Chronic Pain in Adolescents: Who Will Be There to Care?

We have long known that many adolescents have chronic pain. A new study highlights just how widespread it is-and the significant impact it can have.

The study by Hoftun and colleagues¹ comes from Norway where (as part of a larger study) all adolescents who were 13 to 19 years old during 2006 to 2008 were asked to participate and answer questions about pain. Of the 10,485 who fit these criteria, 78% agreed to participate. Each participant completed a questionnaire that asked whether they had suffered pain unrelated to any known disease or injury during the previous 3 months. They were also asked about the impact that pain had on their lives (including its effects on daily activities and sleep).
 
Here are the most notable findings:
• Pain was relatively common; 44.4% of participants had pain at least once a week during the previous 3 months. (19.1% had pain only once a week; 15.1 % had pain more than once a week; and 10.2% had daily pain.)
• Musculoskeletal pain (ie, involving the neck and shoulder) was the most common type of pain; it occurred in 33.4% of the adolescents. This was followed by headaches in 21.8%, and abdominal pain in 11.3%. Pain was present in more than one location in 25.5% of participants.
• Girls were more likely than boys to experience pain. Girls reported abdominal pain 3 times as frequently as boys, headaches more than twice as often, and musculoskeletal pain 1.5 times as often. This sex disparity increased with age.
• Of those with pain in only one location, 48.8% reported that the pain interfered with their daily non-school activities; 36.6% said the pain made it difficult to sit during school; 25% reported that it disturbed them during their physical exercise classes; and 22.7% reported that it interfered with their sleep. These problems were even more common when the pain was present in more than one location.

What This Study Adds
This study confirms that chronic pain is common among adolescents. The most significant finding is that pain often interferes with important daily activities.

The study also raises a number of interesting questions. For example, why are girls more likely than boys to experience chronic pain? This has been a fairly consistent finding across a number of studies on adolescent pain. We also know that for certain forms of pain, such as migraine headaches and fibromyalgia, these gender differences are present in adulthood. Although a number of theories have been propagated, we don’t have an answer.

An editorial accompanying the article notes the need for more longitudinal studies on adolescent pain.² It would be useful to know what factors (if any) predict which adolescent is likely to have pain and (if so), which prophylactic interventions might be possible. And what happens to the pain as adolescents become adults? Why does the pain continue in some and resolve in others?

While the study did not explore the association between psychosocial and lifestyle factors and pain and its impact on adolescents’ lives, this needs to be explored.

Neither the article nor editorial mentions the role that pain might play in the growing problems of childhood obesity and the associated diabetes. It is common to see obese adults in chronic pain: pain can curtail activities and obesity can lead to or exacerbate pain. It’s a vicious cycle.
 
The same cycle is probably at play in adolescents. The Hoftun article found that pain can interfere with participation in physical exercise classes in school. There is the additional confounding problem of poor sleep, which itself can play a role in the onset of diabetes and other health problems.

And finally, there is the important issue of who will manage adolescent pain. When doctors have adult patients with chronic pain, they may be able to seek the assistance of specialists in pain medicine. In the US, however, most pain services do not treat anyone younger than age 16 or-more frequently-18. Pain services for pediatric patients are much less common than those for adults, and those that do exist tend to focus on younger children. Adding to this is the problem of the inadequate education about pain management received by many primary care physicians, as noted by the recent Institute of Medicine’s report on pain.³ For adolescents, there is the frightening likelihood that there will be no one to properly address their pain.
 
References
1. Hoftun GB, Romunstad, Zwart JA, et al. Chronic idiopathic pain in adolescence-high prevalence and disability: the young HUNT study. Pain. 2011. doi:10.1016/j.pain.2011.05.007
2. Jones GT. Pain in children-a call for more longitudinal research. Pain. 2011. doi:10.1016/j.pain.2011.06.016
3. Institute of Medicine Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011