‘Stigma’ surrounding opioids, pain management harms patients, feeds biases
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SAN DIEGO — The stigma surrounding opioid use and pain management continues to significantly impact patient care in rheumatology today, according to a presentation at the Congress of Clinical Rheumatology West.
“One of the important points about this particular talk is that it is important for you to see what we are teaching our future clinicians in medical school right now,” Kevin Zacharoff, MD, clinical professor of preventative medicine at the Renaissance School of Medicine at Stony Brook University, in New York, told attendees.
Zacharoff suggested that considerable stigma has been placed around opioid use in any capacity, even if the patient is experiencing chronic pain and genuinely needs medication to manage it.
“There are people training young physicians to think ‘red flag,’” he said. “They are being taught to just assume the patient is drug seeking right off the bat.”
In addition, medical schools do not teach students about pain, and pain management, thoroughly enough, according to Zacharoff.
“The majority of medical schools still do not have more than an elective in pain management,” he said.
Of further concern is the issue of bias, and how patients who fall into some demographic groups are assumed to be engaging in drug-seeking behavior, whereas other patients are not, Zacharoff said.
“We play the blame game,” he said. “It is possible that we stigmatize, that we profile people.”
According to Zacharoff, the fear of addictive behaviors has impacted the ability of physicians to empathize with patients. This, in turn, disrupts the trust that should be present in the doctor-patient relationship.
“We are worried about what they are going to do, and they are worried about what we are going to say,” Zacharoff said.
Regulatory issues surrounding opioid prescribing have complicated daily practice for many clinicians, he added. Meanwhile, many pain assessment scales — such as rating it from 0 to 10 — are “completely worthless” due to the personal nature of pain for each patient, he said.
As regulators and researchers work out these issues, Zacharoff suggested that individual clinicians can improve their ability to manage pain simply by examining the biases they may be bringing to the clinic each day.
“We are all stocked with biases,” he said, noting that patients are often prejudged based on race, gender, age, socioeconomic status, educational level, substance use history or diagnosis.
“What can we do about it? We need to just be aware of it,” Zacharoff said.
He then detailed several types of biases for rheumatologists to consider.
For example, “anchoring” is to identify one piece of information about a patient and “hang everything on it,” he said.
“You focus on their one single complaint and it creates tunnel vision,” Zacharoff said.
The solution to this bias is to think more broadly and reconsider the diagnosis as new information comes in at each visit.
“Have an open mind that there might be more that is going on that meets the eye,” Zacharoff said.
Another type of bias is “premature closure,” where a clinician will accept the first diagnosis and look no further.
“Always have a differential, look for red flags and follow up on them,” Zacharoff said.
This bias is particularly important in rheumatology, where many patients experience several misdiagnoses before they are appropriately diagnosed, he added.
A “zebra retreat” bias, meanwhile, pertains to rare conditions or uncommon diagnoses.
“We tend to think that if the condition is not common, it can’t be the diagnosis,” Zacharoff said. “Sometimes it may make sense to rule out the zebra, but other times that rare diagnosis is the actual answer.”
Lastly, “blindspotting” is when a clinician fails to see their own biases.
“What to do?” Look in the mirror,” Zacharoff said.
He urged rheumatologists to identify who or what makes them feel uncomfortable and figure out why. This may prevent incorrect assumptions about patients in particular demographic groups.
“We need to look at these biases and stigmas and face them head on,” Zacharoff said. “Stigma is alive and well in health care today. Stigma can be a barrier to treatment of painful conditions.”
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Zacharoff K. Management of chronic pain: Empathy is not equal to sympathy. Presented at: Congress of Clinical Rheumatology West; Oct. 20-23, 2022 (hybrid meeting).
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