Pain in Refugee and Migrant Populations

Among other health challenges, chronic pain is common among refugees and displaced persons, affecting at least 66% of traumatized refugees, according to one study.¹ Yet there are few studies on chronic pain that include refugees and other displaced persons, such as migrants, as subjects. In addition, most studies on multidisciplinary care for chronic pain are conducted in Western nations, with subjects are generally from Western populations.²

The potential study population is massive: according to the United Nations Refugee Agency (UNHCR), at the end of 2021, persecution, violence, conflict, human rights violations, or events that seriously disrupted the public order led to the forcible displacement of more than 89 million people worldwide.³

“We definitely need well-designed, large-scale studies to estimate the effectiveness of culturally adapted multidisciplinary intervention programs over time. We don’t have that,” said Michael Bottros, MD, associate professor of anesthesiology, and medical director of pain services at the Keck School of Medicine at the University of Southern California. “We have some cohort studies; we have a couple of randomized control studies, but nothing that would be really helpful from a big perspective.”

As pain medicine increasingly embraces inter- and multi-disciplinary approaches to the treatment of chronic pain, there is a need, despite the relatively shallow body of evidence, to evaluate how well these modalities work in treating chronic pain and associated symptoms in refugees and immigrants.

A team of researchers from Monash University in Melbourne, Australia, and Deakin University in Burwood, Australia, set out to analyze the studies that we do have. Their systematic review of the effectiveness of interventions for chronic pain in refugee and immigrant populations, was published this past May in the journal Patient Education and Counseling.²

Studies included in the review were drawn from databases including Ovid (MEDLINE and Epub Ahead of Print, EMBASE, and PsychINFO), Cochrane Central, Scopus, and CINAHL. All of the studies selected were published in English and included patients over 18 years of age. Chronic pain related to cancer was excluded. In the final analysis, 21 papers met the inclusion criteria, including 13 cohort studies and eight RCTs. Most of the studies involved multidisciplinary or psychological interventions, although some focused on education, exercise therapy, or culturally adapted information (eg, medication and self-care education).

Only three of the studies included refugees, asylum-seekers, or torture survivors; the rest were focused on migrants. Back pain, shoulder pain, and widespread, indistinct chronic pain were the most commonly reported types of chronic pain. Three studies included participants with fibromyalgia and one included women with chronic pelvic pain. In general, refugees, asylum seekers, or those whose backgrounds involved torture reported greater pain severity than did migrants. Women were more likely to report lower pain tolerance and more baseline symptoms, as well as depression, anxiety, and PTSD.

Sixty-two percent of the included studies used a multidisciplinary approach to managing chronic pain, typically involving consultation or cross-referral among various medical specialties, physiotherapists, social workers, occupational therapists, and psychologists. Bilingual interpreters, cultural support, and translated material were used in the studies, and two of the studies involved bilingual healthcare teams.

Although 80% of the studies found post-intervention improvement in symptoms associated with chronic pain, such as pain intensity, degree of disability, and frequency of pain, not all the improvements were maintained long-term. Studies that did find long-term positive outcomes were ones that used multidisciplinary care and/or physical exercise.

For example, in one study, a group of ethnically diverse individuals who took yoga classes reported less analgesic use (13% versus 73%), less opiate use (none versus 33%), and greater overall improvement (73% versus 27%) when compared with usual care.

In general, however, one of the most striking aspects of this review was not the effectiveness of the interventions, but the relative lack of interventions that addressed the influence of culture on pain. The way that pain is conceptualized and expressed varies from culture to culture and how best to tailor treatment to the individual remains inconsistent – even in stable under-resourced populations of the US.

Still, the study authors wrote, “Our review found that multidisciplinary chronic pain interventions can be effective in managing pain intensity, physical function, and psychological health in refugee or immigrant populations.” But they add, “Without longer follow-up periods it is difficult to elucidate the long-term effectiveness of these interventions.”²

The challenge is formidable. Dr. Bottros pointed out that here in the United States we do not yet have a good sense of what proper pain management is. “There are still those who do not fully understand the multidisciplinary approach and what pain management really should entail,” he said. “If we have that kind of impediment [when treating] the citizens of our own country, then how much more are we going to have a problem with refugees?”

More in our special report on biopsychosocial approaches to pain assessment and management, including the latest terminology.