Original quantitative research – A cross-sectional study of pain status and psychological distress among individuals living with chronic pain: the Chronic Pain & COVID-19 Pan-Canadian Study

Health Promotion and Chronic Disease Prevention in Canada

M. Gabrielle Pagé, PhDAuthor reference footnote 1Author reference footnote 2; Anaïs Lacasse, PhDAuthor reference footnote 3; Lise Dassieu, PhDAuthor reference footnote 1; Maria Hudspith, MAAuthor reference footnote 4; Gregg Moor, BAAuthor reference footnote 4; Kathryn SuttonAuthor reference footnote 4; James M. Thompson, MDAuthor reference footnote 5Author reference footnote 6; Marc Dorais, MScAuthor reference footnote 7; Audrée Janelle Montcalm, MScAuthor reference footnote 1; Nadia Sourial, PhDAuthor reference footnote 1Author reference footnote 8; Manon Choinière, PhDAuthor reference footnote 1Author reference footnote 2

https://doi.org/10.24095/hpcdp.41.5.01
(Published February 10, 2021)

This article has been peer reviewed.

Correspondence: Gabrielle Pagé, Centre de recherche du Centre hospitalier de l’Université de Montréal, Saint Antoine Building, Room S01-122, 850 Saint Denis St., Montréal, QC  H2X 0A9; Tel: 514-890-8000 ext. 31601; Email: gabrielle.page@umontreal.ca

Abstract

Background: The COVID-19 pandemic has had a disproportionate impact on vulnerable populations, including individuals with chronic pain. We examined associations between geographical variations in COVID-19 infection rates, stress and pain severity, and investigated factors associated with changes in pain status and psychological distress among individuals living with chronic pain during the pandemic.

Methods: This investigation is part of a larger initiative, the Chronic Pain & COVID-19 Pan-Canadian Study, which adopted a cross-sectional observational design. A total of 3159 individuals living with chronic pain completed a quantitative survey between 16 April and 31 May 2020.

Results: Two-thirds (68.1%) of participants were between 40 and 69 years old, and 83.5% were women. Two-thirds (68.9%) of individuals reported worsened pain since pandemic onset. Higher levels of perceived pandemic-related risks (adjusted odds ratio: 1.27; 95% confidence interval: 1.03–1.56) and stress (1.21; 1.05–1.41), changes in pharmacological (3.17; 2.49–4.05) and physical/psychological (2.04; 1.62–2.58) pain treatments and being employed at the beginning of the pandemic (1.42; 1.09–1.86) were associated with increased likelihood of reporting worsened pain. Job loss (34.9% of individuals were employed pre-pandemic) was associated with lower likelihood (0.67; 0.48–0.94) of reporting worsened pain. Almost half (43.2%) of individuals reported moderate/severe levels of psychological distress. Negative emotions toward the pandemic (2.14; 1.78–2.57) and overall stress (1.43; 1.36–1.50) were associated with moderate/severe psychological distress.

Conclusions: Study results identified psychosocial factors to consider in addition to biomedical factors in monitoring patients’ status and facilitating treatment access for chronic pain patients during a pandemic.

Keywords: COVID-19, pain, psychological distress, pandemic

Highlights

  • Two-thirds of individuals who completed an online survey reported worsened pain since the beginning of the COVID-19 pandemic.
  • Almost half of respondents experienced moderate to severe psychological distress.
  • Changes to pain treatments during the pandemic were significantly associated with worsened pain.
  • Geographical aspects, such as rural vs. urban living or living in a province with higher infection rates were not associated with pain status or psychological distress.
  • In future waves of the pandemic, consideration must be given to continue offering adequate pharmacological and physical/psychological pain treatments.

Introduction

Chronic pain is defined as a pain that has been present for more than 3 months, that has persisted for longer than the normal tissue-healing time or that is associated with a chronic condition.Footnote 1Footnote 2 Worldwide, approximately 20% of the adult population lives with chronic pain,Footnote 3Footnote 4 Inadequate chronic pain management costs between $38.3 billion and $40.4 billion in annual direct and indirect health care costs in Canada.Footnote 5

Chronic pain can have a wide range of repercussions on a person’s life and their health-related quality of life and mental health comorbidities.Footnote 6 These impacts on physical and mental health and well-being may be heightened during times of high stress. One-quarter of individuals in the general population report experiencing anxiety or depressive symptoms since the beginning of the COVID-19 pandemic.Footnote 7 However, there is a paucity of empirical data on the physical and mental health effects of the COVID-19 pandemic on vulnerable populations such as individuals living with chronic pain. Describing and identifying factors associated with poor physical and mental health statuses can inform public health decisions in future waves of the pandemic.

Based on expert opinion, individuals with chronic pain are likely to experience an exacerbation of their health condition during and after the COVID-19 pandemic.Footnote 8 This crisis and the associated psychological stressors may also precipitate a new onset of chronic pain.Footnote 8 One out of two individuals receiving tertiary chronic pain treatment in Canada live below the poverty line,Footnote 9 and the pandemic has disproportionally affected populations with low socioeconomic status. Furthermore, access to proper pain assessment, treatment and management has been challenging in Canada for a long time—particularly in rural and remote regionsFootnote 10—and the large-scale shut down of pain clinics, allied health professionals’ offices and exercise facilities during the pandemic has worsened pain management access.

The goal of this cross-sectional study was to document the physical and mental health status and socioeconomic status of Canadians living with chronic pain during the COVID-19 pandemic. The specific objectives were to (1) examine the association between geographical variations in COVID-19 infection rate, stress appraisal and pain severity; and (2) investigate the biopsychosocial factors associated with (a) changes in pain status during the COVID-19 pandemic, and (b) psychological distress among individuals living with chronic pain.

We hypothesized that (1) high provincial infection rates of COVID-19 would be associated with higher levels of stress appraisal and pain severity; and (2) the degree of geographical infection rates of COVID-19 and levels of perceived global and pandemic-specific stress would be associated with pain deterioration and psychological distress.

Methods

Design

The present study is part of a larger initiative, the Chronic Pain & COVID-19 Pan-Canadian Study, which used a cross-sectional mixed-method design to answer various pandemic-related research questions.Footnote 11 Quantitative survey data are summarized in the present article.

As shown by the shaded area in Figure 1, the study started at an early stage of the pandemic when the number of cumulative cases was growing exponentially in some provinces and the peak number of COVID-19 cases had not yet been reached.

Figure 1. Cumulative number of cases across provinces and territories, Canada

Figure 1. Cumulative number of cases across provinces and territories, Canada

Text description: Figure 1
Figure 1. Cumulative number of cases across provinces and territories, Canada
Date British Columbia Alberta Saskatchewan Manitoba Ontario Quebec Newfoundland and Labrador New Brunswick Nova Scotia Prince Edward Island Yukon Northwest Territories Nunavut
31-01-2020 1 0 0 0 3 0 0 0 0 0 0 0 0
08-02-2020 4 0 0 0 3 0 0 0 0 0 0 0 0
16-02-2020 5 0 0 0 3 0 0 0 0 0 0 0 0
21-02-2020 6 0 0 0 3 0 0 0 0 0 0 0 0
24-02-2020 6 0 0 0 4 0 0 0 0 0 0 0 0
25-02-2020 7 0 0 0 4 0 0 0 0 0 0 0 0
26-02-2020 7 0 0 0 5 0 0 0 0 0 0 0 0
27-02-2020 7 0 0 0 6 0 0 0 0 0 0 0 0
29-02-2020 7 0 0 0 8 0 0 0 0 0 0 0 0
01-03-2020 8 0 0 0 15 1 0 0 0 0 0 0 0
03-03-2020 12 0 0 0 20 1 0 0 0 0 0 0 0
05-03-2020 21 0 0 0 22 2 0 0 0 0 0 0 0
06-03-2020 21 0 0 0 28 2 0 0 0 0 0 0 0
07-03-2020 27 0 0 0 28 2 0 0 0 0 0 0 0
08-03-2020 27 1 0 0 31 3 0 0 0 0 0 0 0
09-03-2020 32 7 0 0 34 4 0 0 0 0 0 0 0
11-03-2020 39 14 0 0 42 7 0 0 0 0 0 0 0
12-03-2020 46 19 0 0 59 13 0 0 0 0 0 0 0
13-03-2020 53 23 0 1 79 17 0 1 0 0 0 0 0
14-03-2020 64 29 0 1 79 17 0 1 0 0 0 0 0
15-03-2020 73 39 0 4 103 24 0 1 0 1 0 0 0
16-03-2020 73 56 1 4 145 39 0 1 0 1 0 0 0
17-03-2020 103 74 2 7 177 50 0 2 0 1 0 0 0
18-03-2020 186 97 2 8 189 74 0 2 1 1 0 0 0
19-03-2020 271 146 8 17 258 121 1 7 5 2 0 0 0
20-03-2020 271 195 8 17 311 139 3 7 5 2 0 0 0
21-03-2020 424 226 25 11 377 202 3 9 9 2 0 1 0
22-03-2020 424 259 33 11 425 221 3 9 28 3 0 1 0
23-03-2020 472 301 65 11 503 221 4 9 41 3 2 1 0
24-03-2020 617 358 72 11 588 221 4 18 51 3 2 1 0
25-03-2020 659 419 86 11 688 1339 67 26 68 5 3 1 0
26-03-2020 725 486 95 11 858 1629 82 33 73 9 3 1 0
27-03-2020 725 542 104 25 993 2021 102 45 90 11 3 1 0
28-03-2020 884 542 134 25 993 2498 120 51 110 11 4 1 0
29-03-2020 884 621 134 69 1355 2840 135 66 122 11 4 1 0
30-03-2020 960 690 175 83 1706 3430 148 68 127 18 5 1 0
31-03-2020 970 754 184 91 1966 4162 152 70 147 21 5 1 0
01-04-2020 1066 754 193 109 2392 4611 175 81 173 21 5 2 0
02-04-2020 1121 968 206 152 2793 5518 183 91 193 22 6 2 0
03-04-2020 1174 1075 220 164 3255 6101 183 95 207 22 6 4 0
04-04-2020 1203 1075 231 172 3630 6997 195 98 236 22 6 4 0
05-04-2020 1203 1250 249 187 4038 7944 217 101 262 22 6 4 0
06-04-2020 1266 1348 253 190 4347 8580 226 103 293 22 7 5 0
07-04-2020 1291 1373 260 203 4726 9340 228 105 310 22 7 5 0
08-04-2020 1336 1423 271 206 5276 10031 232 108 342 24 7 5 0
09-04-2020 1370 1451 278 207 5759 10912 236 111 373 25 8 5 0
10-04-2020 1410 1500 285 215 6237 11677 239 112 407 25 8 5 0
11-04-2020 1445 1569 289 226 6648 12292 241 112 428 25 8 5 0
12-04-2020 1445 1651 296 226 7049 12846 242 114 445 25 8 5 0
13-04-2020 1490 1732 300 229 7470 13557 244 116 474 25 8 5 0
14-04-2020 1517 1870 301 229 7953 14248 244 116 517 25 8 5 0
15-04-2020 1561 1996 304 231 8447 14860 247 117 549 26 8 5 0
16-04-2020 1561 2158 305 239 8961 15857 252 117 579 26 8 5 0
17-04-2020 1575 2397 306 239 9525 16798 256 117 606 26 9 5 0
18-04-2020 1618 2562 310 243 10010 17521 257 118 649 26 9 5 0
19-04-2020 1618 2562 314 245 10578 18357 257 118 675 26 9 5 0
20-04-2020 1699 2908 316 246 11184 19319 257 118 721 26 11 5 0
21-04-2020 1724 3095 320 246 11735 20126 257 118 737 26 11 5 0
22-04-2020 1795 3401 326 246 12245 20965 256 118 772 26 11 5 0
23-04-2020 1824 3720 331 251 12879 21838 256 118 827 26 11 5 0
24-04-2020 1853 4017 341 252 13519 22616 256 118 850 26 11 5 0
25-04-2020 1948 4233 347 256 13995 23267 257 118 865 26 11 5 0
26-04-2020 1948 4480 353 260 14432 24107 258 118 873 26 11 5 0
27-04-2020 1998 4696 365 261 14856 24982 258 118 900 26 11 5 0
28-04-2020 2053 4850 366 261 15381 25757 258 118 915 27 11 5 0
29-04-2020 2087 5165 383 263 15728 26594 258 118 935 27 11 5 0
30-04-2020 2112 5355 389 264 16187 27538 258 118 947 27 11 5 0
01-05-2020 2145 5573 415 268 16608 28648 259 118 959 27 11 5 0
02-05-2020 2171 5670 421 269 17119 29656 259 118 963 27 11 5 0
03-05-2020 2171 5766 433 270 17553 31865 259 118 971 27 11 5 0
04-05-2020 2224 5836 467 270 17923 32623 259 118 985 27 11 5 0
05-05-2020 2232 5893 487 271 18310 33417 259 119 991 27 11 5 0
06-05-2020 2255 5963 512 273 18722 34327 259 120 998 27 11 5 0
07-05-2020 2288 6017 531 272 19121 35238 261 120 1007 27 11 5 0
08-05-2020 2315 6098 544 273 19598 36150 261 120 1008 27 11 5 0
09-05-2020 2330 6157 553 273 19944 36986 261 120 1011 27 11 5 0
10-05-2020 2330 6253 564 276 20238 37721 261 120 1018 27 11 5 0
11-05-2020 2353 6300 568 278 20546 38469 261 120 1019 27 11 5 0
12-05-2020 2360 6345 573 279 20907 39225 261 120 1020 27 11 5 0
13-05-2020 2376 6407 577 279 21236 39931 261 120 1024 27 11 5 0
14-05-2020 2392 6457 582 278 21581 40724 261 120 1026 27 11 5 0
15-05-2020 2407 6515 590 278 21922 41420 260 120 1034 27 11 5 0
16-05-2020 2428 6587 591 278 22313 42183 260 120 1037 27 11 5 0
17-05-2020 2428 6644 592 278 22653 42920 260 120 1040 27 11 5 0
18-05-2020 2444 6683 592 279 22957 43627 260 120 1043 27 11 5 0
19-05-2020 2446 6716 599 279 23384 44197 260 120 1044 27 11 5 0
20-05-2020 2467 6716 620 279 23774 44775 260 120 1045 27 11 5 0
21-05-2020 2479 6768 622 279 24187 45495 260 121 1046 27 11 5 0
22-05-2020 2507 6800 627 281 24628 46141 260 121 1048 27 11 5 0
23-05-2020 2517 6818 630 281 25040 46838 260 121 1049 27 11 5 0
24-05-2020 2517 6860 632 281 25500 47411 260 121 1050 27 11 5 0
25-05-2020 2530 6879 634 281 25904 47984 260 121 1051 27 11 5 0
26-05-2020 2541 6901 634 281 26191 48598 260 122 1052 27 11 5 0
27-05-2020 2550 6926 637 281 26483 49139 260 123 1053 27 11 5 0
28-05-2020 2558 6955 639 283 26866 49702 261 126 1055 27 11 5 0
29-05-2020 2562 6979 641 283 27210 50232 261 128 1055 27 11 5 0
30-05-2020 2573 6992 645 283 27533 50651 261 129 1056 27 11 5 0
31-05-2020 2573 7010 646 284 27859 51059 261 132 1056 27 11 5 0
01-06-2020 2597 7044 646 284 28263 51354 261 132 1057 27 11 5 0
02-06-2020 2601 7057 646 286 28709 51593 261 133 1057 27 11 5 0
03-06-2020 2623 7076 647 287 29047 51884 261 135 1058 27 11 5 0
04-06-2020 2632 7091 648 287 29403 52143 261 136 1058 27 11 5 0
05-06-2020 2632 7098 649 289 29747 52398 261 136 1058 27 11 5 0
06-06-2020 2632 7138 650 289 30202 52624 261 136 1058 27 11 5 0
07-06-2020 2632 7138 650 289 30617 52849 261 137 1059 27 11 5 0
08-06-2020 2659 7202 654 289 30860 53047 261 146 1059 27 11 5 0
09-06-2020 2669 7229 656 289 31090 53185 261 147 1060 27 11 5 0
10-06-2020 2680 7276 658 289 31341 53341 261 151 1061 27 11 5 0
11-06-2020 2694 7316 660 289 31544 53485 261 153 1061 27 11 5 0
12-06-2020 2709 7346 663 290 31726 53666 261 154 1061 27 11 5 0
13-06-2020 2709 7383 664 292 31992 53824 261 157 1061 27 11 5 0
14-06-2020 2709 7433 665 293 32189 53952 261 157 1061 27 11 5 0
15-06-2020 2745 7453 683 293 32370 54054 261 160 1061 27 11 5 0
16-06-2020 2756 7482 684 293 32554 54146 261 163 1061 27 11 5 0
17-06-2020 2775 7530 693 295 32744 54263 261 164 1061 27 11 5 0
18-06-2020 2783 7579 708 297 32917 54383 261 164 1061 27 11 5 0
19-06-2020 2790 7625 716 300 33095 54550 261 164 1061 27 11 5 0
20-06-2020 2790 7673 726 302 33301 54674 261 164 1061 27 11 5 0
21-06-2020 2790 7704 746 302 33476 54766 261 164 1061 27 11 5 0
22-06-2020 2822 7736 751 303 33637 54835 261 164 1061 27 11 5 0
23-06-2020 2835 7781 753 303 33853 54884 261 165 1061 27 11 5 0
24-06-2020 2849 7825 757 304 34016 54937 261 165 1061 27 11 5 0
25-06-2020 2869 7851 759 305 34205 55079 261 165 1061 27 11 5 0
26-06-2020 2878 7888 772 307 34316 55079 261 165 1061 27 11 5 0
27-06-2020 2878 7957 777 311 34476 55079 261 165 1061 27 11 5 0
28-06-2020 2878 7996 778 311 34654 55079 261 165 1061 27 11 5 0
29-06-2020 2904 8067 779 313 34911 55390 261 165 1061 27 11 5 0
30-06-2020 2916 8108 785 314 35068 55458 261 165 1062 27 11 5 0
01-07-2020 2916 8108 785 314 35068 55458 261 165 1062 27 11 5 0
02-07-2020 2940 8202 795 314 35370 55593 261 165 1064 27 11 5 0
03-07-2020 2947 8259 796 314 35535 55682 261 165 1064 27 11 5 0
04-07-2020 2947 8259 796 314 35656 55784 261 165 1064 30 11 5 0
05-07-2020 2947 8259 796 314 35794 55863 261 165 1064 32 11 5 0
06-07-2020 2978 8389 805 314 35948 55937 261 165 1065 32 11 5 0
07-07-2020 2990 8436 806 314 36060 55997 261 165 1065 32 11 5 0
08-07-2020 3008 8482 808 314 36178 56079 261 165 1066 32 11 5 0
09-07-2020 3028 8519 813 314 36348 56216 261 166 1066 33 11 5 0
10-07-2020 3053 8596 815 314 36464 56316 262 166 1066 33 11 5 0
11-07-2020 3053 8596 815 314 36594 56407 262 166 1066 33 11 5 0
12-07-2020 3053 8596 815 314 36723 56521 262 166 1066 34 11 5 0
13-07-2020 3115 8826 871 314 36839 56621 262 166 1066 35 11 5 0
14-07-2020 3128 8912 876 319 36950 56730 262 167 1066 36 11 5 0
15-07-2020 3149 8994 881 319 37052 56859 262 168 1067 36 11 5 0
16-07-2020 3170 9114 923 320 37163 57001 262 168 1067 36 11 5 0
17-07-2020 3198 9219 936 325 37274 57142 262 168 1067 36 13 5 0
18-07-2020 3198 9219 941 326 37440 57300 262 168 1067 36 13 5 0
19-07-2020 3198 9219 943 332 37604 57466 262 169 1067 36 13 5 0
20-07-2020 3300 9587 962 343 37739 57616 262 170 1067 36 13 5 0
21-07-2020 3328 9728 970 353 37942 57796 263 170 1067 36 13 5 0
22-07-2020 3362 9861 1030 361 38107 57938 264 170 1067 36 13 5 0
23-07-2020 3392 9975 1072 362 38210 58080 264 170 1067 36 13 5 0
24-07-2020 3419 10086 1099 371 38405 58243 265 170 1067 36 14 5 0
25-07-2020 3419 10086 1136 375 38543 58414 265 170 1067 36 14 5 0

Participants

Eligible participants were adults (≥18 years old) living in Canada, fluent in French and/or English, who had pain for more than 3 months and access to the Internet.

Recruitment

The study used a non-probabilistic sampling approach. Study advertisements containing a web-based hyperlink to a consent form and questionnaire in French and English were published through patient associations, pain organizations, research networks and social media across Canada.

Procedures

The study was approved by the research ethics board of the Centre hospitalier de l’Université de Montréal. The survey ran from 16 April to 31 May, 2020, that is, roughly one month after the beginning of public health restrictions in Canada and before these restrictions were lifted. Interested participants answered screening questions regarding their eligibility on the study’s landing page and provided consent electronically. They were then automatically directed to the online study’s questionnaire. Participants were eligible to win one of ten $100 prepaid Visa gift cards. Only one questionnaire completion per IP address was allowed. The full survey was pre-tested by five people with chronic pain and with various education levels.

Measures

Main outcomes

Pain status change was assessed using the Patient Global Impression of Change scale, a 7-point Likert scale (from 1 for considerably worsened to 7 for considerably improved). This scale has high test–retest reliability (intraclass correlation coefficient of 0.80–0.92) and construct validity (moderate correlation with other measures of change [r = 0.53]).Footnote 13 Psychological distress was measured using a validated screening measure of depressive and anxious symptoms, the Patient Health Questionnaire-4 (PHQ-4).Footnote 14 The PHQ-4 has good convergent validity (r = 0.36–0.80 with subscales of a global measure of functioning), internal consistency (α = 0.78–0.82) and item intercorrelation (r = 0.60).Footnote 14Footnote 15

Pain characteristics

We assessed changes (yes/no/not applicable) in pharmacological and physical/psychological treatments since the beginning of the COVID-19 pandemic and initiation of public health safety measures (mid-March 2020 in Canada). The Numerical Rating Scale (NRS) for Pain IntensityFootnote 16Footnote 17 was used to measure average and worst pain intensity and pain unpleasantness over the past 7 days. The Brief Pain Inventory (BPI)Footnote 18 measured pain interference on various aspects of daily living. The BPI is a reliable (α > 0.70) scale that has demonstrated good convergent (r = 0.57–0.81 with generic pain measures) validity and sensitivity to change.Footnote 19Footnote 20 The EQ-5D-5LFootnote 21 assessed health-related quality of life and has been shown to have adequate construct validity and responsiveness among individuals with chronic pain.Footnote 22

Impact of the COVID-19 pandemic

A group of pain researchers, clinicians and patient representatives developed a questionnaire based on Lazarus and Folkman’s transactional stress modelFootnote 23 to measure (a) stressors and (b) primary appraisal. The following scores were computed from this questionnaire:

  • emotional reactions toward the COVID-19 pandemic;
  • stress (human and material);
  • appraisal of the COVID-19 pandemic experience; and
  • restrictions (work-related, health, social).

For scores on emotional reactions toward the COVID-19 pandemic, participants were asked to report the extent to which they experienced different emotions (sadness, worries, solitude, anger, powerlessness, anxiety, surprise, relief and hope) when they thought or heard about the COVID-19 pandemic on a scale from 0 (not at all) to 10 (enormously). A data reduction approach was used for further analyses: after removing skewed variables (surprise and hope) and the only positive emotion left (relief), parallel factor analysis revealed a one-factor solution. Regression analysis was carried out to generate a unique factor score for each participant.

For scores on stress (human and material), participants were asked to rate the extent to which they found several pandemic-associated factors stressful on a scale from 0 (not at all) to 10 (extremely). A similar data reduction strategy was used for these items. Factor 1, called material stress, included stress related to finances, food and essential items. Factor 2, called human stress, included stress associated with the pandemic and virus, and public health safety measures.

We used the Perceived Stress Scale-4 (PSS-4)Footnote 24 to measure the extent to which individuals found their life unpredictable, uncontrollable and overloaded over the past month. The PSS-4 has excellent internal consistency (α = 0.81) and adequate convergent validity (= 0.66–0.73) with measures of depression and anxiety.Footnote 24

Appraisal of the COVID-19 pandemic experience was measured in terms of (1) individuals’ perceived susceptibility (accessibility of screening tests for COVID-19; perceived risk of being infected); (2) perceived severity (having access to necessary medical help should individuals get infected and their perceived change of recovery from COVID-19); (3) perceived benefits (agreement levels with confinement measures and the extent to which, despite the confinements, they can experience an active social life); and (4) perceived risks (decreased social activities and increased dependence toward others).

To assess restrictions (work-related, health, social), individuals were asked to identify which of the public health measures set in place were directly affecting them. For each subcategory (work, health, social), a sum of the number of restrictions endorsed was computed.

Data analysis

We used descriptive statistics to examine pain, geographical variations in COVID-19 infection rates, public health restriction measures and characteristics of psychological well-being.

To examine the effect of geographical variations in COVID-19 infection rate as a function of number of provincial cases, urban/rural living and their interaction with stress (Model 1: human and material-related stress, PSS-4) and pain (Model 2: pain interference, worst and average pain intensity, quality of life), we used multivariate analysis of variance.

To identify variables associated with pain deterioration (Model 3) and psychological distress (Model 4), we used multivariate logistic regression analyses. The dependent variable in Model 3 was pain deterioration (somewhat, a lot or considerably worsened vs. remained unchanged, somewhat, a lot or considerably improved). In Model 4, the dependent variable was psychological distress (PHQ-4 scores 6–12 [moderate/severe psychological distress] vs. 0–5 [no/mild psychological distress]). All variables of theoretical/clinical interest were entered in the model; the full list can be found in Table 2.

We ascertained multicollinearity using variance inflation factors (VIF) and correlation coefficients. Analyses were carried out in SAS version 9.4 (SAS Institute Inc., Cary, NC, USA) and SPSS version 26.9 for Windows (IBM, Chicago, IL, USA).

Sample size estimation

Guidelines for multivariate logistic regression analysis from large observational studiesFootnote 25 recommend a sample size greater than 500 to ensure accuracy of coefficient. A sample size of 1700 participants allows for the inclusion of all explanatory factors considered in this study.

Results

Study participants

A total of 3159 eligible participants completed the study questionnaire in part or entirely (see Figure 2). Table 1 shows participants’ sociodemographic, COVID-19 and pain characteristics. Participants were predominantly women (83.5%) and White (88.3%); two-thirds (68.1%) were between 40 and 69 years old. At a mean (standard deviation [SD]) of 6.13 (1.84) out of 10, participants’ average pain intensity in the past 7 days was moderate, and 46.9% had had pain for more than 10 years.

Figure 2. Study flow chart

Figure 2. Study flow chart

Text description: Figure 2

Figure 2. Study flow chart

This figure depicts the flow chart of the study sample.

3428 individuals accessed the questionnaire. The following participants were deemed non-eligible and therefore excluded: 167 due to pain < 3 months and 102 due to missing pain data duration. A total of 3159 individuals thus answered the study questionnaire. 279 were excluded from inferential models as their pain change status was unknown, and 457 were excluded from inferential models because of missing data on key independent variables. A total of 2423 individuals were included in inferential analyses.

Table 1. Participants’ characteristics for the overall sample and according to pain status and psychological distress for those included in the inferential analyses
Characteristics Total sample (N = 3159) Pain status
(n = 2423)
Psychological distress
(n = 2423)
Worsened (n = 1697) Unchanged or improved (n = 726) No/mild psychological distress
(n = 1365)
Moderate /severe psychological distress (n = 1058)
Sociodemographic characteristics
Age in years, n (%)
18–39 646 (24.2) 434 (25.6) 166 (23.0) 297 (21.8) 303 (28.7)
40–69 1814 (68.1) 1181 (69.6) 472 (64.9) 945 (69.2) 708 (66.9)
≥70 205 (7.7) 82 (4.8) 88 (12.1) 123 (9.0) 47 (4.4)
Missing 494
Sex, n (%)
Female 2225 (83.5) 1466 (86.4) 568 (78.2) 1115 (81.7) 919 (86.9)
Male 429 (16.1) 231 (13.6) 158 (21.8) 250 (18.3) 139 (13.1)
Undetermined 11 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Missing 494
Ethnicity, n (%)
White 2350 (88.2) 1502 (88.5) 648 (89.3) 1228 (90.0) 921 (87.0)
Other 315 (11.8) 195 (11.5) 78 (10.7) 137 (10.0) 137 (13.0)
Missing 494
Living condition, n (%)
Alone 560 (21.0) 348 (20.5) 159 (21.9) 283 (20.7) 224 (21.2)
Other 2105 (79.0) 1349 (79.5) 567 (78.1) 1082 (79.3) 834 (78.8)
Missing 494
Civil status, n (%)
Married or common law 1555 (58.6) 1005 (59.2) 417 (57.4) 842 (61.7) 580 (54.8)
Other 1099 (41.4) 692 (40.8) 309 (42.6) 523 (38.3) 478 (45.2)
Missing 505
Education, n (%)
Less than university 1444 (54.8) 939 (55.4) 385 (53.0) 678 (49.7) 646 (61.1)
University 1193 (45.2) 758 (44.6) 341 (47.0) 687 (50.3) 412 (38.9)
Missing 522
Living area, n (%)
Rural 359 (11.4) 227 (13.4) 104 (14.3) 183 (13.4) 148 (14.0)
Urban 2800 (88.6) 1470 (86.6) 622 (85.7) 1182 (86.6) 910 (86.0)
Work status, n (%)
Working part-time or full-time 976 (34.9) 610 (40.0) 247 (34.2) 518 (38.0) 339 (32.1)
Temporary or permanent invalidity 899 (32.2) 600 (35.5) 189 (26.0) 369 (27.1) 420 (39.6)
Other 918 (32.9) 487 (24.5) 290 (39.8) 478 (34.9) 299 (28.3)
Missing 366
Work status change, n (%)
Loss of employment 276 (10.0) 148 (8.7) 87 (12.0) 127 (9.2) 108 (10.2)
No loss of employment 2484 (90.0) 1549 (91.3) 639 (88.0) 1238 (90.8) 950 (89.8)
Missing 399
COVID-19 pandemic-related characteristics
Geographical variations in COVID-19 infection rates (per 100 000), n (%)
>150 1923 (73.4) 1214 (71.5) 564 (77.7) 1025 (75.0) 753 (71.2)
50–150 641 (24.5) 443 (26.2) 147 (20.3) 312 (22.9) 278 (26.3)
<50 57 (2.1) 40 (2.3) 15 (2.0) 28 (2.1) 27 (2.5)
Missing 538
COVID-19 infection, n (%)
Yes, with complications requiring care 8 (0.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Yes, without complications 16 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Waiting for test result 15 (0.5) 12 (0.7) 1 (0.1) 8 (0.6) 5 (0.5)
Untested but with symptoms 77 (2.8) 56 (3.3) 12 (1.7) 32 (2.3) 36 (3.4)
Not infected 2671 (95.8) 1629 (96.0) 713 (98.2) 1325 (97.1) 1017 (96.1)
Missing 372
Work-related restrictions, mean score (SD) 0.57 (0.70) 0.58 (0.70) 0.55 (0.69) 0.58 (0.71) 0.56 (0.68)
Health-related restrictions, mean score (SD) 1.22 (0.76) 1.30 (0.75) 1.04 (0.77) 1.11 (0.75) 1.36 (0.76)
Social-related restrictions, mean score (SD) 0.87 (0.83) 0.89 (0.85) 0.80 (0.79) 0.76 (0.77) 1.00 (0.88)
COVID-19 perceived susceptibility, n (%)
0–4 2296 (84.6) 1409 (83.0) 634 (87.3) 1219 (89.4) 824 (77.9)
>4 419 (15.4) 288 (17.0) 92 (12.7) 146 (10.6) 234 (22.1)
Missing 444
COVID-19 perceived severity, n (%)
0–4 1636 (60.2) 1006 (59.3) 431 (59.4) 803 (58.8) 634 (59.8)
>4 1081 (39.8) 691 (40.7) 295 (40.6) 562 (41.2) 424 (40.2)
Missing 442
COVID-19 perceived benefits, n (%)
0–4 747 (27.6) 479 (28.2) 171 (23.6) 287 (20.9) 363 (34.3)
>4 1963 (72.4) 1218 (71.8) 555 (76.4) 1078 (79.1) 695 (65.7)
Missing 449
COVID-19 perceived risks, n (%)
0–4 1460 (54.0) 861 (50.7) 453 (62.4) 827 (60.7) 487 (45.9)
>4 1245 (46.0) 836 (49.3) 273 (37.6) 538 (39.3) 571 (54.1)
Missing 454
Stress associated with the pandemic, mean score (SD) 6.88 (2.40) 7.17 (2.30) 6.18 (2.48) 6.01 (2.34) 7.99 (1.98)
Stress associated with the public health restrictions, mean score (SD) 5.88 (2.70) 6.21 (2.62) 5.15 (2.70) 5.14 (2.58) 6.85 (2.51)
Psychological characteristics
PHQ-4, n (%)
No/mild psychological distress 1513 (56.8) 850 (50.1) 515 (71.0)
Moderate/severe psychological distress 1153 (43.2) 847 (49.9) 211 (29.0)
Missing 493
PSS-4, mean score (SD) 7.84 (3.24) 8.25 (3.18) 6.84 (3.15) 6.28 (2.74) 9.84 (2.68)
Pain characteristics
Pain location, n (%)
Generalized pain 359 (11.8) 210 (12.4) 74 (10.2) 157 (11.5) 127 (12.1)
Head 82 (2.7) 31 (1.8) 23 (3.2) 34 (2.5) 20 (1.9)
Upper limb and upper body 242 (7.9) 124 (7.4) 62 (8.4) 103 (7.5) 83 (7.9)
Lower limb and lower body 2379 (77.2) 1322 (77.8) 563 (77.6) 1064 (78.0) 821 (77.5)
Multisite 13 (0.4) 5 (0.3) 2 (0.3) 6 (0.4) 1 (0.1)
Unknown/missing 84 5 (0.3) 2 (0.3) 1 (0.1) 6 (0.5)
Pain origin, n (%)
Accident 750 (25.1) 441 (26.9) 160 (22.4) 324 (24.0) 287 (27.4)
Disease 757 (25.4) 419 (25.0) 203 (28.4) 374 (27.9) 248 (23.7)
Movement/trauma 334 (11.2) 175 (10.4) 88 (12.3) 150 (11.2) 113 (10.8)
No precise event 763 (25.6) 422 (25.1) 182 (25.5) 343 (25.5) 261 (24.9)
Other 380 (12.7) 213 (12.6) 81 (11.4) 154 (11.4) 140 (13.2)
Missing 175 27 12 20 9
BPI, mean score (SD) 43.39 (14.24) 45.23 (13.33) 39.06 (15.32) 38.83 (13.74) 49.26 (12.65)
Average pain intensity, mean score (SD) 6.13 (1.84) 6.36 (1.68) 5.64 (2.00) 5.76 (1.81) 6.63 (1.69)
Worst pain intensity mean score (SD) 7.65 (1.77) 7.91 (1.51) 7.18 (2.03) 7.38 (1.81) 8.09 (1.51)
Global quality of life, mean score (SD) 55.66 (20.03) 54.17 (19.78) 58.80 (19.65) 59.68 (19.04) 50.80 (19.73)
Pain duration, n (%)
≤2 years 390 (12.7) 180 (10.5) 111 (15.3) 166 (12.2) 125 (11.8)
3–10 years 1248 (40.4) 718 (42.4) 260 (35.8) 517 (37.8) 461 (43.6)
>10 years 1444 (46.9) 799 (47.1) 355 (48.9) 682 (50.0) 472 (44.6)
Missing 77
Changes in pain status change, n (%)
Considerably worsened 418 (14.5) 126 (9.2) 232 (22.0)
Worsened a lot 577 (20.0) 220 (16.2) 275 (26.0)
Somewhat worsened 990 (34.5) 504 (36.9) 340 (32.1)
Remained unchanged 750 (26.0) 431 (31.5) 183 (17.3)
Improved (somewhat, a lot, considerably) 145 (5.0) 84 (6.2) 28 (2.6)
Missing 279
Changes to pharmacological treatments, n (%)
Yes 970 (33.9) 707 (41.7) 113 (15.6) 392 (28.7) 428 (40.5)
No 1563 (54.6) 803 (47.3) 512 (70.5) 792 (58.0) 523 (49.4)
Not applicable 331 (11.5) 187 (11.0) 101 (13.9) 181 (13.3) 107 (10.1)
Missing 315
Changes to physical/psychological treatments, n (%)
Yes 1685 (59.5) 1140 (67.2) 334 (46.0) 821 (60.3) 653 (61.7)
No 786 (27.7) 369 (21.7) 272 (37.5) 379 (27.7) 262 (24.8)
Not applicable 362 (12.8) 188 (11.1) 120 (16.5) 165 (12.0) 143 (13.5)
Missing 326

Abbreviations: BPI, Brief Pain Inventory; PHQ-4, Patient Health Questionnaire – 4; PSS-4, Perceived Stress Scale – 4.
Note: Percentages are calculated based on completed data (and excludes missing data), as such the denominator can vary from one variable to another.

Many participants reported that their pain had worsened since the beginning of the COVID-19 pandemic (68.9%). Less than 1% had a confirmed diagnosis of COVID-19. A majority (73.4%) were living in provinces with higher infection rates (>150 cases per 100 000 population). Mean (SD) levels of stress (on a 0–10 scale) associated with the pandemic itself (6.9 [2.4]) and with the lockdown (5.9 [2.7]) were however moderate. Levels of psychological distress were moderate to severe in close to half the participants (n = 1153; 43.2%). Among those who were working at the beginning of the pandemic, over one-quarter (28.3%; 276/976 employed individuals) had lost their job.

Associations between geographical variations in COVID-19 infection rates, stress appraisal and pain

Results showed that provincial infection rates (Pillai’s trace = 0.004; F(6; 5168) = 1.87; p = 0.082), urban vs. rural settings (Pillai’s trace = 0.001; F(3; 2583) = 0.48; p = 0.695) or their interaction (Pillai’s trace = 0.002; F(6; 5168) = 0.74; p = 0.621) were not associated with perceived stress (PSS-4, human and material stress associated with the pandemic) (Model 1). Provincial infection rates (Pillai’s trace = 0.024; F(6;5148) = 10.54; p < 0.001), but neither urban/rural living conditions (Pillai’s trace = 0.001; F(3; 2573) = 1.09; p = 0.352) nor their interaction (Pillai’s trace = 0.003; F(6; 5148) = 1.15; p = 0.332), were associated with pain interference (but not with average or worst pain intensity or quality of life) such that individuals from provinces with between 50 and 150 cases per 100 000 reported mean (SD) higher levels of pain interference (47.5 [12.9]) compared to those from provinces with more than 150 cases per 100 000 (42.1 [14.3]) (F(5;2593) = 15.4; p < 0.01) (Model 2).

Variables associated with pain status change and psychological distress

There were no clinically significant differences (>20% difference on total scores between the groupsFootnote 26 or in proportions across groups for categorical variables) between those who were included (n = 2423) and those who were excluded (n = 736) due to missing data, except for the number of public health restrictions. Compared to those retained in the model, individuals who were excluded were more likely to report no health restrictions (19.3% vs. 69.5%), no work restrictions (54.0% vs. 82.9%) and no social restrictions (37.9% vs. 73.4%). All individuals who reported being infected with COVID-19 (n = 24) were excluded from the regression analyses because of missing data; however, this represented only 0.8% of participants.

Due to high correlations between pain interference (BPI score) and the two pain intensity measures (average pain: r = 0.631; worst pain: r = 0.564), only the BPI score was included in the model.

Detailed results of the pain status change (Model 3) are shown in Table 2. Descriptive statistics on relevant variables as a function of pain status change are shown in Table 1. Older adults (adjusted odds ratio [aOR]: 0.49; 95% confidence interval [CI]: 0.32–0.76) and those who had lost their employment since the beginning of the pandemic (0.67; 0.48–0.94) were less likely to report worsened pain than younger adults or those still employed or not in the workforce.

Table 2. Associations between characteristics of patients and worsened pain or psychological distress
Variables Model 3
Worsened pain
Model 4
Moderate-severe psychological distress
Adjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value
Time of questionnaire completion
Weeks 1–3 (complete confinement) Ref. Ref.
Weeks 4–5 (initial lifting of restrictions) 0.90 (0.71–1.13) 0.361 1.03 (0.79–1.33) 0.837
Weeks 6–8 (additional lifting of restrictions) 1.01 (0.78–1.31) 0.961 0.96 (0.72–1.27) 0.767
Age, years
18–39 Ref. Ref.
40–69 0.92 (0.71–1.18) 0.487 0.75 (0.57–0.98) 0.034
≥70 0.49 (0.32–0.76) 0.002 0.54 (0.32–0.92) 0.024
Sex
Male Ref. Ref.
Female 1.19 (0.92–1.55) 0.182 1.10 (0.80–1.50) 0.560
Civil status
Other Ref. Ref.
Married / common law 1.07 (0.83–1.37) 0.626 0.94 (0.71–1.24) 0.659
Living condition
Alone Ref. Ref.
Other 0.96 (0.71–1.31) 0.801 1.06 (0.75–1.48) 0.757
Education
Less than university Ref. Ref.
University 0.96 (0.78–1.19) 0.721 0.85 (0.68–1.07) 0.166
Location
Rural Ref. Ref.
Urban 1.20 (0.91–1.59) 0.205 1.06 (0.77–1.46) 0.711
Work status
Other Ref. Ref.
Full-time or part-time 1.42 (1.09–1.86) 0.011 1.12 (0.83–1.52) 0.458
Permanent / temporary disability 1.23 (0.94–1.60) 0.132 1.16 (0.86–1.55) 0.327
Work status change
No loss of employment Ref. Ref.
Loss of employment 0.67 (0.48–0.94) 0.019 1.09 (0.74–1.61) 0.663
Geographical variations in COVID-19 infection rates (per 100 000)
0 to <50 Ref. Ref.
50–150 1.05 (0.53–2.08) 0.887 0.79 (0.37–1.70) 0.547
>150 1.00 (0.52–1.93) 0.991 0.83 (0.39–1.76) 0.632
COVID-19 perceived susceptibility
0–4 Ref. Ref.
>4 0.98 (0.73–1.31) 0.886 1.17 (0.86–1.60) 0.309
COVID-19 perceived severity
0–4 Ref. Ref.
>4 0.92 (0.76–1.13) 0.437 0.92 (0.74–1.15) 0.475
COVID-19 perceived benefits
0–4 Ref. Ref.
>4 1.00 (0.79–1.26) 0.997 1.03 (0.80–1.32) 0.844
COVID-19 perceived risks
0–4 Ref. Ref.
>4 1.27 (1.03–1.56) 0.022 0.91 (0.73–1.13) 0.381
Work-related restrictions 0.99 (0.83–1.17) 0.856 1.06 (0.88–1.27) 0.547
Health-related restrictions 1.10 (0.96–1.27) 0.174 1.08 (0.92–1.25) 0.349
Social-related restrictions 0.98 (0.86–1.12) 0.786 1.08 (0.94–1.24) 0.275
COVID-19 emotional reactionsFootnote a 1.17 (0.99–1.38) 0.059 2.14 (1.78–2.57) <.001
Stress (material needs)Footnote a 0.93 (0.82–1.05) 0.224 1.08 (0.95–1.22) 0.268
Stress (virus threat, social interactions)Footnote a 1.21 (1.05–1.41) 0.011 1.39 (1.17–1.66) <.001
PSS-4 – Perceived stress 1.04 (1.00–1.08) 0.046 1.43 (1.36–1.50) <.001
PHQ-4
No/mild distress Ref.
Moderate/severe distress 1.18 (0.92–1.52) 0.188
BPI – Pain interference 1.02 (1.01–1.03) <0.001 1.02 (1.01–1.03) <0.001
Pain duration, years
0–2 Ref. Ref.
3–10 1.69 (1.24–2.29) 0.001 1.00 (0.71–1.42) 0.984
>10 1.40 (1.03–1.90) 0.033 0.83 (0.59–1.18) 0.308
Pain status change
Unchanged or improved Ref.
Worsened 1.14 (0.88–1.47) 0.316
Changes to pharmacological treatments
No Ref. Ref.
Yes 3.17 (2.49–4.05) <0.001 1.27 (1.00–1.62) 0.054
Changes to physical/psychological treatments
No Ref. Ref.
Yes 2.04 (1.62–2.58) <0.001 1.04 (0.79–1.37) 0.783

Abbreviations: BPI, Brief Pain Inventory; CI, confidence interval; OR, odds ratio; PHQ-4, Patient Health Questionnaire-4; PSS-4, Perceived Stress Scale-4; Ref., reference.
Note: Statistically significant p-values are bolded.

Footnote a

Regression scores derived from exploratory factor analysis.

Return to footnote a referrer

Individuals who worked were more likely to report worsened pain than those who were not employed and not on disability (1.42; 1.09–1.86). Higher levels of perceived risks (but not susceptibility, severity or benefits) associated with COVID-19 (1.27; 1.03–1.56) and higher levels of stress associated with individuals’ health and safety (human stress composite score) (1.21; 1.05–1.41) were associated with greater likelihood of reporting worsened pain. Longer pain duration (3–10 years: 1.69; 1.24–2.29; >10 years: 1.40; 1.03–1.90) and changes in pharmacological treatments (3.17; 2.49–4.05) and physical/psychological treatments (2.04; 1.62–2.58) were also associated with greater likelihood of reporting worsened pain.

Based on the study analyses, one cannot rule out that some individuals may have reported improved pain status as a result of treatment change; however, only 5% of the overall sample reported this pain status.

Detailed results of psychological distress (Model 4) are shown in Table 2. Descriptive statistics on relevant variables as a function of psychological distress are shown in Table 1. Results revealed that older adults (40–69 years old: aOR = 0.75; 95% CI: 0.57–0.98; ≥70 years old: 0.54; 0.32–0.92) were less likely to report moderate/severe psychological distress than younger adults.

Higher intensity of negative emotions associated with the pandemic (aOR = 2.14; 95% CI: 1.78–2.57), higher levels of stress associated with individuals’ health and social interactions (human stress: 1.39; 1.17–1.66) and higher perceived global stress (1.43; 1.36–1.50) were associated with greater likelihood of reporting moderate/severe psychological distress.

Discussion

To our knowledge, this study is one of the first to document the effects of the COVID-19 pandemic in a large sample of individuals with chronic pain who participated in an online survey. The COVID-19 pandemic had detrimental effects on many individuals in terms of pain deterioration (70% of individuals) and psychological distress (moderate/severe distress in close to half of individuals). This is important, knowing that chronic pain is very unlikely to remit on its own and 33% of individuals on a pain clinic waitlist report suicidal ideation.Footnote 27

These statistics are consistent with those of people with other chronic diseases that show higher rates of stress, depression and anxiety than the general population during the pandemic.Footnote 28 Two important reasons for this were identified and concerned higher deaths rates following infection with the coronavirus among medically compromised populations and inaccessibility of medical services and treatments.Footnote 28 Changes in pharmacological and physical/psychological pain treatments since the onset of the pandemic had the strongest associations with pain deterioration in the present study. The rapid shift toward virtual care or alternative accessible health care and other support options is of utmost importance in such circumstances.Footnote 29

Pain status change associated with factors other than geography

Regional variations in COVID-19 infection rates, living in urban centres where transmission is more likely than in rural settings and experiencing higher numbers of public health safety measures were not associated with pain status or psychological distress. Prevalence of chronic pain is typically higher among rural or remote Canadian dwellers than urban dwellers,Footnote 30 but this does not mean that those individuals are also at higher risk of chronic pain deterioration. In Asian and European studies, geographical severity of the coronavirus outbreak has been positively associated with general psychological distress,Footnote 28 but has not been examined in relation to pain status.

Stress appraisal and management—a crucial element

Perceived stress was associated with both pain deterioration and psychological distress. Earlier studies on the COVID-19 pandemic have shown that sources of stress are numerous and include, for example, fear of COVID-19 infection, socioeconomic worries and traumatic stress responses.Footnote 31Footnote 32

In this study, stress appraisal had stronger associations with pain status and psychological distress than degree of geographical variations in COVID-19 infection. This is a clinically important finding, since minimizing the absolute number of stressors may be difficult during a pandemic; alternatively, helping individuals manage and appraise stress more optimally is achievable.Footnote 33

Counterintuitively, having lost one’s job during the pandemic was associated with lower likelihood of reporting worsened pain; however, being in the workforce at the beginning of the pandemic was associated with an increased likelihood of reporting worsened pain. While the type of employment was not measured in this study, working during the pandemic may push the boundaries of a person’s physical capacity if environmental demands (e.g. caring for children at home, adjusting to remote working) increase. Losing one’s job, if widely available national emergency financial programs can be made use of, may decrease an individual’s level of physical activity or allow for greater engagement in pain self-management.

Deteriorated pain and psychological distress were less prevalent with older age. This is consistent with a systematic review that showed younger adults were at increased risk of psychological distress during the pandemic, likely because of the financial and professional stress associated with lockdowns in addition to increased responsibilities such as childcare.Footnote 28

Magnitude of psychological distress

Psychological distress in this sample (43%) was double that of the general population during the COVID-19 pandemic.Footnote 8 Our findings showed that those who felt particularly vulnerable to the COVID-19 pandemic or express concerns about the health of others were more likely to report psychological distress. The COVID-19 pandemic puts individuals in an unpredictable situation over which they have little control, a perfect recipe for increased stress.Footnote 33 In contrast to pain status change, changes in pharmacological or physical/psychological treatments for pain did not increase the odds of reporting moderate to severe psychological distress. Some of those treatment changes may have been initiated by individuals with chronic pain to limit their risk of COVID-19 infection (e.g. by avoiding hospitals), which in turn may have led to a reduced perceived threat. For others, unwanted changes to their treatments may have led to a worsening of their psychological distress.

Strengths and limitations

The cross-sectional design of this study precluded the ability to make causal inferences. The self-selection of participants in the study through a convenience sampling strategy that included patient organizations limited generalizability of our findings to all individuals with chronic pain. However, compared to other large random surveys, our study sample was of a similar age (mean age: 49.7 compared to 46.6–48.4)Footnote 2Footnote 34Footnote 35 and had a similar percentage of workers (34.9% compared to 38–44%)Footnote 2Footnote 34; pain duration (46.9% with pain duration >10 years compared to 46–46.7%)Footnote 2Footnote 36; and pain intensity (mean 0–10 pain score: 6.1 vs. 6.3–6.9)Footnote 34Footnote 37 compared to other large random surveys.

Female participants were overrepresented in this study compared to other studies.Footnote 2Footnote 34Footnote 35Footnote 37 It is possible that such representation was in part due to the recruitment strategies that relied primarily on social media.Footnote 38Footnote 39 Nonetheless, we were able to recruit a nonnegligible number of male participants (n = 429), allowing us to consider this variable in the multivariate models.

The exclusion of individuals with missing data likely resulted in a sample that was less affected by the pandemic than those included. Moreover, patient self-report data may have been subject to recall bias and/or misclassification. These characteristics, however, allow to focus on the individuals’ perspectives and to document their lived experience, something very difficult to achieve in large epidemiological studies using medico-administrative databases.

Implications and recommendations

Given the cross-sectional nature and convenience sampling procedure used in this study, it will be important to validate study findings in other samples of individuals living with chronic pain. Study results showed deteriorated pain and psychological status during the COVID-19 pandemic in a population that already faced multiple types of physical, socioeconomic and mental health challenges. The pandemic has exacerbated all of these challenges.Footnote 40Footnote 41 Given the trajectory of chronic pain, it is likely that many individuals will not return to their pre-pandemic pain state once it is over, and rates of chronic pain may increase over time.Footnote 5 As suggested in the latest report of the Canadian Pain Task Force, tangible system responses to the COVID-19 pandemic should be implemented to improve the conditions of individuals living with chronic pain.Footnote 5 These include the identification of pain as a health care priority, supporting epidemiological research on pain (including post viral pain), facilitating the implementation of virtual stepped care for pain and mental health, facilitating access to self-management tools and creating centralized and interdisciplinary assessment, intake and care.Footnote 5

Acknowledgements

The authors would like to thank the Pain BC and the Canadian Arthritis Patient Alliance for their feedback on the study design and questionnaires, and for their recruitment efforts. MGP is a Junior 1 research scholar and AL is a Junior 2 research scholar from the Fonds de recherche du Québec – Santé (FRQS).

We also want to thank our patient partners—Camille Fauteux, Jacques Laliberté and Linda Wilhelm—for their insights and collaborations throughout the project. They were involved in the pre-test of the study questionnaires and provided their feedback on the interpretation of study results.

Dissemination

Study results have been presented at two conferences—Canadian Psychological Association and Centre de recherche du Centre hospitalier de l’Université de Montréal (CHUM). Two public webinars also took place to disseminate study results to the general public. In addition, we plan to further disseminate study results to participants and the general public through infographics, and press releases through partnering organizations.

Funding

Financial support for this study was provided by the Chronic Pain Network of the Canadian Institutes of Health Research (CIHR)’s Strategy for Patient-Oriented Research (SPOR grant SCA-145102), the Quebec Pain Research Network of the FRQS and Pain BC.

MH, GM and KS are employees of Pain BC, a charitable non-profit organization working to enhance the well-being of people living with pain. They were involved in the study design, participants’ recruitment and review of the manuscript. All other funding sources had no role in the study design, collection, analysis and interpretation of data, writing of the manuscript or decision to submit the paper for publication.

Conflict of interest

All authors declare no support from commercial entities for the submitted work. MH, GM and KS are employees of Pain BC, a charitable non-profit organization working to enhance the well-being of people living with pain; this organization receives funding from the British Columbia Ministry of Health. GM received funding from the Michael Smith Foundation for Health Research through InSearch Research Group for work unrelated to this submission.

Authors’ contributions and statement

MGP – conceptualization, data curation, formal analysis, investigation, methodology, writing – original draft and review and editing; AL – conceptualization, data curation, funding acquisition, methodology, writing – review and editing; LD – conceptualization, data curation, funding acquisition, methodology, writing – review and editing; MH – conceptualization, data curation, funding acquisition, methodology, writing – review and editing; GM – conceptualization, data curation, funding acquisition, methodology, writing – review and editing; KS – conceptualization, data curation, funding acquisition, methodology, writing – review and editing; JMT – conceptualization, data curation, funding acquisition, methodology, writing – review and editing; MD – formal analysis, writing-review and editing; AJM – conceptualization, data curation, methodology, project administration, writing – review and editing; NS – methodology, analysis, writing-review and editing; MC – conceptualization, data curation, funding acquisition, methodology, writing – review and editing.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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