"I felt like I had a scarlet letter": Recurring experiences of structural stigma surrounding opioid tapers among patients with chronic, non-cancer pain.

Benintendi A, Kosakowski S, Lagisetty P, Larochelle M, Bohnert ASB, Bazzi AR. "I felt like I had a scarlet letter": Recurring experiences of structural stigma surrounding opioid tapers among patients with chronic, non-cancer pain. Drug and Alcohol Dependence. 2021 May 1; 222:108664.

Related HSR&D Project(s)

• CDA 09-204 – Prescription Opiates in Overdoses Among VHA Patients

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Abstract:

BACKGROUND: Efforts to address opioid-involved overdose fatalities have led to widespread implementation of various initiatives to taper (i.e., reduce or discontinue) opioid prescriptions despite a limited understanding of patients'' experience. METHODS: From 2019-2020, we recruited patients with chronic, non-cancer pain who had undergone a reduction in opioid daily dosage of = 50 % in the past two years at Boston Medical Center or Michigan Medicine. Participants completed semi-structured interviews exploring health history, opioid use, and taper experiences. Inductive analysis, guided by theoretical conceptualizations of structural stigma, identified emergent themes. RESULTS: Among 41 participants, three elements of structural stigma were identified across participants'' lives. First, participants identified themselves as overlooked subjects of the U.S. opioid crisis, who experienced overprescribing, subsequent stigmatization and surveillance of opioid use (e.g., toxicology screening, "pill counts"), and various tapering initiatives. Second, during the course of pain treatment, participants felt stigmatized and invalidated by cultural norms linking chronic pain to stereotypes of acting disingenuously (e.g., "drug-seeking"). Finally, during and after tapers, institutional policies and programs further increased participants'' feelings of marginalization, producing multiple unintended consequences, including reduced access to medical care and feeling "orphaned by the system." CONCLUSIONS: Opioid tapers may exacerbate the social production and burden of stigma among patients with chronic pain, especially when processes are perceived to invalidate pain, endorse stereotypes, and label previously effective, acceptable treatment as inappropriate. Findings highlight how various tapering initiatives reinforce the devalued status of people living with chronic pain while also reducing patients'' wellbeing and confidence in medical systems.