Why Americans Feel More Pain

Ever since Bobbie Wert was 8 years old, her stomach has hurt. “My tummy hurts,” was her refrain as a girl, and the ache was accompanied by vomiting and diarrhea that kept her out of school — sometimes for half the days in the school year. Doctors poked and scanned but couldn’t figure out anything wrong.

Over the years, they cut her open and removed bits and pieces yet couldn’t drive away the pain. So doctors prescribed opioids in increasing doses — even fentanyl patches — that left her addicted. At age 43, she now is off opioids but still suffers every single day, enduring chronic pain like an estimated 50 million other Americans.

Wert is part of a vast and mysterious panorama of pain that is increasing, sometimes with no obvious physical cause. And while chronic pain is a global problem, it is particularly puzzling in America. In other wealthy countries, it’s the elderly who report the most chronic pain, which makes some sense.

But in the United States it’s the middle-aged — especially the jobless and people like Wert, who did not graduate from high school — who suffer the most. It is a plague on the less educated. All this raises the question: Is this physical suffering a canary in the coal mine warning us of larger dysfunction in our society? Here’s what we do know: Tens of millions of Americans are suffering pain.

But chronic pain is not just a result of car accidents and workplace injuries but is also linked to troubled childhoods, loneliness, job insecurity and a hundred other pressures on working families. This essay is the first in an occasional series I’ll be writing about the interrelated crises unfolding in working-class America. I’ll explore the cluster of tightly woven problems that hold back our people and our country: childhood trauma, educational failure, addiction, mental health issues, homelessness, loneliness, family breakdown, unemployment — and, we increasingly recognize, physical pain.

“People’s lives are coming apart, and this leads to huge increases in physical pain,” said Angus Deaton, a Nobel Prize winner in economics who with Anne Case popularized the term “deaths of despair. ” He, Case and Arthur A. Stone warn in a recent that “the mystery of American pain reveals a warning for the future.

” Americans die from deaths of despair — drugs, alcohol and suicide — at a rate of more than a quarter-million a year, and the number of walking wounded is far greater. We do have some evidence for how we can address our country’s pathologies, so this series will also focus on recovery. I a few years ago about how more than of the kids who rode my No.

6 school bus in rural Oregon with me are gone from deaths of despair. Some friends are homeless and on the run from the law, and when I asked them what went wrong, they often spoke about their physical pains. Sometimes I wondered if this might be malingering.

Now I understand that the pain was very real, but often more complicated than a broken arm from a brawl. “I believe pain is the most complex experience a human body can have,” told me. Dr.

Warraich is a cardiologist who teaches at Harvard Medical School, but his familiarity with pain is personal: While still in medical school, he began to suffer disabling back pain that for many years took over his life. Dr. Warraich said that we tend to misperceive chronic pain simply as pain that lasts longer.

Acute pain typically has a specific anatomical source — such as the shock you feel when you touch a hot stove — while chronic pain sometimes, not always, originates in the brain rather than the body. An extreme example is , in which an amputee feels intense pain in a limb that no longer exists. Accustomed to treating acute pain, physicians diagnose through imaging and knowledge of anatomy: If someone suffers from chronic back pain, get an X-ray! And imaging often finds something odd that may suggest a surgical solution.

In Dr. Warraich’s case, there were prolapsed discs. But it’s also true that X-rays of people with no pain show similar anatomical faults.

It’s the brain-body gap: Researchers that some people with substantial knee pain have normal X-rays, while many whose X-rays suggest significant arthritis feel no pain at all. Think of the brain as the control panel for a pain alarm system that mostly protects the body from injury — but sometimes goes haywire. It can blare like a home alarm system that maddeningly thinks a window has been opened when it hasn’t been.

Unfortunately, brain alarms are harder to turn off. * Medicines that work very well for acute pain, like opioids, were prescribed for many years for chronic pain like Wert’s, resulting in a tsunami of addiction that now claims more than 100,000 lives a year in overdoses alone — and leaving large numbers of pain sufferers dependent on pills that they now struggle to obtain. While opioids can provide relief, some experts also believe that opioids were never a sound choice for long-term pain.

Fortunately, some new treatments are emerging for chronic pain, but they are imperfect and often not covered by insurance. For starters, we’re learning that pain sometimes responds better to approaches that target the brain and psyche, not the body. For example, phantom limb pain is helped with , in which the sufferer repeatedly looks in the mirror at a remaining limb, to trick the brain into thinking that the body is doing just fine.

There is no single pain center in the brain, but chronic pain often reverberates in parts of the brain that can also be involved in emotions and traumatic memories, and that resonates with Bobbie Wert. She looks back at her odyssey through unexplained pain and addiction and has a simple explanation: “It was trauma. ” As the title of a best-selling book by Bessel van der Kolk on how psychological trauma can manifest as physical pain, puts it, “ .

” After Wert’s parents divorced when she was 5 years old, life became particularly chaotic. The family was periodically homeless, Wert said, and physical and sexual abuse swirled around her in Washington State. She remembers that when she was 8, a boy punched her and held her down while another raped her 9-year-old sister.

She recalls only fragments of the rest of those difficult years. “It was just men in and out of our house constantly,” she said. “I remember old men coming in, but I don’t remember what happened.

” For all the school she missed, Wert was a brilliant student who managed to stay near the top of her class. But she fell in love at age 15 with a man six years older, then, seeking stability in a chaotic life, married him and dropped out of school. She had two children by the time she was 18.

Instead of subsiding, the pain ramped up. For a while, doctors thought it was irritable bowel syndrome. Then they said it was endometriosis, leading to surgery at the age of 20 and a full hysterectomy a year later.

None of that helped, and doctors later diagnosed interstitial cystitis, part of a spectrum called painful bladder syndrome. All of these diagnoses — irritable bowel syndrome, endometriosis and painful bladder syndrome — are commonly applied to people with chronic pain that is difficult to explain. The end of the diagnostic line is often fibromyalgia, a catchall to describe chronic pain in several locations.

Wert’s sister suffered from similar inexplicable pain and was likewise treated with large doses of opioids that left her addicted, too. She has been diagnosed with fibromyalgia. * Chronic pain is unusual among diseases of despair in that it disproportionately strikes women, who according to one study are more likely than men to report severe pain.

That apparently is because testosterone eases pain (boys and girls suffer pain equally until puberty). The big factor in pain differences is class. One study that poor Americans are more than three times as likely to report pain as wealthy Americans.

Another found that just 2 percent of those with graduate degrees report severe pain, while almost of high school dropouts do. “Basically, if you’ve got a B. A.

, you’re vaccinated against all of this crap,” said Deaton, the economist. Deaton, Case and Stone found that each successive generation among less-educated Americans has reported more pain at any given age. “If these patterns continue, pain prevalence will continue to increase for all adults,” they in The Proceedings of the National Academy of Sciences.

“Tomorrow’s elderly will be sicker than today’s elderly, with potentially serious implications for health care. ” The brain appears very sensitive to expectations of pain, which is why placebos ease pain — and this may be a factor in faith healing as well. In injections of saline solution turned out to be almost as effective as injections of pain medication in reducing arm pain.

Conversely, when research subjects received the saline but were warned it might increase pain — that’s a nocebo, the opposite of a placebo — they suffered significantly more. The idea that chronic pain can arise from emotional discomfort isn’t new. An iconoclastic physician named wrote a 1991 best-selling book, “Healing Back Pain: The Mind-Body Connection,” that emphasized the physical consequences of repressed emotions.

Some patients swore by him, while many doctors rolled their eyes. He may have been something of a prophet, but today science has advanced far beyond his ideas and methods. America’s increasing chronic pain doesn’t come primarily from obesity or workplace injuries but may have something to do with the financial and social stresses in working-class America.

When jobs are lost, pain increases. found that a 3 percent increase in the unemployment rate is associated with a 1 percent increase in the number of people reporting pain. have found that economic insecurity is associated with more pain.

So are and . Pain can lead to depression, causing further pain. “Loneliness strongly predicts the development of pain,” another found.

In effect, chronic pain is tightly woven into the bundle of diseases of despair, and causation probably runs in several directions. There’s some evidence that trauma and stress teach the brain to be hypervigilant and put the pain alarm system on a hair trigger. This builds on itself: Researchers have also found that chronic pain can result in greater sensitivity, so that pain breeds more pain.

Pain even changes the physical brain. Several studies have that long-term pain leads to a loss of gray matter in the prefrontal cortex, although experts are still working out the implications of that. * The upshot is that whether pain is from psychological trauma or from physical injury, it can tip someone into a downward spiral.

That’s what happened to Aaron Lopez. Like Wert, he grew up in a troubled home. At about 12, Lopez began using drugs and drinking whiskey, and that was the backdrop for an incident at age 18 in which a sheet of plywood fell on his head and damaged his cervical spine.

“I just went home and got drunk,” he recalled. “I drank it away. ” Lopez later managed his pain with OxyContin, and for a while he got by.

He landed a good job as a medic at a university in Oregon and had a house, two cars, a girlfriend and a son. But once he couldn’t get OxyContin prescriptions, he began buying painkillers on the street, and that proved unaffordable. So he bought heroin.

The first heroin high proved difficult to replicate — and Lopez’s habit grew expensive. He started dealing so that he could be paid in powder. His son bounced between him and his now ex-girlfriend (who also became addicted), depending on who was in better shape.

On top of his excruciating pain, Lopez was regularly on the run from the law, and he lost his home and his health care provider’s license. He overdosed nine times. Lopez admits that he made bad choices.

But pain made poor choices more likely. “When I would have my bouts of neck pain, it magnified everything,” he told me. “Depression, anxiety, despair, everything was worse when I was in pain.

” He was eventually homeless. Finally, in 2019, Lopez gave up. “I just decided I was going to end it,” he recalled.

“So I did a massive dose of heroin. ” He overdosed and turned blue, but rescuers managed to revive him with five doses of naloxone. Awakening, he was exhausted and felt he had hit bottom.

After that, drugs were less satisfying, and he found out that his girlfriend was pregnant. Soon after, he resolved to live: He went through detox and hasn’t used drugs since 2019. Now he is more prudent about avoiding anything that might aggravate his pain, but it still returns in waves, such as when his daughter unexpectedly jumped on his back.

When it comes, he bulls through it with over-the-counter remedies and manages to go on with his life. So how can we heal from chronic pain? What can experts advise those suffering from it? , director of the Chronic Pain and Fatigue Research Center at the University of Michigan, believes that we already have a toolbox of remedies that can help 80 percent or 90 percent of chronic pain sufferers but that our treatment system and insurance protocols betray those in need. “We’ve really over-medicalized pain,” he told me.

His first recommendation to patients with chronic pain is simple: Get more sleep and exercise. There’s no simple solution, he emphasized, and it takes work by patients to recover. “I’m a huge advocate of physical therapy,” he added, and he also sees positive results from yoga, acupuncture, acupressure, cognitive behavioral therapy and meditation.

He mimics addressing a patient: “Mrs. Jones, I don’t know if acupuncture is going to work for you, or if it’s going to be physical therapy or chiropractic manipulation. But I do know that if you try three of these non-pharmacologic therapies, on average one of the three will work pretty well.

And then the next year we’ll try two or three more, and you’ll get better yet. ” The demographic most vulnerable to chronic pain — unemployed middle-aged Americans with limited education — is less likely to have health insurance or the means to pay for treatment (much of which isn’t covered by insurance in any case). So these people suffer, or they may for a fentanyl-laced pill to delay the suffering.

New approaches are emerging, but they are not necessarily more accessible. seems promising for alleviating chronic pain. is sometimes helpful.

Cannabis helps many people, with the most promising cannabinoids easing pain without producing a high, and researchers are some encouraging indications that psilocybin (the hallucinogenic substance in “magic mushrooms”) as well. Kevin Boehnke, a pain researcher at the University of Michigan, said that if cannabis were discovered today, the scientific world would be dazzled and would rush to test various cannabinoids for their medical potential. “There’s this vast untapped potential there,” he said, but it’s often not available because insurers are wary — even as they cover expensive surgeries that have a poor record in resolving pain.

* Today Wert still suffers pain every day but is able to hold a job counseling children through a group in McMinnville, Ore. , called . She is always on the lookout for kids with unexplained tummy aches.

She has some luck keeping her pain in check. “I use a heating pad, and I take a lot of hot baths,” she said. “If I feel pain coming, I work on crafts or keep myself busy.

It’s mind over matter. I keep repeating, ‘It’s not so bad. ’” Another longtime pain sufferer, Anne Muilenburg, who used opioids for a time and then became homeless, told me something that stuck with me.

She now struggles regularly with pain but gets by with physical therapy, ice and ibuprofen. “The pain is not as bad as the addiction,” she said. “My worst day clean is so much better than my best day using.

” Another approach is to move from Band-Aids to prevention. Since pain and deaths of despair fall heavily on the poorly educated and unemployed, we might address educational gaps: getting everyone through high school and equipping graduates with a marketable skill. Before the pandemic caused setbacks, there was some progress in raising America’s pathetic high school graduation rate and in bolstering vocational training with initiatives like .

Prevention also entails addressing broader social dysfunction. We’ve done a good job reducing workplace injuries, for example, but we haven’t shown the same determination to prevent the kinds of abuse that seared Wert and her sister. The foster care system is often a disaster that sets children up for diseases of despair.

Home-visiting programs like coach parents on everything from avoiding substance abuse and chipped lead paint to talking frequently with one’s child, and they have a remarkable of improving outcomes for disadvantaged children. High-quality pre-K can similarly help get kids on track to success. People recovering from addictions often talk about the importance of facing reality and accepting difficult truths.

Here’s one for all of us to confront: Tens of millions of Americans are suffering in ways that lead to addiction, pain and a tangle of other pathologies and then transmit this misery to the next generation. Maybe the brain’s pain alarm system is trying to tell us about how America heals: To ease our chronic pain, we must do better at addressing deeper wounds in our economy and society. .