Decoding the mystery of American pain reveals a warning for the future

Abstract

There is an expectation that, on average, pain will increase with age, through accumulated injury, physical wear and tear, and an increasing burden of disease. Consistent with that expectation, pain rises with age into old age in other wealthy countries. However, in America today, the elderly report less pain than those in midlife. This is the mystery of American pain. Using multiple datasets and definitions of pain, we show today's midlife Americans have had more pain throughout adulthood than did today's elderly. Disaggregating the cross-section of ages by year of birth and completion of a bachelor's degree, we find, for those with less education, that each successive birth cohort has a higher prevalence of pain at each age-a result not found for those with a bachelor's degree. Thus, the gap in pain between the more and less educated has widened in each successive birth cohort. The increase seen across birth cohorts cannot be explained by changes in occupation or levels of obesity for the less educated, but fits a more general pattern seen in the ongoing erosion of working-class life for those born after 1950. If these patterns continue, pain prevalence will continue to increase for all adults; importantly, tomorrow's elderly will be sicker than today's elderly, with potentially serious implications for healthcare.

Keywords: birth cohort analysis; educational divide; international comparison; pain prevalence.

Fig. 1.

Cross-sectional “snapshot” reports of pain with age in the United States and internationally. A plots, by age, the fraction of US Black and White non-Hispanic adults ages 25 y to 79 y who report pain in the Gallup Health and Wellbeing Index, pooled over years 2008–2017 (n = 1,925,388), and in the NHIS 1997–2018 (n = 217,752). B plots, by age, the fraction of adults ages 25 y to 79 y who report pain in other wealthy countries in the Gallup World Poll 2006–2018 (n = 234,785) and in the EHIS 2013–2015 (n = 149,453). B also plots, from the EHIS 2013–2015, the fraction of adults in other wealthy countries who report that pain interferes with daily life (n = 148,240).

Fig. 2.

Pain prevalence by educational attainment in the United States and internationally. A plots, by age, the fraction of Black and White non-Hispanic respondents ages 25 y to 79 y in the Gallup Health and Wellbeing Index data who report pain, separately for those with and without a bachelor’s degree (n = 1,038,550 with no BA, n = 879,761 with BA). B plots, by age, the fraction of respondents in the Gallup World Poll reporting pain, separately by attainment of some tertiary education (n = 141,726 without, and n = 70,891 with tertiary education). In addition, B plots, by age, the fraction of respondents in the EHIS reporting pain, by tertiary education (n = 99,493 without, n = 48,553 with tertiary education).

Fig. 3.

Pain by education and birth cohort in Gallup US and Gallup World Poll data. A plots reports of pain by age in the United States for every 5-y birth cohort from those born 1940–1944 through those born 1980–1984. Plots are drawn separately for those with and without a BA, using the Gallup Health and Wellbeing Index. B plots reports of pain in other wealthy countries analogously using the Gallup World Poll.

Fig. 4.

Pain prevalence age and year of birth effects in Gallup US and World Poll data. A and B present the estimated age effects from regressions of pain on a complete set of age indicators and year of birth indicators, for those aged 25 y to 79 y, born between 1935 and 1990, using data on Black and White non-Hispanics from (A) the Gallup Health and Wellbeing Index and (B) the Gallup World Poll. C and D present the estimated birth cohort effects from the same regressions. The regressions are run separately by level of education. (A and C: n = 984,800 with no BA; n = 853,132 with BA. B and D: n = 137,686 without tertiary education, n = 69,706 with tertiary.)