet complex condition associated with many adverse impacts including reduced functional ability, work productivity, mental health status, and general health status. The biopsychosocial model of pain describes how pain perception and experience are influenced by complex interactions of biological, psychological, and social factors, many of which disproportionately affect adults with disabilities. Despite this, research on the experiences of adults with disabilities with co-occurring CP has been neglected. CP is a difficult condition to manage, and even with proper treatment, it is often not completely eliminated. If patients do not receive necessary pain specialty care or treatments, it may lead to inadequate treatment, potentially encouraging risky self-medication behaviors (e.g. alcohol use) for pain relief. The relationship between alcohol as a self-medication method for adults with disabilities who have co-occurring CP has not been studied, although this population is at greater risk for undertreatment of pain from existing barriers to medical care.
The emergence of the Severe Acute Respiratory Syndrome (SARS)-CoV2 (COVID-19) pandemic in March 2020 is important to consider for adults with disabilities with co-occurring CP, as it worsened many of the contextual factors known to affect pain experience. No research studies, to our knowledge, have investigated the impact of the COVID-19 pandemic on pain experiences by disability status in the United States.
The focus of this three-paper dissertation was to fill these research gaps, exploring associations between disability status and CP, pain experiences (level of pain, treatment methods), and other relevant factors influencing pain including alcohol use (self-medication) and the COVID-19 pandemic. All three papers used data from the National Health Interview Survey, although they draw on different samples, with Paper 1 using the 2019 adult sample, Paper 2 using the 2019-2020 longitudinal adult panel, and Paper 3 using the 2020 adult sample.
Using binary and multinomial logistic regression models, Paper 1 found that adults with disabilities were more likely to report experiencing CP and higher levels of pain than non-disabled adults. These associations were even greater among those with physical disabilities compared to those without physical disabilities. We also found adults with disabilities were more likely to report their pain was less effectively managed, and that overall types of pain treatments used varied, with adults with disabilities being more likely to report only using opioids to treat their CP than adults without disabilities. Results from this study indicate that more efforts are needed to address CP for people with disabilities, and to ensure that adults with disabilities receive multimodal care to improve treatment outcomes, with an emphasis on not relying solely on prescription opioids, which convey risks.
Paper 2 used a series of random effects generalized estimating equations and multinomial logistic regression models to evaluate changes in pain experiences (CP prevalence, level of pain, treatment methods) during the COVID-19 pandemic by disability status. We found that 64% of adults with disabilities had CP, nearly three times the prevalence of adults without disabilities (17%), and they also had greater levels of pain than people without disabilities. Treatment methods utilized varied, with disabled adults being more likely than others to indicate that they used only opioids or opioids and another method. Overall, there was no evidence that the COVID-19 pandemic changed associations between the included pain measures by disability status, despite widespread disruptions in health and social services. Adults with disabilities had persisting higher prevalences of pain, pain levels, and opioid use than those without, signaling CP for disabled people is inadequately addressed in both crisis and routine contexts. Overall, more work is needed to address CP for adults with disabilities.
Paper 3 used binary logistic regression models and a negative binomial regression model to evaluate the associations between disability status and three past-year alcohol measures (any alcohol, any binge drinking, average drinks consumed on days drinking). Then among adults with CP, we evaluated the role of high impact CP as a moderator of those relationships. Adults with disabilities reported having CP at disproportionately higher prevalences (62% versus 18%). Among people with CP, disabled adults qualified as having high impact CP approximately twice the prevalence of non-disabled adults. After multivariable adjustment, disabled adults were significantly less likely to report any past year alcohol use compared to non-disabled adults, although disability status was not associated with past-year binge drinking or average number of drinks. Adults with CP had an increased average number of drinks consumed on days drinking and higher odds of binge drinking in the past year, compared to adults without chronic pain; however, CP was not associated with any past year alcohol use. Overall, we found that high impact CP did not modify the relationship between disability status and any past year alcohol use, binge drinking, or average alcoholic drinks consumed on days drinking alcohol. These findings indicate that alcohol use for disabled adults with CP may be influenced by other non-measured factors, rather than pain or high impact CP alone.
The findings from this dissertation offer a unique contribution to the literature, providing the most comprehensive US based prevalence estimates of CP, high intensity CP, pain experiences, and pain treatments by disability status. Although the temporal relationship between disability and CP could not be examined in this dissertation due to limitations in available data, the findings collectively illuminated a pattern of high co-prevalence of CP, increased levels of pain, higher impact to daily function, worse pain treatment, and a lack of multimodal care for adults with disabilities. More work is needed to better meet the needs of adults with disabilities with co-occurring CP and improve associated outcomes.