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


This study examined the natural social experiment imposed on patients with chronic pain by the COVID-19 pandemic. We observed a self-reported increase in both pain severity and interference under social distancing conditions. Notably, pain severity and interference were quite variable among individuals with chronic pain during social distancing. Our subsequent exploratory assessment of factors that were related to greater pain severity with social distancing implicated a number of sociodemographic and psychosocial factors known from previous work to be related to pain. These exploratory findings may suggest that certain demographics (female sex, nonwhite race, lower education, and disability status) and psychosocial characteristics (higher pain catastrophizing) convey higher risk under conditions of social isolation. If there are future waves requiring another social distancing mandate, patients with these characteristics may benefit more from curated, targeted interventions.

Sociodemographic Factors Impacting Pain

Although chronic pain is common, some individuals are at higher risk.[62] Pain susceptibility seems to be influenced by sociodemographic factors, including sex,[26,47,50,52] race and ethnicity,[11,37,55] education,[29,51,56] and employment,[22] making individuals with these characteristics more vulnerable.[4,8,21,33,34] In addition, the impact of social context in which an individual experiences pain has been understudied compared with biological and psychological constructs.[39,45] The current study examined pain severity and interference in a sample of individuals with chronic pain during a period of newly imposed social isolation, shortly after the institution of social distancing mandates to prevent SARS-CoV-2 spread in Massachusetts. We observed that female sex, nonwhite race, lower education, and disability employment status were independently associated with greater pain severity during newly imposed social isolation. This effect was seen despite the study having a relatively small number of nonwhite participants and a large proportion of female participants.

Throughout the COVID-19 pandemic, sociodemographic factors have played an important role, with inequities in case incidence, morbidity, and mortality amongst minorities, and this pattern is expected to worsen.[59] COVID-19 has revealed broader disparities within our society, providing an opportunity to prioritize strategic efforts to address inequity, including basic needs, access to medical services, and appropriate pain care.[1,48] Despite our study sample having a relatively small number of minority participants, we still observed an association with greater pain severity, which suggests that it would be beneficial to develop additional research and programs targeting and rectifying this inequity. Furthermore, it is a priority is to combat the structural inequity of resources for marginalized populations, which lead to greater risk of chronic pain incidence, as well impact their ability to self-manage their pain. More proximal changes include targeting pain research to underrepresented minorities and involving researchers with diverse backgrounds in study design and conduct.[54] This would allow for a more informed understanding of what mechanisms may be distinctly at work among minority patients, thus allowing also more effective and inclusive therapies for them.[5] Furthermore, increasing the recognition of diversity of pain processing pain between individuals (even within a given demographic group) will support better-informed and more personalized medicine.[6]

Psychosocial Characteristics, Including Pain Catastrophizing

We were interested in investigating how psychosocial characteristics may interact with the social isolation imposed by the COVID-19 pandemic, which is itself associated with significant uncertainty and fear.[40,67] Interestingly, although loneliness was associated with worse pain interference on the univariable regression analysis, we did not observe that loneliness per se was independently associated with worse pain outcomes in the multivariable regression analysis. This is consistent with the fact that patients did not cite feelings of loneliness per se as the most important drivers of pain increase during social distancing.

Under normal conditions, anxiety, depression, and stress are frequently comorbid with chronic pain and may in turn exacerbate and meaningfully worsen the experience of painful symptoms.[13,44] Although we found that anxiety, stress, depression, and sleep disturbance were all associated with worse pain under conditions of social isolation, pain catastrophizing was the only psychosocial variable that was independently predictive of worsening of pain severity and interference. It seems plausible that being physically and socially isolated may contribute to higher levels of catastrophic thinking, including feelings of helplessness, rumination, and magnification. Catastrophic thinking has also been shown to be higher amongst many individuals with fibromyalgia, which was also associated with worse pain outcomes in our sample.[9] Pain catastrophizing may represent an essential communicative function during socializing for patients with chronic pain. Collectively, it may be that the heightened pain expression exemplified by catastrophizing serves a useful purpose, allowing the individual's distress about pain to be recognized and managed within their social context.[36] Pain catastrophizing may therefore simultaneously fulfill adaptive functions (eg, recruiting social support) and maladaptive functions (eg, amplifying pain severity and disability),[35] a process that is consistent with our study findings.

Implications for Pain Management Services

Our study findings suggested that fibromyalgia was independently associated with greater pain severity during newly imposed social isolation. This is consistent with previous research demonstrating that in patients with fibromyalgia, increased stress has a potent impact on symptom severity,[2,28,49] and suggests that targeting individuals with fibromyalgia during social distancing may be of particular importance. However, many patients with chronic pain will likely benefit from the development and targeting of novel approaches to help improve care. Before the pandemic, telemedicine and eHealth approaches to chronic pain were already under development,[15,24] and the current pandemic has accelerated the development and implementation of these approaches. There has been an increased demand and recommendation to use remotely supported eHealth pain management services with the outbreak, which brings unique changes in service delivery of pain management.[18,25] A recent systematic review found that teletherapy and remote online cognitive behavioral therapy (CBT) strategies can be effective in improving quality of life among persons with chronic pain,[41] with 1 study suggesting that online group CBT may be as effective in improving coping among persons with chronic pain as in-person groups.[42] Such findings are promising, although additional research is needed to evaluate the impact of eHealth while recognizing the unique challenges created by the pandemic. Our study sample reported a significant disruption to their lives, including restricted access to pain-related service, and a need to increasingly rely on self-management techniques and remote/online forms of communication for social support.[66] The increase in global use of social media platforms to maintain connections while social distancing[14,19,43,53] suggests that people are becoming more accustomed and open to remote formats, perhaps making it an ideal time to implement these therapies into regular practices. Pandemic conditions aside, improvements in eHealth services could provide lasting impact on addressing the current dearth in necessary providers needed to meet overwhelming rates of individuals with chronic pain.