Chronic pain, defined as pain that persists or recurs for more than 3 months [1], is a complex condition that can arise through different mechanisms (e.g., nerve damage, tissue injury, etc.) [2, 3]. It is a common condition in the United States, affecting approximately 51.6 million (20.9%) U.S. adults in 2021 [4]. This debilitating condition has been found to disproportionally affect certain populations such as females, older adults, and adults with a history of specific chronic diseases, including diabetes [4]. Additionally, research demonstrates that individuals living with chronic pain are more likely to experience sleep disorders [5], anxiety and depression [6], suicidality [7], and several other negative health outcomes [8]. It is also costly in the United States, with costs estimated between $560-$635 billion per year in 2010 [9].

Chronic pain affected nearly 38% of U.S. adults with diabetes in 2021 [4]. This high frequency reflects the pathophysiology of diabetes complications, including diabetic neuropathic pain [10–12] and other sources of pain (e.g., relating to musculoskeletal conditions) [13–16]. The high occurrence of chronic pain among U.S. adults with diabetes highlights an opportunity for improving pain management for a large segment of this population, which in turn may improve diabetes self-management [17] and quality of life for numerous adults with diabetes [18].

The Centers for Disease Control and Prevention’s 2022 Clinical Practice Guideline for Prescribing Opioids for Pain recommends maximizing nonpharmacological pain management techniques (e.g., physical therapy, cognitive behavioral therapy [CBT], certain complementary therapies, etc.) and nonopioid pharmacologic therapies as appropriate for the specific condition and patient among adults with chronic pain [19]. This recommendation is supported by evidence that various nonpharmacological pain management techniques can improve pain and function without risk of serious harms [20]. The recent American Academy of Neurology (AAN) recommendations for treating painful diabetic polyneuropathy also state that pain management techniques such as CBT, exercise, Tai Chi, and mindfulness may be offered to individuals who prefer nonpharmacological approaches [21]. Both recommendations reinforce the potential benefits that nonpharmacological approaches may provide adults suffering from chronic pain, including pain associated with diabetes complications.

Recent studies have characterized the use of different pain management techniques among U.S. adults with chronic pain [22–24]. While previous studies have described prescription pain medication use patterns among individuals with diabetes [25–27], recent data have not been used to assess the utilization of nonpharmacological pain management techniques from a nationally representative sample of U.S. adults with diabetes and chronic pain. Thus, the objective of the current study is to describe select pain management technique usage among U.S. adults experiencing chronic pain by diabetes status and the association of the co-occurrence of these two conditions with social functioning limitations.

In the current study, key differences were observed between adults with and without diabetes experiencing chronic pain. First, these two groups differed across a variety of sociodemographic characteristics. Further, adults with diabetes and chronic pain were more likely to report using select pharmacological pain management techniques, but less likely to utilize several different nonpharmacological techniques. Lastly, social functioning limitations were found to be more common among adults experiencing both diabetes and chronic pain. These findings provide valuable public health insights and help better contextualize the common intersection between chronic pain and diabetes.

Findings from the current study align with existing research indicating that prescription pain medication use is more common among individuals with diabetes than individuals without diabetes [25, 27]. For example, a recent study using 2005 to 2018 National Health and Nutrition Examination Survey data observed that adults with diabetes were twice as likely to be prescribed pain medications, including opioids, than adults without diabetes [27]. In the present study, the greater use of nonopioid prescription pain relievers among adults with diabetes experiencing chronic pain may be related to the use of AAN recommended medications for painful diabetic neuropathy (e.g., gabapentinoids, serotonin-norepinephrine reuptake inhibitors, etc.) [21, 31]. While the AAN does not recommend opioids be used to treat painful diabetic neuropathy [21], the higher use of opioids among adults with diabetes experiencing chronic pain may have been due to poor tolerance and failure of AAN recommended medications [21, 31, 32] and the greater reporting of intense pain among adults with diabetes in the present study. However, it is also important to consider that the observed results may also be related to additional comorbidities among adults with diabetes, as noted by a recent study that assessed opioid prescriptions among Medicare beneficiaries by diabetes status [25].

The lower utilization of several nonpharmacological pain management techniques among adults with diabetes and chronic pain is a noteworthy finding of the current study. Evidence suggests that modalities that are recommended for diabetes management, such as exercise, yoga, and Tai Chi [33], may also be beneficial for pain [34–38]. For example, significant reductions in pain interference and musculoskeletal pain have been observed from exercise-based interventions among adults with diabetes [36, 38]. Additionally, while no difference in talk therapy and peer support group use was observed between adults with and without diabetes experiencing chronic pain, the low prevalence of use observed in the present study is disconcerting since these techniques have been found to improve pain outcomes among people living with diabetes [39, 40]. Overall, results from the present study indicate that adults with diabetes and chronic pain may be missing beneficial opportunities to manage their pain.

Although nonpharmacological approaches are not associated with risks similar to those of opioid therapies (e.g., opioid use disorder and overdose) [19, 20], research suggests access and insurance coverage may play a role in how adults choose to manage their pain [41, 42]. In a study among Medicare beneficiaries experiencing persistent musculoskeletal pain, results demonstrated that availability of select nonpharmacological approaches lowered the odds of an older adult filling an opioid prescription [42]. Other research has highlighted limitations in insurance coverage of different nonpharmacological pain management techniques [41]. Given the sociodemographic differences observed in the present study, it is possible that the reported use of select pain management techniques may be related to barriers that commonly affect disadvantaged populations with higher diabetes prevalence [43]. Thus, increased access to nonpharmacological approaches, including low-cost options, may help increase utilization among adults with diabetes experiencing chronic pain.

The current study also detected differences in several social functioning limitations using a recent, nationally representative sample of U.S. adults with chronic pain. Diabetes and chronic pain have previously been shown to be independently linked with limitations and disabilities [23, 44, 45]; however, the present study further illustrates the excess limitations experienced among adults with diabetes living with chronic pain. These results stress the need for improved pain management amongst this population and increased public health awareness of the debilitating joint effect of diabetes and chronic pain. Moreover, these results also suggest the potential need for increased attention around the psychological well-being of adults with diabetes experiencing chronic pain given the common ties between these conditions, limited sociability, and adverse mental health outcomes [46–50].

This study has limitations that should be considered. First, all measured outcomes were self-reported and subject to recall and social desirability bias. Additionally, due to low prevalence of select outcomes, additional covariates (e.g., race/ethnicity, education, etc.) could not be incorporated into the adjustment set (i.e., age and sex) because doing so would have caused statistical positivity violations; thus, the observed results may be subject to uncontrolled confounding bias. Sample size constraints limited assessments of effect measure modification by key sociodemographic factors as well. It is also important to note that disruptions associated with the COVID-19 pandemic may have affected health care access and social functioning activities in 2020, with potential for differential impacts by diabetes status. The data are also cross-sectional and hence cannot be used to establish causal relationships. Lastly, the response rate decreased notably during the 2020 interviews and the potential for non-response bias should be considered.

The present study describes the use of pain management techniques and social functioning limitations among adults with chronic pain by diabetes status. The results demonstrate that adults with diabetes and chronic pain are more likely to utilize pharmacological approaches to combat chronic pain, but less likely to use several different nonpharmacological approaches, than those without diabetes experiencing chronic pain. Moreover, social functioning limitations were found to be more common among adults with diabetes and chronic pain than adults without diabetes who have chronic pain. Low utilization of various nonpharmacological techniques and excess social functioning limitations suggest that adults with diabetes and chronic pain may be missing beneficial opportunities to manage chronic pain and that improved pain management would be advantageous in this population. While further research may be beneficial, the results from the present study provide public health considerations since improved pain management among adults with diabetes experiencing chronic pain may help limit pain-related competing demands that could be interfering with diabetes management.