1. Introduction
The COVID-19 (SARS-CoV-2) pandemic has changed the social environment in which people
live and work, as well as the social systems they rely on.
39,88
To contain the spread of coronavirus and to prepare for a dramatic increase in demand
for limited hospital/medical facilities and resources, societies have enforced physical
distancing measures. Consequently, there have been limitations on the use of public
transportation, public spaces, and work, education, and recreational facilities. Furthermore,
access to vital, but nonurgent, healthcare services (including pain management services)
has been restricted. These changes have affected the way people connect with each
other, manage their health and wellbeing, and fulfil their social roles. For some,
these changes may present opportunities (eg, increased time with family, normalisation
of flexible working, and reduced demand for travel). For others, however, these social
changes can also represent significant threats to health and wellbeing.
The negative impact of social changes prompted by the COVID-19 crisis may disproportionately
affect individuals living with long-term painful conditions. Living with chronic pain
can threaten an individuals' fundamental social needs for autonomy (agency or independence),
belonging (social connection), and justice (fairness). In turn, for some, experiencing
heightened social threat can maintain and exacerbate chronic pain.
48
In this review, we draw attention to the potential for social and systemic changes
associated with attempts to contain the spread of COVID-19 to precipitate, maintain,
and exacerbate pain by increasing the social threats faced by individuals with chronic
pain (Fig. 1). We also suggest strategies for mitigating the social impact of COVID-19
on those living with chronic pain, for instance by learning from the resilience demonstrated
by people in pain who have found ways to deal with social threat. Finally, we suggest
several time-critical, high-impact research questions for further investigation (Fig.
1).
Figure 1.
Schematic representation of how the COVID 19 pandemic (A) exacerbates existing levels
of social threat (B), thereby inducing several social challenges (C) for people with
chronic pain, and ultimately increasing the risk for the development, maintenance,
and exacerbation of chronic pain complaints (D). Possible protecting processes and
interventions countering the effects of the pandemic are portrayed as well (E).
2. Social threats posed by the COVID-19 pandemic
1.1. Social disconnection and loneliness
One of the most immediate effects of the pandemic on our social lives is the introduction
of physical distancing measures and restriction of travel. It is well known that spontaneous
social interactions with others and participation in social roles can build and maintain
a generalised sense of trust in others (social capital), promote feelings of wellbeing,
76
provide protection from the harmful effects of stress,
95
promote social connectedness, and reduce pain sensitivity.
91
Conversely, social isolation is associated with loneliness, higher levels of depression
and anxiety, poorer health behaviours, poorer sleep, higher blood pressure, poorer
immune function, and pain.
40,42
Chronic pain conditions place individuals at an increased risk of social isolation,
smaller social network size, and reduced social role functioning,
37,38,78
all of which have negative implications for pain interference and pain intensity over
time.
7,31,47
Indeed, disruption to social roles and relationships is one of the most distressing
aspects of living with chronic pain.
81
Physical distance from others and reduced participation in work and social activities
can cause people to feel lonely or socially distanced from others,
73
and there are concerns that the COVID-19 pandemic will lead to a steep rise in the
prevalence of loneliness.
5,22,35,39
People living with chronic pain, who may have entered the pandemic with fewer social
resources than others, may be particularly vulnerable to feelings of loneliness and
social disconnection at this time. Unless individuals have the ability and means to
maintain meaningful connections with others despite physical distancing measures,
being physically isolated from others threatens to exacerbate pain and associated
disability.
1.2. Risk of increased social proximity
The paradox of COVID-19 is that being physically isolated from one's community can
mean living in closer proximity to one's household members. People living with chronic
pain conditions may benefit from more frequent contact with family members because
closer proximity offers more opportunity to improve social bonds. However, enforced
close-proximity living could also bring challenges to autonomy and independence. Although
social support can help buffer against pain,
14,15,18,56
an increase in solicitous behaviours in such close proximity might unintentionally
contribute to the chronicity of pain.
34,43,72
For example, in households where a child is in pain, increased social proximity could
lead to increased exposure to protective parental behaviours and reductions in child
autonomy and activity. Conversely, family members could become desensitised to the
pain of others, or even become avoidant, risking further isolation for individuals
living with pain. Those living with pain may experience increased feelings of guilt
in response to increased support, especially if they perceive themselves to be a burden.
50,75
Alternatively, fear of rejection could lead to masking pain from others in shared
living spaces, preventing individuals with pain from asking for help to meet their
needs.
13,65
There is also a risk that for people living with chronic pain, living in close proximity
and enclosed environments could increase exposure to interpersonal conflict,
63,69
which is known to amplify pain and disability.
11,26,36,61
For some, COVID-19 has brought about increased risks of conflict among household members,
as they deal with the stresses associated with unexpected financial pressures, job
insecurity, and unemployment.
21
Many people are struggling to juggle multiple social roles and responsibilities—supporting
children with schoolwork, working from home, and parenting—leading to emotional exhaustion.
Women, in particular, are likely to carry a greater social burden and greater responsibility
for childcare during COVID-19.
1,92
Critically, domestic abuse has increased during the COVID-19 lockdown,
10
which has also been shown to contribute to chronic pain.
2,60
1.3. Reduced access to high-quality pain management
COVID-19 potentially poses a significant challenge for patients seeking to access
pain management. Although pain management is a fundamental right,
23
the health system responses to mitigate the impact of COVID-19 may significantly affect
access for patients with complex medical conditions (eg, people with comorbid mental
health conditions and addiction) and widen existing inequities in relation to pain
management for socially disadvantaged populations.
90
For some people with chronic pain, the pandemic might bring life stressors that result
in pain flare-ups, and increase the need for pain services.
77
Furthermore, individual pain experiences may not be considered as immediately important
when compared to the need to treat life-threatening symptoms associated with COVID-19,
12
leading to less help-seeking and psychological distress.
Pain management during this pandemic for clinicians involves balancing access to care
with minimising safety risk from exposure to COVID-19 for vulnerable patients and
clinicians themselves.
79
Cancelled elective surgeries, closure of pain management services, and redeployment
of clinicians to other areas of care all result in limited access to high-quality
care. Consequently, the increased burden on healthcare workers may result in a greater
focus on biomedical management (eg, opioid prescribing), rather than psychological
and interdisciplinary treatment approaches. Although this may be deemed necessary
in the context of the pandemic due to heightened needs from patients for pain relief,
clinicians and patients may not agree on opioid prescription/deprescription.
66
In addition, the individual assessment required to address the risks and benefits
of opioid use and the monitoring of its use
85
may be complicated by a lack of access to face-to-face pain services.
In the absence of the availability of face-to-face contact, telehealth is increasingly
being recommended as a first line of care for patients,
19
including those with chronic pain.
29
The rapid transition to telehealth in response to physical distancing regulations
allows people to access high-quality care without travelling, potentially increasing
patient access to care. It also opens up new opportunities and enables us to think
about new ways of delivering pain management. However, this mode of delivery may be
particularly challenging for vulnerable groups due to poor health status and low technological
literacy.
71
Even when services are delivered through telehealth, the fear of sharing confidential
information from home and juggling multiple social responsibilities, particularly
for women, pose further barriers to engaging in high-quality care.
64
In the context of delivery, practical challenges in conducting multidisciplinary treatment
through telehealth
77
may lead to a prioritising of individual over multidisciplinary approaches. This is
despite evidence that care delivered through telehealth can be as effective as face-to-face
care for people experiencing pain conditions.
55
1.4. Exacerbation of social injustice and social inequalities
COVID-19 is exacerbating existing social injustices and inequalities. Extreme events
such as terrorist attacks and natural disasters
32,44,96
are known to undermine the fundamental belief that the world is just, stable, orderly,
and predictable,
52
with ramifications for perceived life control, future prospects, and wellbeing.
67,86
This is particularly relevant to chronic pain because commitment to the belief in
a just world can buffer against its adverse effects.
57
A pandemic-initiated violation of just-world beliefs could exacerbate perceived injustices
associated with pain.
16
For example, physical distancing policies could further increase social isolation
and potentially worsen perceived injustices,
80
while disrupting social networks that are sources of justice and support
74
may heighten perceptions of invalidation among those with pain, driven by the sense
that one does not matter to others.
17
Variation in the effect of COVID-19 illustrates social inequalities around pain, and
health care more generally. There are known individual differences in pain associated
with social identities, including sex, ethnicity, and age.
6,33
There are also social inequalities and biases, which can affect pain burden
25
and access to pain care.
24,82
Structural and individual biases towards minority and marginalized groups that are
heightened by uncertainty, stress, and fear
49
are likely to be exacerbated by COVID-19. Discrimination experienced by marginalized
groups can affect peripheral and central processes, including immune functioning,
20,28,83
thus compounding the negative effects associated with the stigmatization of chronic
pain.
26
Those living in poorer and/or more remote communities have higher rates of chronic
pain and comorbidities
60,62
and limited access to health care, which can lead to greater unmanaged pain and disability.
3,4
Reduced access to health care, higher costs, and language might form additional barriers
to pain management in these communities (eg, refugees). For example, disabling chronic
pain can be more prevalent in Indigenous populations, who are also less likely to
access support services.
3,4,8
Travel restrictions imposed to limit the spread of COVID-19 into remote communities
are likely to disrupt the provision of nonessential services, further limiting access
to pain care. Socioeconomic disadvantage also increases vulnerability to disease,
including COVID-19, through many potential pathways including lower social support,
89
overcrowding, poorer sanitation, neighbourhood, and housing conditions, and poorer
health behaviours (eg, smoking, diet, alcohol consumption, and reduced exercise).
9,70
Furthermore, although people from lower socioeconomic backgrounds are overrepresented
in “essential” employment sectors, which have been largely spared from COVID-19-related
redundancies, many of these employees are now facing longer working hours under more
demanding conditions. All these factors could not only lead to increased risk of exposure
to COVID-19, but also, if left untreated, exacerbate other conditions, including chronic
pain. In short, COVID-19 has disproportionately affected socially disadvantaged groups,
and the ensuing global economic fallout could magnify these inequalities in pain further.
90
The concern is that the most economically disadvantaged will be most likely to be
exposed to the hazard, most susceptible to harm from it, and most likely to experience
negative outcomes from it.
88
3. Responding to social threats posed by COVID-19
The wide range of social threats that COVID-19 brings to those in pain means that
no one response will address all these issues. However, by identifying such threats,
we can start to think of more focused and targeted approaches. For example, just as
some treatments have moved online, it may also be possible to mitigate some of the
impacts of physical distancing and social isolation using technology. Social media
platforms, due to their wide reach and penetration, can help disseminate key information
about COVID-19, providing virtual support to enhance social connectedness.
58
People with pain already report using digital peer-support groups to connect with
similar others and derive benefits from feeling validated and heard.
59
Online peer-support could potentially be used to help reduce felt social distance
while maintaining physical distance. Increasing digital social connectedness might
afford people with chronic pain more social contact and accessibility than is possible
face-to-face because it does not require physical mobility. However, we also need
to ensure that the use of social platforms is beneficial, and do not increase risk
(eg, due to the exposure to poor-quality health information that reinforces disability
or propagating unproven and potentially harmful approaches).
27
Even so, the pandemic has provided an opportunity to understand how social media might
be better used as a tool to develop a sense of community and reduce isolation.
Online technology can be used to facilitate the delivery of healthcare interventions,
under the guidance of healthcare professionals. For example, cognitive behavioural
therapies for loneliness delivered online can decrease loneliness and improve mental
wellbeing.
45,46
Online pain management programs seem to hold promise,
29
particularly when patients have contact with healthcare providers, albeit remotely.
54
Online resources can disseminate pain education, and online training programs on pain
self-management can be developed for healthcare professionals, those with pain, and
their close others.
30,41,84
However, these novel digital interventions might not be accessible for all and may
even put up new barriers to those who require them the most (eg, socially disconnected
individuals with limited digital literacy).
We also need to think beyond technology. The COVID-19 pandemic served to highlight
the upstream social determinants of health, many of affect chronic pain directly.
Historic social inequalities and unequal access to resources shape individual-level
risk factors, which in turn produce and perpetuate health disparities.
53
These structural problems require structural solutions
51,93
with the aim to improve population health, for instance by bolstering social welfare
systems, public health funding, and improved global cooperation.
68,87,94
At the local level, online technologies could mitigate the social threat of existing
social inequalities and injustices, providing access to relatively inexpensive, location-independent
treatment, and social connection. Coupled with systemic interventions such as increased
government funding to telehealth services, reducing the costs and barriers to internet
access, and making computers and mobile devices available to those who otherwise might
not have access to them can further reduce these disparities.
97
4. Conclusions and future directions
The current pandemic has exacerbated existing sources of social threat for people
with chronic pain. To prevent a population-level increase in the severity and impact
of chronic pain, it is critical to devote scientific attention to the assessment,
mitigation, and prevention of sources of social threat for people with chronic pain.
Table 1 outlines several high-impact areas for research to this end. Crucially, COVID-19
should not only be regarded as a challenge but also as a unique opportunity for researchers
and clinicians to develop new ways to deliver social support and pain management,
as well as understand the impact of social adjustment among individuals with chronic
pain.
Table 1
Priorities for research on social factors resulting from the COVID-19 pandemic.
Conflict of interest statement
The authors have no conflicts of interest to report.