When T.R. Reid, an American reporter, went to his American doctor for an old shoulder injury, he got a very American recommendation. The doctor suggested a total shoulder arthroplasty, a Cadillac of a procedure that would saw off his shoulder joint, replace it with silicon and titanium, and cement it into place.
Reid declined, then set off to get the same shoulder treated in five other countries, documenting the experience in his book, The Healing of America.
A French doctor demurred, saying a total shoulder replacement was only for those in constant pain. A British NHS doctor didn’t mince words: “You are living your normal life without much impairment. So [surgery] is not indicated.”
Reid’s book offers a frank look at how differently national health systems approach pain management. The Americans—zealously, expensively—and the British—stiff-upper-lippedly—came up with wildly different cures for the same problem. (The British doctor did agree to “maybe” some physical therapy—if Reid developed “acute pain.”)
Now, a new National Bureau of Economic Research paper explores how Americans also perceive and report pain differently from people in other countries. In other words, not only are our doctors more trigger-happy when it comes to treating pain; we seem to find ourselves covered in Bengay and sitting on the exam table more than most.
The paper, which is fittingly titled “Unhappiness and Pain in Modern America,” featured a question from a 2011 survey that asked people across 30 countries the following:
During the past four weeks, how often have you had bodily aches or pains? Never; seldom; sometimes; often; or very often?
About a third of Americans said they feel aches and pains “very often” or “often”—more than people in any other country. Australia and Great Britain came close, but in the average nation only about 20 percent gave one of those responses. In the Philippines or South Africa, just 11 percent felt pain that often.
“Although on first hearing it seems hard to believe (and was for us),” the paper’s authors write, “there is evidence that Americans are in more pain than citizens of other advanced, and even not-so-advanced, countries.”
Of course, it’s worth noting that language and cultural differences can affect how people think and talk about their pain. But given that Americans are still seeking out both legal and illicit painkillers at an astonishing rate, it’s worth considering the root causes of all this pain. In my conversations with pain researchers, three leading theories emerged:
“Americans are fatter than everyone else, and pain relates to obesity,” the Dartmouth College economist David Blanchflower, an author of the NBER paper, told me when I asked him for his theory.
The idea was echoed by a couple other experts I contacted. The United States has one of the highest obesity rates in the world, and there is some evidence that obese people are more sensitive to pain in some parts of their bodies. It’s not clear why, but it could be because of inflammation, the stress the weight puts on their joints, or the disturbed sleep that comes from sleep apnea.
Too many painkillers
Other experts questioned how big of a factor obesity really is. Instead, some pointed out the fact that Americans consume so many prescription painkillers—nearly 80 percent of the global supply, by some measures. Paradoxically, opioids heighten the perception of pain, rather than dulling it.
Opioids can cause a sort of all-over, neurological pain that gets overlaid on top of the original pain, said Eldon Tunks, a professor emeritus of psychiatry at McMaster University. Doctors in other countries are less quick to dispense opioids for pain, other than for major surgical procedures.
It’s all in our heads (sort of)
The NBER paper also found that Americans, especially those of low education levels, have been gradually growing less happy since the 1970s, according to the General Social Survey.
Happiness Among Different Educational Groups in the United States
The pain that Americans report might be very real, but psychological factors might be contributing to it. As I’ve previously written, depression changes how the body releases its own, endogenous, pain-relieving chemicals, and it tends to exacerbate the perception of pain.
“Unhappiness and pain complaints go together, and the pain complaints didn’t always come first,” said Mark Sullivan, a professor of psychiatry at the University of Washington. In the United States, freedom comes with expectations—and for some, disappointment, he added.
The use of opioids and hallucinogens increases during economic downturns, so some of these patterns could be cyclical: Working-class Americans lose their jobs, so they become unhappy, so they start using opioids, so they start to feel more sensitive to pain.
Carol Graham, a Brookings fellow and University of Maryland public-policy professor, makes a similar point in her recent book Happiness for All? She and her colleagues found that sadness, anger, worry, stress, and physical pain were all higher among the poor in the United States than among the rich.
That might seem strange, given that prestigious jobs can appear demanding and stressful. But Graham suggests it’s just the opposite: “Stress that is associated with daily struggles and circumstances beyond individuals’ control—as is more common for the poor—has more negative effects than that associated with goal achievement—as is more common for those with more means and education,” she writes.
Tunks also pointed out that a sense of losing control—“being abused, being in a subservient job, being in a country with a lot of people shooting each other,” as he put it—can lead to anxiety, which, in turn, amps up the likelihood of pain.
There lies, in this anxiety, yet another potential cause of Americans’ greater reporting of pain: the worry that something must be wrong, and the feeling that we’re not doing enough to treat it. Arthur Barsky, a Harvard psychiatry professor who researches hypochondria, says it’s uniquely American to think all sorts of aches and pains are treatable, rather than just being part of life. The thinking seems to be, “if we can transplant hearts, and do fetal surgeries, we ought to be able to cure those migraine headaches!” he said.
The internet has made it easier to research symptoms and “label something as a disorder or disease,” he said. Among two patients with the same level of arthritis, for example, one might think it’s basically fine, and the other might say, “I can’t stand this any longer.”
In Barsky’s view, the preoccupation with perfect health is impairing Americans’ ability to cope with a little bit of pain.
“Curable pain is unbearable pain,” he said. “It’s when you think you shouldn’t have to suffer it, there there should be some solution out there, that it becomes even more intolerable.”