Cross-sectional Study of Psychosocial and Pain-related Variables Among Patients With Chronic Pain During a Time of Social Distancing Imposed by the Coronavirus Disease 2019 Pandemic

Valerie Hruschaka; K. Mikayla Flowers; Desiree R. Azizoddin; Robert N. Jamison; Robert R. Edwards; Kristin L. Schreiber


Pain. 2021;162(2):619-629. 

In This Article


COVID-19 in Massachusetts, Stay at Home Advisory, and Phased Reopening

Figure 1 depicts the development of the COVID-19 pandemic in Massachusetts from March 10, 2020, to June 15, 2020. Importantly, participants completed the survey between April 28 and May 22, representing a time of early social distancing in MA. All residents were required to practice proper hygiene, maintain social distancing, and use facial coverings when it was absolutely necessary to go to public places. Individuals who were at a higher risk of contracting COVID-19 (eg, people older than 65 years and those with underlying health conditions) were given additional guidance that strongly encouraged them to stay at home, with the exception of essential errands such as going grocery shopping and attending to health care needs.

Figure 1.

Study timeline in relation to COVID-19 pandemic in Massachusetts. All study surveys were completed between April 28 and May 22. The timeline includes key dates relevant to social distancing mandates in Massachusetts around the time of survey administration.

Participant Recruitment and Study Flow

Figure 2 outlines the process of study recruitment, which included email invitations to patients with chronic pain including a general email blast through the Partners Healthcare System (Rally) research enrollment site, as well as outreach to patients participating in previous studies. Of the eligibility surveys completed, 204 eligible participants were emailed the main study survey, and 150 ultimately completed the study survey.

Figure 2.

Study flow chart.

Participant Demographics

Participants had a mean age of 41 years, were female majority, and predominantly non-Hispanic Anglo-American, with most having some postsecondary education (Table 1). Employment status before the pandemic included 60.1% employed full-time and 10.8% reporting receiving disability benefits. A range of incomes were reported, with relatively few participants reported outright job loss due to the pandemic. Most participants (72%) received a COVID-19 economic stimulus check. Questions regarding economic hardship indicated some difficulty with transportation to medical care or employment (10%-12%), as well as difficulty with food (14%), or housing (11%) security. Approximately 18% of participants reported being tested for COVID-19 and, only 1 participant screened positive for SARS-CoV-2. When participants were asked to self-report the nature of their chronic pain, 57% reported back pain, 25% fibromyalgia, 11% persistent postsurgical pain, and 58.7% other pain, with many participants reporting multiple sites/types of chronic pain (Appendix Figure 1, available at A minority reported taking opioid medications (12.7%) for their pain condition.

Degree of Social and Physical Distancing, Loneliness, and use of Social Media and Technology

The majority of participants reported engaging in social distancing practices for an average of 4 to 8 weeks at the time of survey completion. Comparing current state with recalled state from before social distancing, most respondents reported a significant increase in both physical (t = 20.50, P < 0.001) and social isolation (t = 16.80, P < 0.001) at the time of survey completion (Figure 3A). On average, participants reported feeling 54% more physically isolated (95% CI: 49%-59.11%) and 42% more socially isolated (95% CI: 37%-47%) compared with before social distancing. Participants reported changes in use of electronic means of communication and connection (Figure 3B). Compared with before social distancing, 65% of participants reported an increase in phone usage (talking or texting), 91% reported an increase in video chatting, 43% reported an increase in using social media to connect with others, and 67% reported taking online classes. Unsurprisingly, 71.2% of participants reported no longer attending in-person community or religious gatherings. Approximately 14% of the study sample reported living alone, with the remaining participants reporting a mean of 2 ± 1 other household members. Participants reported a mean loneliness score of 6.2 ± 2 (range 1–9) and average introversion scores of 4.9 ± 3 (range 0–10).

Figure 3.

Effects of social distancing on isolation and social contact methods. (A) compares participants' recalled perceived social and physical isolation before social distancing to perceived isolation at the time of survey completion under conditions of social distancing. (B) depicts reported changes in how often participants use various social contact methods since they started distancing, compared with how often they recall using the method before social distancing.

Changes in Pain Severity and Interference Under Social Distancing

Participants' average pain severity and pain interference, measured by the Brief Pain Inventory, was quite variable (Figure 4). Compared with patients' recall of pain before social distancing, both current pain severity and pain interference significantly increased (pain severity: t = 7.15, P < 0.001; pain interference: t = 3.93, P < 0.001). Current pain severity increased an average of 8% (0.79/10 points; 95% CI: 0.53–1.01), and current pain interference increased by 6% (4.28/70 points; 95% CI: 2.13–6.43), although this was quite variable between participants.

Figure 4.

Participants' average pain severity and pain interference under social distancing conditions. (A) shows the distribution of current pain severity scores amongst participants during social distancing. (B) shows the distribution of current pain interference scores amongst participants during social distancing. (C) reports proportion of patients with changes in perceived pain severity since starting social distancing compared with their recalled pain. (D) reports proportion of patients with change in perceived pain interference since starting social distancing.

Factors Associated With Worse Pain Severity and Interference Under Social Distancing

Univariable (simple) regression analyses were performed to assess patient characteristics associated with greater pain severity and interference during social distancing (Table 2), revealing association of several factors with worse pain. Female sex, lower education, and higher Brief Basic Needs Questionnaire scores were associated with both worse pain severity and interference. Older age was associated with greater pain interference, but not pain severity, while nonwhite race was associated with greater pain, but not pain interference. Regarding isolation, a greater degree of social and physical isolation was weakly associated with greater pain severity, but more strongly associated with greater pain interference. Similarly, self-reported loneliness was related to pain interference but not to pain severity. Psychological factors were also variably related to pain severity and interference. Higher pain catastrophizing, sleep disturbance, anxiety, and depression were associated with greater pain severity and interference. Perceived stress was associated only with pain interference. More frequent drug use was associated with greater pain severity and interference, while alcohol use was only marginally related to pain severity.

Multivariable Linear Regression of Factors Predicting Worse Pain Outcomes Under Social Distancing

Recognizing that many of the variables in the univariable analysis are closely related, we used multivariable (multiple) linear regression to examine factors that were independently associated with worse pain outcomes during social distancing, including variables that were significantly associated with the outcomes on univariable (simple) regression analysis at the P < 0.1 level. Model 1 explained 43.3% of the variance in pain severity and revealed female sex, nonwhite race, lower education, disability employment status, fibromyalgia, and higher pain catastrophizing scores as independently associated with worse pain severity (Table 3). Similarly, model 2 explained 48.4% of the variance in pain interference and revealed only female sex and higher pain catastrophizing as significant independent predictors.

Perceived Impact on Care and Causes for Pain Worsening

Generally, participants reported decreased usage of pain management services and at the same time reported overall increased use of self-management techniques for pain (Figure 5A and B). Patients endorsed the importance of treatment restrictions (70.7% agreed or strongly agreed) and decreased activity levels (66.7% agreed or strongly agreed) due to social distancing as an important reason for their pain worsening. In addition, increased stress (67.3% agreed or strongly agreed) and lower mood (53.4% agreed or strongly agreed) due to social distancing was cited as important to pain worsening as well. Interestingly, fewer participants cited loneliness (46.7% agreed or strongly agreed) as responsible for worsening pain (Figure 5C).

Figure 5.

Effects of social distancing on utilization of pain management strategies, access to treatments, and quality of life. (A) shows what physical and behavioral pain management resources patients recalled using before social distancing and whether utilization of the resource has been affected since social distancing. (B) shows what self-management techniques for pain participants recalled engaging in before social distancing and how usage of each technique has been affected by social distancing. (C) depicts the extent participants attribute social distancing changes to factors contributing to changes in reported pain.