Why government and employers should think more about ‘chronic pain workers’

The summer holidays are ending, meaning many people will return to work. For some of them, that means physical pain. That pain doesn’t get enough attention from policymakers and employers.

Chronic pain is remarkably common: 20% of people suffer globally and best estimates suggest prevalence of around 43% for the UK population. There are considerable individual social and economic costs of chronic pain, including poor sleep, social isolation, reduced capacity to complete daily activities, and severe and persistent discomfort.

Given the current discourse surrounding pain and ill health in the UK, you might suspect that this is going to be a commentary on NHS backlogs or the great British post-COVID workforce exodus or the flight of older workers. Those are critical concerns that policymakers and employers should take seriously and no doubt a tighter labour market due to growing sickness poses a real threat to the UK’s prosperity and public service provision.

But in this blog, I want to focus on something that receives less attention: the problem of chronic pain amongst those who stay in the workforce. My view is that chronic pain is bad for workers, bad for businesses (and anyone else who cares about economic growth), and possibly even bad for those who care about the survival of capitalism.

Britain’s workforce chronic pain problem

First, a definition. Pain has to trouble someone persistently or intermittently well beyond normal tissue or disease healing time – typically more than three months – to be considered chronic. The aetiology is complex[1], but the WHO’s 2022 disease classifications can add some clarity:

• Primary chronic pain is a specific condition in its own right. In other words, it is long-lasting pain that cannot be explained by something else. Non-specific musculoskeletal problems would be a common example.
• Secondary chronic pain is that which arises from an underlying disease or health event, like cancer or tissue injury.

Chronic pain manifests along well-observed patterns of ethnic and socio-economic health inequalities (Figure 1). Unsurprisingly, it gets more common with age. What is perhaps more surprising is just how common chronic pain is amongst those of working age. The best data available – the 2017 Health Survey for England (HSE) – suggest that 27% of people in employment experience chronic pain, as well as 29% of those who looking for work or on a government training scheme.[2] A crude calculation would suggest roughly 8 million workers are in chronic pain, if we use the HSE estimate combined with the latest payroll data.

Millions of in-pain workers is concerning enough but consider another dimension. There was little change in average levels of chronic pain reported across working-age groups between the 2011 and 2017 iterations of the HSE. But we know that there were 8.7 million fewer sick days taken in 2019 compared with 2009, including 10.9 million fewer days lost due to musculoskeletal conditions, which is by far the most common source of chronic pain (n.b. that other reasons for absence, notably mental health, have risen).

Why does this matter? Because it implies that whether due to economic insecurity, dependence on pain medications, being resigned to living in pain or for some other reason, increasingly many in employment are simply carrying on working through chronic pain. And that brings real problems.

Why chronic pain in the workforce matters

Numerous studies point to poor health outcomes and individual social costs of chronic pain. According to one Australian study, if you wanted to compensate for the unhappiness caused by chronic pain for an individual with a daily equivalised disposable income of £47, you’d have to hand them an extra £423 per day to reach the same level of life satisfaction as someone who isn’t in pain.

But for those in employment there are additional effects of chronic pain. The cost of absenteeism is one of the most important. A US-based study published this year has found that on average, 10.3 days are lost annually for those reporting chronic pain, compared to 2.8 days for their peers. Having almost four times as many days off sick results in $80 billion in lost wages.

In the long-term, intermittent workplace absence due to sickness is linked to a reduced likelihood of gaining a promotion, although studies specifically focusing on the relationship between career progression and chronic pain are lacking. We should also give due consideration to job satisfaction, where the picture is bleak. Research shows that people with chronic pain are much more likely to say their job isn’t rewarding compared with their pain-free peers, and that they feel ostracised or discriminated against in the workplace.

For some workers, managing pain and employment may become too much, pushing them into economic inactivity. For others, reliance on pharmacological treatments may become necessary. Survey data from IPSOS indicate that 24% of 16-75 year olds are taking opioids to manage chronic pain. Whilst these data aren’t segmented by employment status, it seems plausible that tens if not hundreds of thousands of workers are using opioids to manage pain at work. Of course, we should be wary of concluding that the UK is on course for a US-style opioid crisis. But the most recent data do nonetheless show record levels of opiate-related deaths in England and Wales in 2020 (2,263).

From a business perspective, absenteeism is a real problem but probably surpassed by presenteeism. This is the concept of showing up to work but working less productively for some reason, in this instance due to chronic pain. To illustrate, estimates suggest that for women with endometriosis the average hours of employment productivity lost due to absenteeism each week is 1.1 hours but 5.3 hours for presenteeism. There will be some tolerance in numbers like these — self-reported estimates of productivity are a pretty imperfect measure. But even with a pinch of salt, it seems likely that at least a small proportion of the UK’s well-recognised productivity crisis can be attributed to the effects of chronic pain in the workforce.

It is worth pausing for a moment and considering that employers are particularly well-placed to do something about chronic pain in the workforce. And, fortunately, there is no shortage of solutions. Early-intervention can help reduce long-term absence by 12% for musculoskeletal problems. Offering flexible working patterns might help workers manage a job around their pain load, increasing productivity. For instance, ankylosing spondylitis – a type of arthritis – is typically more uncomfortable in mornings. Insurance models that offer therapies and income support bring mutual benefits for both employees in chronic pain and the business itself. I would argue that a movement akin to that which has seen mental health become a genuine priority for businesses is needed to properly address chronic pain in the workplace.

Policymakers scratching their heads about how to stoke economic growth would do well to think about chronic pain at work. The drag on productivity caused by workplace absence and presenteeism is certainly a real problem. The overall cost of lost productivity has recently been estimated for the United States at $216 billion of foregone GDP annually, roughly 1% of total GDP.[3] If that analysis is even somewhat illustrative of the economic costs in the UK, the recent chronic pain guidelines issued by the National Institute for Health and Care Excellence, which seem to pave the way for the decommissioning of pain management services and withdrawal of some pharmacological treatments, particularly baffling.

What could the UK government do? First, the chronic pain module of the Health Survey for England should be re-run. We need a clearer picture of the scale of the problem and the 2017 data are outdated, possibly significantly so in light of COVID-19. Second, learn from Scotland, where chronic pain is taken increasingly seriously by government. This is typified by the recent creation of a National Advisory Committee on Chronic Pain. Third, the National Health Security Agency should commission or carry out research on the total socio-economic costs of chronic pain in the UK. Ministers need to know reliably what chronic pain means for the economy and health system so they can act. Exactly what policy interventions are required is beyond the scope of this blog, but the answers are likely to involve improving the quality and provision of prevention and treatment services and demanding more support from businesses for their staff.

The ‘worker with chronic pain’ is someone government and the policy community should give more thought to. They – and remember they comprise around a quarter of the workforce – suffer the consequences in their pay packets, career progression and workers’ wellbeing. That matters for productivity and economic growth. And, more speculatively, it could even have ramifications for attitudes towards work and the broader economic settlement. Amidst soaring inflation and stagnating wage growth, the experience of millions of unhappy, in-pain workers is only likely to exacerbate disillusionment with the way the economy currently works for the people in it.

And for an economy that’s running short of workers – especially workers over 50 – as more people leave the labour market for inactivity or early retirement, making work a less painful experience should be regarded as something of a priority.

[1] Neuroscientific research now suggests that the circuits of the brain that are active during acute ‘nociceptive’ pain (think stubbing your toe) and chronic pain (like persistent but unidentifiable back pain) are very different and can shift quite considerably as acute pain becomes chronic. Fascinatingly, tissue injury or disease may heal, but the brain seems to be changed in chronic pain patients such that pain symptoms persist.

[2] Due to a small sample size, the latter estimate has relatively large confidence intervals.

[3] Estimate is based on GDP per hour worked in 2019, calculated at $71.78, combined with the total estimated lost days of work due to chronic pain