Chronic pain affects about one in five American adults, with an estimated societal cost of $560-635 billion each year for medical care, loss of productivity, and disability services. Individuals with chronic pain typically experience pain every day for six months or longer. They are more likely to have anxiety, depression, sleep problems, and report poor quality of life. The burden of chronic pain is disproportionately carried by women, persons of lower socioeconomic status, older adults, and rural residents.
Although pain has been widely accepted as a biopsychosocial phenomenon for decades, much of the existing clinical and research efforts focus on biological and psychological risk factors and treatments for chronic pain. Flavia Kapos, a doctoral candidate in the University of Washington (UW) Department of Epidemiology, is interested in understanding social factors that contribute to the development of chronic pain, in order to identify potential strategies to address pain disparities. This novel approach in applying social determinants of health theory and methods to this issue has landed her the 2019-2020 Patrick-Beresford Fellowship in Social Epidemiology.
The funds from this scholarship will support Flavia’s dissertation research, which examines the role of neighborhood characteristics and healthcare policy in socioeconomic pain disparities. With the support of her dissertation chair and mentor, Assistant Professor Anjum Hajat, Flavia will investigate whether access to affordable healthcare through Medicaid expansion helps low-income adults get the pain treatment they need and whether states that expanded Medicaid reduced the prevalence of chronic pain in this population. She will also determine whether neighborhood deprivation is associated with a higher burden of chronic pain, above and beyond individual socioeconomic status and demographic characteristics.
“This will be the first nationwide study to look at chronic pain beyond the individual, acknowledging that people don’t live in a vacuum,” said Flavia. “We will start to quantify the contribution of multilevel factors to chronic pain, including neighborhood context and state policies for access to healthcare. This fellowship highlights the value of social epidemiology in the pain field: it can help us better understand the multiple layers of causes of chronic pain and lead to better prevention and treatment strategies.”
Flavia has spent the last nine years engaged in solving complex puzzles of chronic pain. First, as a dental student, then as a practicing dentist in São Paulo, Brazil, later as an orofacial pain resident at the University of Minnesota, and now as an epidemiology doctoral candidate at the UW School of Public Health. Over the years of treating patients with orofacial pain—mostly chronic, non-dental pain in the mouth, face, and head—Flavia found herself with more questions than answers at the clinical level, which led to her pursuit in research
In 2015, Flavia participated in the UW School of Dentistry’s Summer Institute in Dental and Craniofacial Clinical Research Methods.
“I took a clinical epidemiology class and was fascinated by that perspective. The introduction to epidemiologic methods presented during that course provided me with a way to organize my ideas and I found that public health had the tools I needed to begin answering important questions in my field,” said Flavia, who at the time was completing a master's of science degree in parallel with her residency training at the University of Minnesota. “I wanted to learn more, and that really changed my professional trajectory towards a more research-heavy route.”
Following the completion of her program in Minnesota, Flavia set out to gain more skills in epidemiologic methods through the UW Department of Epidemiology’s doctoral program. A course on social determinants of health triggered Flavia to think about the disparities in chronic pain and how social history, life experiences, and multilevel context can shape individual biological and psychological risk factors for pain.
“I really enjoyed the diverse environment at UW Epi and was fortunate to interact with people who deeply care about how social issues affect health,” Flavia said. “I was shocked when I realized the magnitude of pain disparities, and how little I had heard of them after so many years in the field. The disparities strongly suggest that social factors contribute to the development and impact of chronic pain on people’s lives, and yet social aspects of pain are severely under-researched.”
Beyond her dissertation work, Flavia recently received a small grant from the Latino Center For Health to validate a brief questionnaire to measure pain and function for Spanish-speaking primary care patients receiving opioids or other treatments for chronic pain. In partnership with Dr. Christine Hancock at SeaMar Community Health Centers and under the supervision of Dr. Mark Jensen at the UW Department of Rehabilitation Medicine, this project aims to help improve the quality of care and opioid prescribing safety in this population.
There are currently no Spanish-language instruments validated to measure pain and function that are suitable for busy primary-care settings. Although the routine use of such measures is recommended by the Centers for Disease Control & Prevention and Washington state opioid prescribing guidelines, today this is only possible for English speakers.
“This is a great example of a population-level intervention to reduce disparities in pain care,” Flavia said. “We all know how hard it can be to describe our pain; imagine doing that in a language that is not your first! This project will extend the benefit of a validated pain and function measure to millions of Spanish-speaking primary care patients in the United States, and is aligned with other efforts to fight the opioid crisis.”
Flavia’s passion to address the issue of chronic pain using a social epidemiology approach is helping her to build a successful track record in competitive applications for research support within the UW and from external organizations. In the last year, in addition to the Patrick-Beresford Fellowship in Social Epidemiology, Flavia has received funding from the Scan Design Foundation Innovations in Pain Research Award, the American Academy of Orofacial Pain, the Philanthropic Education Organization International Peace Scholarship and the Latino Center For Health. In recognition of her engagement in and out of the classroom, Flavia was also named a Husky 100, a university-wide award recognizing 100 undergraduate and graduate students making the most of their time at the UW.
“I’m excited to bridge across the fields of pain research and public health through social epi. The social justice lens makes my work a lot more meaningful and will hopefully guide the future development of strategies to prevent and minimize the impact of chronic pain in the population, especially for those who need it the most.”