Chronic pain, one of the most common reasons adults seek medical care (
1
), has been linked to restrictions in mobility and daily activities (
2
,
3
), dependence on opioids (
4
), anxiety and depression (
2
), and poor perceived health or reduced quality of life (
2
,
3
). Population-based estimates of chronic pain among U.S. adults range from 11% to
40% (
5
), with considerable population subgroup variation. As a result, the 2016 National
Pain Strategy called for more precise prevalence estimates of chronic pain and high-impact
chronic pain (i.e., chronic pain that frequently limits life or work activities) to
reliably establish the prevalence of chronic pain and aid in the development and implementation
of population-wide pain interventions (
5
). National estimates of high-impact chronic pain can help differentiate persons with
limitations in major life domains, including work, social, recreational, and self-care
activities from those who maintain normal life activities despite chronic pain, providing
a better understanding of the population in need of pain services. To estimate the
prevalence of chronic pain and high-impact chronic pain in the United States, CDC
analyzed 2016 National Health Interview Survey (NHIS) data. An estimated 20.4% (50.0
million) of U.S. adults had chronic pain and 8.0% of U.S. adults (19.6 million) had
high-impact chronic pain, with higher prevalences of both chronic pain and high-impact
chronic pain reported among women, older adults, previously but not currently employed
adults, adults living in poverty, adults with public health insurance, and rural residents.
These findings could be used to target pain management interventions.
NHIS is a cross-sectional, in-person, household health survey of the civilian noninstitutionalized
U.S. population, conducted by the National Center for Health Statistics (NCHS).* Data
from the 2016 Sample Adult Core for adults aged ≥18 years (33,028; response rate = 54.3%)
†
were analyzed. Information about pain was collected through responses to the following
questions: “In the past six months, how often did you have pain? Would you say never,
some days, most days, or every day?” and “Over the past six months, how often did
pain limit your life or work activities? Would you say never, some days, most days,
or every day?” Chronic pain was defined as pain on most days or every day in the past
6 months, as recommended by the International Association for the Study of Pain,
§
modified to account for intermittent pain, and used in both the National Pain Strategy
and National Institutes of Health Task Force on Chronic Back Pain (
6
). As suggested in the National Pain Strategy, high-impact chronic pain was defined
as chronic pain that limited life or work activities on most days or every day during
the past 6 months (
5
). The prevalence of chronic pain and high-impact chronic pain (both crude and age-adjusted,
with 95% confidence intervals) were estimated for the U.S. adult population overall
and by various sociodemographic characteristics. These characteristics, collected
with the Family Core questionnaire, included age, sex, race/ethnicity, education level,
current employment status,
¶
poverty status (calculated using NHIS imputed income files),** veteran status, health
insurance coverage type (reported separately for adults aged <65 and ≥65 years), and
urbanicity. All prevalence estimates met NCHS reliability standards.
††
Because pain prevalence varies by age, age-adjusted estimates were used in comparisons
of chronic pain and high-impact chronic pain between subgroups. Based on two-tailed
Z-tests, all reported differences between subgroups are statistically significant
(unless otherwise noted; p<0.05). Analyses were conducted using statistical software
that accounts for the stratification and clustering of households in the NHIS sampling
design. Estimates incorporated the final sample adult weights adjusted for nonresponse
and calibrated to population control totals to enable generalization to the civilian
noninstitutionalized population aged ≥18 years.
In 2016, an estimated 20.4% of U.S. adults (50.0 million) had chronic pain and 8.0%
of U.S. adults (19.6 million) had high-impact chronic pain (Table), with higher prevalence
associated with advancing age. Age-adjusted prevalences of both chronic pain and high-impact
chronic pain were significantly higher among women, adults who had worked previously
but were not currently employed, adults living in or near poverty, and rural residents.
In addition, the age-adjusted prevalences of chronic pain and high-impact chronic
pain were significantly lower among adults with at least a bachelor’s degree compared
with all other education levels.
TABLE
Prevalence of chronic pain* and high impact chronic pain
†
among U.S. adults aged ≥18 years, by sociodemographic characteristics—National Health
Interview Survey, 2016
Characteristic
Chronic pain*
High-impact chronic pain†
Estimated no.§
Crude
% (95% CI)
Age-adjusted¶
% (95% CI)
Estimated no.§
Crude
% (95% CI)
Age-adjusted¶
% (95% CI)
Total
50,009,000
20.4 (19.7–21.0)
19.4 (18.7–20.0)
19,611,000
8.0 (7.6–8.4)
7.5 (7.1–7.9)
Age group (yrs)
18–24
2,082,000
7.0 (5.8–8.5)
—**
446,000
1.5 (0.9–2.3)
—**
25–44
11,042,000
13.2 (12.3–14.1)
—**
3,681,000
4.4 (3.9–5.0)
—**
45–64
23,269,000
27.8 (26.6–29.0)
—**
10,044,000
12.0 (11.2–12.9)
—**
65–84
11,808,000
27.6 (26.4–29.0)
—**
4,578,000
10.7 (9.9–11.6)
—**
≥85
1,766,000
33.6 (30.1–37.3)
—**
830,000
15.8 (13.2–18.9)
—**
Sex
Male
21,989,000
18.6 (17.7–19.5)
17.8 (17.0–18.7)
8,276,000
7.0 (6.5–7.6)
6.7 (6.2–7.3)
Female
28,049,000
22.1 (21.2–23.0)
20.8 (19.9–21.6)
11,296,000
8.9 (8.4–9.4)
8.2 (7.7–8.7)
Race/Ethnicity
Hispanic
5,856,000
15.1 (13.6–16.7)
16.7 (15.2–18.4)
2,754,000
7.1 (6.0–8.3)
7.9 (6.9–9.2)
White, non-Hispanic
36,226,000
23.0 (22.2–23.8)
21.0 (20.3–21.8)
13,230,000
8.4 (7.9–8.9)
7.4 (7.0–7.9)
Black, non-Hispanic
5,148,000
17.9 (16.4–19.6)
17.8 (16.3–19.4)
2,387,000
8.3 (7.2–9.4)
8.1 (7.1–9.2)
Other, non-Hispanic††
2,774,000
13.8 (12.1–15.7)
14.4 (12.7–16.3)
1,326,000
6.6 (5.3–8.1)
7.0 (5.7–8.5)
Education
Less than high school
7,809,000
26.1 (24.2–28.2)
23.7 (21.7–25.7)
4,069,000
13.6 (12.3–15.2)
12.1 (10.7–13.7)
High school/GED
14,441,000
23.7 (22.5–25.0)
22.6 (21.2–23.9)
5,910,000
9.7 (9.0–10.6)
9.1 (8.4–10.0)
Some college
17,129,000
22.6 (21.5–23.8)
22.9 (21.8–24.0)
6,518,000
8.6 (7.9–9.4)
8.7 (8.0–9.5)
Bachelor's degree or higher
10,383,000
13.4 (12.6–14.3)
12.4 (11.7–13.3)
2,944,000
3.8 (3.4–4.3)
3.5 (3.1–4.0)
Employment status
Employed
22,085,000
14.7 (14.1–15.5)
14.5 (13.8–15.2)
5,108,000
3.4 (3.1–3.8)
3.2 (2.9–3.6)
Not employed; worked previously
25,737,000
31.5 (30.3–32.7)
29.2 (27.8–30.6)
13,318,000
16.3 (15.4–17.2)
16.1 (15.0–17.3)
Not employed; never worked
2,083,000
15.9 (13.8–18.2)
18.7 (16.1–21.6)
1,192,000
9.1 (7.6–10.9)
11.1 (9.1–13.4)
Poverty status
<100% FPL
8,017,000
25.8 (24.2–27.6)
29.6 (27.9–31.3)
4,630,000
14.9 (13.6–16.4)
17.5 (16.1–19.0)
100% ≤FPL<200%
11,357,000
26.2 (24.5–27.9)
25.9 (24.2–27.7)
5,375,000
12.4 (11.3–13.6)
12.3 (11.2–13.5)
200% ≤FPL<400%
14,181,000
20.3 (19.2–21.4)
19.3 (18.3–20.4)
5,100,000
7.3 (6.7–8.1)
6.9 (6.2–7.6)
≥400% FPL
16,441,000
16.3 (15.4–17.2)
14.6 (13.8–15.5)
4,438,000
4.4 (4.0–4.9)
3.9 (3.5–4.4)
Veteran
Yes
6,379,000
29.1 (27.1–31.2)
26.0 (23.5–28.7)
2,258,000
10.3 (9.1–11.8)
9.2 (7.7–11.1)
No
43,519,000
19.5 (18.9–20.2)
19.0 (18.4–19.7)
17,407,000
7.8 (7.4–8.2)
7.5 (7.1–7.9)
Health insurance coverage§§
Age <65 yrs
Private
20,539,000
15.1 (14.3–15.8)
14.0 (13.3–14.8)
5,713,000
4.2 (3.8–4.7)
3.8 (3.4–4.2)
Medicaid and other public coverage
8,215,000
29.3 (27.3–31.5)
30.0 (28.0–32.2)
4,822,000
17.2 (15.6–19.0)
17.8 (16.2–19.6)
Other
3,860,000
43.5 (40.0–47.2)
34.8 (31.2–38.7)
2,263,000
25.5 (22.5–28.8)
19.3 (16.4–22.5)
Uninsured
3,683,000
16.2 (14.4–18.2)
17.0 (15.2–19.0)
1,319,000
5.8 (4.7–7.2)
6.2 (5.0–7.6)
Age ≥65 yrs
Private
5,606,000
28.0 (26.3–29.9)
28.1 (26.3–30.0)
1,842,000
9.2 (8.1–10.5)
9.3 (8.2–10.6)
Medicare and Medicaid
1,428,000
42.5 (37.6–47.5)
42.5 (37.6–47.5)
816,000
24.3 (20.4–28.6)
24.3 (20.4–28.6)
Medicare Advantage
3,094,000
25.5 (23.1–28.1)
25.8 (23.4–28.4)
1,226,000
10.1 (8.5–11.8)
10.3 (8.7–12.1)
Medicare only, excluding Medicare Advantage
2,115,000
25.9 (23.1–28.9)
25.9 (23.1–28.9)
939,000
11.5 (9.5–13.7)
11.5 (9.5–13.7)
Other
1,229,000
31.6 (27.2–36.3)
31.8 (27.4–36.5)
545,000
14.0 (11.3–17.3)
14.3 (11.5–17.7)
Uninsured
106,000
—¶¶
—¶¶
59,000
—¶¶
—¶¶
Urbanicity***
Urban
38,401,000
19.0 (18.3–19.7)
18.4 (17.7–19.0)
14,754,000
7.3 (6.9–7.8)
7.0 (6.6–7.4)
Rural
11,575,000
26.9 (25.4–28.5)
24.0 (22.5–25.6)
4,776,000
11.1 (10.2–12.2)
9.8 (8.8–10.9)
Abbreviations: CI = confidence interval; FPL = federal poverty level; GED = General
Educational Development certification.
* Pain on most days or every day in the past 6 months.
† Chronic pain limiting life or work activities on most days or every day in the past
6 months.
§ The estimated numbers, rounded to 1,000s, were annualized based on the 2016 data.
Counts for adults of unknown status (responses coded as “refused,” “don’t know,” or
“not ascertained”) with respect to chronic pain and high-impact chronic pain are not
shown separately in the table, nor are they included in the calculation of percentages
(as part of either the denominator or the numerator), to provide a more straightforward
presentation of the data.
¶ Estimates are age-adjusted using the projected 2000 U.S. population as the standard
population and five age groups: 18–29, 30–39, 40–49, 50–59, and ≥60 years.
** Not applicable.
†† Non-Hispanic other includes non-Hispanic American Indian and Alaska Native only,
non-Hispanic Asian only, non-Hispanic Native Hawaiian and Pacific Islander only, and
non-Hispanic multiple race.
§§ Based on a hierarchy of mutually exclusive categories. Adults reporting both private
and Medicare Advantage coverage were assigned to the Medicare Advantage category.
“Uninsured” includes adults who had no coverage as well as those who had only Indian
Health Service coverage or had only a private plan that paid for one type of service
such as accidents or dental care. “Other” comprises military health care including
TRICARE, VA, and CHAMP-VA, and certain types of local and state governmental coverage,
not including the Children’s Health Insurance Program.
¶¶ Estimates are considered unreliable according to the National Center for Health
Statistics’ standards of reliability.
*** Based on U.S. Census Bureau definitions of urban and rural areas (https://www2.census.gov/geo/pdfs/reference/ua/Defining_Rural.pdf).
Whereas non-Hispanic white adults had a significantly higher age-adjusted prevalence
of chronic pain than did all other racial and ethnic subgroups, no significant differences
in high-impact chronic pain prevalence by race/ethnicity were observed. Similarly,
the age-adjusted prevalence of chronic pain was significantly higher among veterans
than among nonveterans, but no significant difference was observed in the prevalence
of high-impact chronic pain.
Among adults aged <65 years, the age-adjusted prevalences of chronic pain and high-impact
chronic pain were higher among those with Medicaid and other public health care coverage
or other insurance (e.g., Veteran’s Administration, certain local and state government)
than among adults with private insurance or those who were uninsured. Among adults
aged ≥65 years, those with both Medicare and Medicaid had higher age-adjusted prevalences
of chronic pain and high-impact chronic pain than did adults with all other types
of coverage.
Discussion
Pain is a component of many chronic conditions, and chronic pain is emerging as a
health concern on its own, with negative consequences to individual persons, their
families, and society as a whole (
4
,
5
). Healthy People 2020 (https://www.healthypeople.gov/), the nation’s science-based
health objectives, has a developmental objective to “decrease the prevalence of adults
having high-impact chronic pain.” This analysis extends previous national studies
of chronic pain prevalence by identifying adults with high-impact chronic pain. In
2016, approximately 20% of U.S. adults had chronic pain (approximately 50 million),
and 8% of U.S. adults (approximately 20 million) had high-impact chronic pain. This
estimate of high-impact chronic pain is similar to or slightly lower than estimates
reported in the few studies that have looked at pain using a similar construct. For
example, a recent study that used a measure of high-impact chronic pain similar to
the one used in this study reported an estimate of 13.7% among a sample of U.S. adult
health plan enrollees (
7
). Similarly, a 2001 study of adults from a region in Scotland found that 14.1% of
survey participants reported significant chronic pain, and 6.3% reported severe chronic
pain, and a 2001 study of Australian adults reported that 11.0% of men and 13.5% of
women reported chronic pain that interfered, to some degree, with daily life activities
(
3
,
8
). The results of subgroup analyses in the current study were consistent with findings
in these studies (
3
,
8
) insofar as the prevalence of high-impact chronic pain was higher among women, adults
who had achieved lower levels of education, and those who were not employed at the
time of the survey, and was lower among adults with private health insurance compared
with public and other types of coverage. In addition, high-impact chronic pain was
also found to be higher among adults living in poverty and among rural residents.
Socioeconomic status appears to be a common factor in many of the subgroup differences
in high-impact chronic pain prevalence reported here. Indicators of socioeconomic
status such as education, poverty, and health insurance coverage have been determined
to be associated with both general health status and the presence of specific health
conditions (
9
) as well as with patients’ success in navigating the health care system (
9
). Identifying populations at risk is necessary to inform efforts for developing and
targeting quality pain services.
The findings in this report are subject to at least five limitations. First, data
are self-reported and subject to recall bias. Second, data are cross-sectional, precluding
drawing causal inferences. This might be particularly relevant for socioeconomic status,
which can be both a risk factor for and a consequence of chronic pain or high-impact
chronic pain, or both. Third, no information is available on treatment for chronic
pain to assess the prevalence of chronic pain and high-impact chronic pain among those
with and without treatment. Fourth, NHIS excludes important populations, such as active
duty military and residents of long-term care facilities or prisons. And finally,
NHIS does not collect data on chronic pain or high-impact chronic pain in children.
Despite these limitations, three strengths of this study are that it used a large,
nationally representative data source to produce estimates of chronic pain and high-impact
chronic pain across many demographic subgroups, it used standard broad definitions
of pain that were not limited to one or more specific health conditions (e.g., headache
or arthritis), and it used the standard case definition for high-impact chronic pain
proposed by the National Pain Strategy.
Chronic pain contributes to an estimated $560 billion each year in direct medical
costs, lost productivity, and disability programs (
4
). The National Pain Strategy, which is the first national effort to transform how
the population burden of pain is perceived, assessed, and treated, recognizes the
need for better data to inform action and calls for estimates of chronic pain and
high-impact chronic pain in the general population (
5
). This report helps fulfill this objective and provides data to inform policymakers,
clinicians, and researchers focused on pain care and prevention.
Summary
What is already known about this topic?
Chronic pain has been linked to numerous physical and mental conditions and contributes
to high health care costs and lost productivity. A limited number of studies estimate
that the prevalence of chronic pain ranges from 11% to 40%.
What is added by this report?
In 2016, an estimated 20.4% of U.S. adults had chronic pain and 8.0% of U.S. adults
had high-impact chronic pain. Both were more prevalent among adults living in poverty,
adults with less than a high school education, and adults with public health insurance.
What are the implications for public health practice?
This report helps fulfill a National Pain Strategy objective of producing more precise
estimates of chronic pain and high-impact chronic pain.