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A glimpse into a neglected population – Emerging adults

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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 17 Issue 1

In this issue of the Scandinavian Journal of Pain Rana Qadeer and co workers [1] have extrapolated information from a national data base in Canada [2] that is derived from structured interviews as opposed to more standard questionnaire data. This article addresses some interesting questions about pain and physical/mental health in a segment of the Canadian population. The major findings are that “emerging adults” have a prevalence of chronic pain, psychiatric diagnoses, and chronic disease states almost to the same degree as revealed by surveys from the whole adult population. The young are commonly thought to be relatively healthy as opposed to an older population but this does not seem the case in this cross-sectional survey. The interactions of chronic disease, mental health, including substance abuse and pain are reviewed with some surprising and some not so surprising conclusions. The statistics make interpretation in simple terms for a non-statistician a bit difficult but the data are important, not only for those interested in pain but also for all healthcare providers.

1 Emerging adults in transition from child to adult: 15 and 30 years of age

The identification of this age group, initially ages 18-25 [3] but subsequently extended and in this article ages 15-30, was based on the sociological phenomenon of the changing culture of “youth” in the western world under the last half century. Previously, and still in some cultures, children assumed adult duties and responsibilities at a much earlier age than they do now, but in the western world, increased affluence and the demands of longer formal education have postponed the transition from childhood to adulthood. This new group, emerging adults, often lack the financial and family responsibilities of older adults but face other challenges in the transition from childhood to adulthood.

2 Care gaps: emerging adults often lost in the health care system

What is important about this report? The first point raised by Qadeer et al. is that many in this age group can be rather lost in the healthcare system and there are barriers to adequate care [4,5]. The group bridges the pediatric-adult medicine dichotomy and there is a tendency for the lower segment, i.e. ages 18-25, of the emerging adult group, to be viewed as neither pediatric nor adult. Standard follow-up of health problems is often neglected. Changing behaviors, especially risk-taking [6], make them vulnerable and the change from the standard childhood vaccination routine and the treatment of childhood diseases to the treatment of the results of trauma or drug experimentation is often how the healthcare system views this age group. A factor behind this and not well appreciated is that brain maturation continues until age 20 or more, longer in males than in females [7]. This is associated with what is called immature behavior where thrill seeking and lack of appreciating the consequences of risk taking make this age group vulnerable.

3 Chronic pain and chronic health conditions in emerging adults

Qadeer et al. have focused on chronic pain, chronic health conditions (CHC) (other than psychiatric) and psychiatric health in emerging adults to give a demographic profile to compare with data we have from the “adult” population that usually includes all from either age 18 or age 20 throughout the full span of life. What can we learn about this group in particular? One of the aspects is that the predictors for reporting CHC, i.e. female gender, low income, low education, and comorbid psychiatric diagnoses, in emerging adults are the same as for the report of chronic pain in the whole adult population [8,9,10]. Qadeer et al. did not look at the pain group for predictors in the same manner as adult studies on the demography of chronic pain but incidentally came up with the same correlations.

It is not surprising that having a CHC, having a psychiatric disorder, or having an alcohol/drug problem all independently increase the odds of having pain. This is not new territory but dissecting the relationships and interactions of the variables does reveal some surprises - see below.

4 Disruptive pain preventing activity

Although pain is a focus, it is restricted to “pain preventing activity” which may not be the same as “chronic pain” in many demographic studies. Here, 11.0% of the total population report “pain preventing activity”. This is a rather low prevalence as compared to statistics from general population surveys world-wide which vary from 11% to 64% [11,12,13] but given the fact that the prevalence of chronic pain increases with age in all studies, this low figure is not too surprising. It is a criticism of the information from the Statistics Canada survey that it did not include some standard measure of pain such as an NRS or VAS that could be correlated with other demographic studies.

5 The healthy youths - not so healthy in 4 of 10 emerging adults

A very high proportion of emerging adults, 41%, report having a CHC although the full range of options in the survey is not available. This is surprisingly high but prevalence by diagnosis was not possible due to limits imposed for ethical reasons on the data available made this impossible but would make interesting reading. Although the impression is that teenagers and young adults are generally quite healthy, this data indicates that this is not the case.

There are some standout statistical conclusions worth noting and emphasizing here. One is that the presence of “an alcohol or drug disorder”, excluding cannabis, is associated with an increased risk for the probability of having “pain preventing activities” in those without a CHC but, at least statistically, with a diminished risk for the same in subjects reporting a CHC. The authors hypothesize that this is due to a beneficial effect of alcohol or drugs other than cannabis in some way. Why alcohol and other drugs should reduce pain as they suggest in one cohort and not the other is difficult to understand. The protective effect may be only statistical and not clinically significant but there is a marked difference between the two cohorts that is probably not just a Type 1 error. This information needs to be explored further with population studies since it is not intuitively obvious that there should be a difference.

6 Cannabis not helpful for pain and more risky in emerging adults

Even more surprising is the fact that cannabis did not seem to influence the presence of “pain inhibiting activity” in either group. If “alcohol and other drugs” seem to have a moderating effect on the presence of “pain inhibiting activity”, why not cannabis that is being widely proposed as an analgesic useful for the treatment of many chronic pain disorders [14,15,16]? This is an important finding that supports the lack of controlled studies in chronic pain where most evidence is anecdotal [17,18]. There are unpublished reports where no efficacy has been shown as well [19]. With the increasing public support for legalization of cannabis for the treatment of chronic pain in the developed world, the information from Qadeer et al. needs to be added to the evidence base.

7 Be aware of high risk of suicide behavior in emerging adults

Although the prevalence of “Suicidal Behavior” in the population with “Chronic Health Conditions” and the total population seems high at 9.1% and 5.3% respectively, this is consistent with data from other studies [20]. Data is scarce and various definitions make interpretation difficult but the prevalence of suicide and suicide behavior are high in younger individuals.

8 Healthy immigrants in Canada

A side note is the evidence for the “healthy immigrant” phenomenon that seems to be alive and well in Canada. This is a topic much discussed in the literature and here we have support from another country that indicates better general health in the immigrant population as compared to Canadian-born subjects [21,22].

9 Importance of delayed central nervous system maturation in emerging adults

To return to what is not stated about this population but is important, especially with regard to chronic pain and substance abuse, is the fact that central nervous system (CNS) maturation is a gradual process that usually continues past the age of 20, especially in males [7]. This is thought to be associated with impulsive behavior as a part of the maturing process [23]. There is very strong support for the CNS priming by pain and stress in infants and young children that predisposes them to chronic pain and psychological problems as adults. It is proposed that the increased plasticity in infants and children makes them vulnerable [24]. Could this also be the case for “emerging adults” or is it that we are seeing the effects in this group of earlier problems? This point needs further exploration.

There is also evidence that “emerging adults” are more susceptible to CNS changes that become permanent with the use of cannabis in all its forms. Sequelae such as schizophrenia and psychosis, addiction, and other behavioral disorders are associated with even brief exposure to cannabis in “emerging adults” as evidence for CNS vulnerability which may be related to CNS immaturity [25]. The original articles on “emerging adults” as a cultural phenomenon also discuss the changes in this group that, for good or bad, have long term effects on their social and family lives. Since chronic “pain inhibiting activity” by definition and chronic disease impair socializing and school/university attendance, what are the lasting effects of these problems in later adulthood?

This article by Qadeer et al. highlights some health problems in a segment of the population and this indicates the need further study in this group. Better medical supervision and routine evaluation could reduce chronic pain and illness later in life in this population [5 or 26].

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.07.009.

Pain Center, Akademisk Sjukhuset, 751 85 Uppsala, Sweden

  1. Conflict of interest The author declares no conflict of interest.

References

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Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
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  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
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  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
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  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
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  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
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  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
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  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
  35. Original experimental
  36. Comparison of spatial summation properties at different body sites
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  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
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  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
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  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
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  48. Opioids in chronic pain – Primum non nocere
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  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
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  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
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  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
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  102. Targeting cytokines for treatment of neuropathic pain
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https://doi.org/10.1016/j.sjpain.2017.08.005

Articles in the same Issue

  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
  5. Clinical pain research
  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
  7. Clinical pain research
  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
  35. Original experimental
  36. Comparison of spatial summation properties at different body sites
  37. Editorial comment
  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
  41. Editorial comment
  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
  70. A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
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