The expectations we build: reframing chronic pain outcomes as a systems level public health issue.

Chronic pain is a public health issue that affects a substantial proportion of adults and limits life, work, and social participation. Although pain is understood as a multidimensional experience shaped by biological, psychological, social, and contextual factors, chronic pain care is often organized around the expectation that pain can be identified, treated, and resolved through targeted clinical intervention. This perspective argues that chronic pain outcomes are often misattributed to individual factors such as adherence, motivation, or resilience, when they may also reflect expectations generated by healthcare systems, health professions education, payment structures, and broader societal messaging. These systems can reinforce expectations of fixability, rapid resolution, and passive care, making it harder to support recovery, resilience, and sustained engagement. When those expectations are not met, individuals with chronic pain may be labeled as noncompliant, resistant, or insufficiently resilient, shifting attention away from the structures that shaped both the expectations and the outcomes. This mismatch is particularly consequential for underserved populations, who may experience higher pain burden, reduced access to comprehensive care, and greater structural barriers to sustained engagement. Reframing chronic pain as a systems level public health issue highlights the need to align clinical care, public education, professional training, and prevention oriented policies with the complex realities of chronic pain. Improving chronic pain outcomes requires systems that create realistic expectations, support resilience and recovery, and reduce the misattribution of system shaped outcomes to individual failure.