Chronic Pain Among Adults — United States, 2019–2021

Chronic pain (i.e., pain lasting ≥3 months) is a debilitating condition that affects daily work and life activities for many adults in the United States and has been linked with depression (1), Alzheimer disease and related dementias (2), higher suicide risk (3), and substance use and misuse (4). During 2016, an estimated 50 million adults in the United States experienced chronic pain, resulting in substantial health care costs and lost productivity (5,6). Addressing chronic pain and improving the lives of persons living with pain is a public health imperative. Population research objectives in the National Pain Strategy, which was released in 2016 by the Interagency Pain Research Coordinating Committee, call for more precise estimates of the prevalence of chronic pain and high-impact chronic pain (i.e., chronic pain that results in substantial restriction to daily activities) in the general population and within various population groups to guide efforts to reduce the impact of chronic pain (3). Further, a 2022 review of U.S. chronic pain surveillance systems identified the National Health Interview Survey (NHIS) as the best source for pain surveillance data (7). CDC analyzed data from the 2019–2021 NHIS to provide updated estimates of the prevalence of chronic pain and high-impact chronic pain among adults in the United States and within population groups defined by demographic, geographic, socioeconomic, and health status characteristics. During 2021, an estimated 20.9% of U.S. adults (51.6 million persons) experienced chronic pain, and 6.9% (17.1 million persons) experienced high-impact chronic pain. New findings from this analysis include that non-Hispanic American Indian or Alaska Native (AI/AN) adults, adults identifying as bisexual, and adults who are divorced or separated are among the populations experiencing a higher prevalence of chronic pain and high-impact chronic pain. Clinicians, practices, health systems, and payers should vigilantly attend to health inequities and ensure access to appropriate, affordable, diversified, coordinated, and effective pain management care for all persons (8).

NHIS is a cross-sectional, household survey of the civilian, noninstitutionalized population conducted annually by the National Center for Health Statistics (NCHS).* Data were analyzed using the 2019–2021 Sample Adult Interviews.^† Survey questions used to estimate the prevalence of pain included, “In the past three months, how often did you have pain? Would you say never, some days, most days, or every day?” and “Over the past three months, how often did your pain limit your life or work activities? Would you say never, some days, most days, or every day?” If the participant was physically or mentally unable to respond to survey questions, then a knowledgeable proxy was permitted to answer on their behalf. Consistent with previous work, chronic pain was defined as pain on most days or every day during the previous 3 months, and high-impact chronic pain was defined as chronic pain that also limited daily life or work activities on most days or every day during the previous 3 months (5).

Using data from the 2019–2021 NHIS, the prevalence of chronic pain and high-impact chronic pain (including estimated number, crude rates, and age-adjusted rates with Korn-Graubard 95% CIs) were estimated for the adult U.S. population overall and within population groups defined by demographic, geographic, socioeconomic, and health status characteristics. Age-adjusted rates were calculated because the prevalence of pain is reported to vary by age (5). Estimates not meeting the NCHS reliability standards^§ were not reported. Demographic characteristics included sex, age, race and ethnicity, sexual orientation, marital status, veteran status, and nativity (U.S.-born or non–U.S.-born). Geographic characteristics included region^¶ and urban-rural classification. Socioeconomic characteristics included family income relative to the federal poverty level, education level, employment status, and health insurance coverage (reported separately by NHIS for adults aged <65 years and ≥65 years). Health status characteristics included general health status, disability status, and history of chronic medical conditions. Analysis was conducted using SAS (version 9.4; SAS Institute) and used weight and variance estimation variables** that account for the complex survey design of NHIS. All reported differences between subgroups in crude rates and in age-adjusted rates were significantly different on the basis of two-tailed Z-tests (p<0.05). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^††

Between 2019 and 2021, the prevalence of chronic pain among U.S. adults ranged from 20.5% to 21.8%, and the prevalence of high-impact chronic pain ranged from 6.9% to 7.8% (Figure). During 2021, an estimated 51.6 million U.S. adults (20.9%) experienced chronic pain, and 17.1 million (6.9%) experienced high-impact chronic pain (Table). The age-adjusted prevalence of both chronic pain and high-impact chronic pain was notably higher among certain demographic population groups including AI/AN adults, adults identifying as bisexual, and adults who were divorced or separated. The age-adjusted prevalence of high-impact chronic pain among AI/AN adults (12.8%) was six times as high as among non-Hispanic Asian adults (2.1%) and nearly twice as high as among non-Hispanic White adults (6.5%). The age-adjusted prevalence of chronic pain among adults identifying as bisexual was 32.9%, compared with 19.3% among adults identifying as straight and 20.7% among those identifying as gay or lesbian. The age-adjusted prevalence of chronic pain and high-impact chronic pain among adults who were divorced or separated (29.6% and 10.1%, respectively) was nearly twice as high as among those who were married (18.2% and 5.2%, respectively). The age-adjusted prevalence of chronic pain and high-impact chronic pain among those born in the United States (21.6% and 7.0%, respectively) was nearly twice as high as among those born outside the United States (11.9% and 4.1%, respectively).

Within population groups defined by geographic and socioeconomic characteristics, the age-adjusted prevalence of high-impact chronic pain among adults residing in nonmetropolitan areas (9.2%) and adults with a family income <100% of the federal poverty level (FPL) (14.4%) was approximately two and four times as high, respectively, as among those residing in large central metro areas (5.5%) and those with family income ≥400% FPL (3.5%). Adults reporting poor general health and adults with a disability experienced an exceptionally high prevalence of chronic pain (67.6% and 52.4%, respectively) and high-impact chronic pain (48.7% and 32.0%, respectively). Among all chronic medical conditions reported, the age-adjusted prevalence of chronic pain and high-impact chronic pain was highest among adults with a history of myalgic encephalomyelitis/chronic fatigue syndrome (70.0% and 43.8%, respectively) and dementia (54.9% and 34.2%, respectively).

Corresponding author: S. Michaela Rikard, [email protected].

¹Division of Overdose Prevention, National Center for Injury Prevention and Control, CDC.

References

1. Zis P, Daskalaki A, Bountouni I, Sykioti P, Varrassi G, Paladini A. Depression and chronic pain in the elderly: links and management challenges. Clin Interv Aging 2017;12:709–20. https://doi.org/10.2147/CIA.S113576 PMID:28461745
2. Khalid S, Sambamoorthi U, Umer A, Lilly CL, Gross DK, Innes KE. Increased odds of incident Alzheimer’s disease and related dementias in presence of common non-cancer chronic pain conditions in Appalachian older adults. J Aging Health 2022;34:158–72. https://doi.org/10.1177/08982643211036219 PMID:34351824
3. Interagency Pain Research Coordinating Committee. National Pain Strategy: a comprehensive population health-level strategy for pain. Washington, DC: US Department of Health and Human Services, National Institutes of Health; 2016. https://www.iprcc.nih.gov/node/5/national-pain-strategy-report
4. Ditre JW, Zale EL, LaRowe LR. A reciprocal model of pain and substance use: transdiagnostic considerations, clinical implications, and future directions. Annu Rev Clin Psychol 2019;15:503–28. https://doi.org/10.1146/annurev-clinpsy-050718-095440 PMID:30566371
5. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1001–6. https://doi.org/10.15585/mmwr.mm6736a2 PMID:30212442
6. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain 2012;13:715–24. https://doi.org/10.1016/j.jpain.2012.03.009 PMID:22607834
7. Duca LM, Helmick CG, Barbour KE, et al. A review of potential national chronic pain surveillance systems in the United States. J Pain 2022;23:1492–509. https://doi.org/10.1016/j.jpain.2022.02.013 PMID:35421595
8. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. https://doi.org/10.15585/mmwr.rr7103a1 PMID:36327391
9. U.S. Department of Health and Human Services. Healthy People 2030. Washington, DC: US Department of Health and Human Services; 2023. https://health.gov/healthypeople/objectives-and-data/browse-objectives/chronic-pain.
10. Morales ME, Yong RJ. Racial and ethnic disparities in the treatment of chronic pain. Pain Med 2021;22:75–90. https://doi.org/10.1093/pm/pnaa427 PMID:33367911

FIGURE. Prevalence of chronic pain* and high-impact chronic pain^† among adults — United States, 2019–2021^§,¶

* Pain reported on most days or every day during the previous 3 months.

^† Chronic pain that limited life or work activities on most days or every day during the previous 3 months.

^§ Sample sizes for chronic pain and high-impact chronic pain were as follows: 2019 (n = 31,304; n = 31,281), 2020 (n = 31,126; n = 17,409), 2021 (n = 28,759; n = 28,740). Survey responses coded as “refused,” “don’t know,” “not ascertained,” or missing responses were excluded from the analysis. In 2020, the survey question used to define high-impact chronic pain was only included in quarters 3 and 4. Therefore, the sample size was smaller, and survey weights were doubled to produce annual estimates for high-impact chronic pain for 2020.

^¶ With 95% CIs indicated with error bars.

Abbreviations: AI/AN = American Indian or Alaska Native, non-Hispanic; COPD = chronic obstructive pulmonary disease; FPL = federal poverty level; GED = general educational development certificate; ME/CFS = myalgic encephalomyelitis/chronic fatigue syndrome; NA = not applicable; NHIS = National Health Interview Survey.
* Pain reported on most days or every day during the previous 3 months.
^† Chronic pain that limits life or work activities on most days or every day during the previous 3 months.
^§ Weighted estimates are rounded to the nearest 1,000. Responses coded as “refused,” “don’t know,” “not ascertained,” or missing responses were excluded from the analysis.
^¶ Estimates are age-adjusted using the projected 2000 U.S. Census Bureau population as the standard population and five age groups (18–24, 25–44, 45–64, 65–84, and ≥85 years) except for health insurance coverage. For health insurance coverage for those aged <65 years, three age groups were used (18–24, 25–44, and 45–64), and for health insurance coverage for those aged ≥65 years, two age groups were used (65–84 and ≥85).
** Persons who reported AI/AN only or AI/AN and another race are included in the AI/AN category. Persons who reported a single race other than Black or African American, Asian, AI/AN, or White, or who reported more than one race not including AI/AN were combined into the “other single and multiple race” category.
^†† Based on the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties (https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf). Nonmetropolitan includes counties in micropolitan statistical areas and noncore counties.
^§§ Missing data on family income and earnings in the NHIS are imputed using a multiple imputation methodology. Family income is reported as a percentage of the FPL using the weighted average thresholds published annually by the U.S. Census Bureau. https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html
^¶¶ Persons who performed seasonal or contract work and worked during the previous 12 months, or those who were working at a job or business, but not for pay, were considered employed.
*** https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2021/srvydesc-508.pdf
^††† Estimates considered unreliable according to the National Center for Health Statistics’ standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf
^§§§ Based on the Washington Group Adult Composite Disability Indicator.
^¶¶¶ Based on the survey question, “Have you ever been told by a doctor or other health professional that you had…” except for asthma and ME/CFS, which are a combination of the previous question and “Do you still have asthma?,” or “Do you still have CFS or ME?”