Breaking barriers: addressing opioid stigma in chronic pain and opioid use disorder

1. Introduction Opioid stigma is an overlooked barrier to public health efforts targeting the opioid overdose epidemic.15,70 Opioid stigma is stigma because of the use of opioids and can occur regardless of opioid type (pharmaceutical or illicit), reason for use (medical or nonmedical),65 and presence of substance use disorders (SUDs).6 Stigma is a social process that entails stereotyping, judgment, status loss, and discrimination and is a fundamental cause of health inequities.40,59 While there is extensive literature describing stigma related to HIV, mental illness, and SUDs,24,79 literature on opioid stigma is just beginning to emerge. Opioid stigma is particularly salient among people with chronic pain and opioid use disorder (OUD). Despite limited evidence of benefit,18,49 guidelines acknowledge opioids may be beneficial in select chronic pain cases.30 Chronic pain and OUD also have a reciprocal relationship,28 made more complex by opioid stigma. This perspective paper describes opioid stigma relating to OUD and medications for OUD (MOUD) among patients with comorbid chronic pain. Using the Health Stigma and Discrimination Framework (HSDF),90 we outline key drivers, facilitators, experiences, and outcomes of opioid stigma and highlight strategies to reduce harms including overdose deaths. 1.1. Health stigma and discrimination framework The HSDF is a cross-cutting framework that describes how stigma unfolds from a socioecological perspective.90 The framework consists of 4 broad domains: (1) drivers and facilitators (factors that directly impact whether a person experiences health-related stigma); (2) intersecting stigmas (stigmatized personal characteristics, eg, race); (3) stigma experiences (eg, discrimination) and practices (eg, negative beliefs, attitudes, or actions); and (4) outcomes at the federal, clinic, clinician, and patient level. Here, we apply the HSDF domains to people with OUD and chronic pain to inform intervention efforts (Fig. 1).Figure 1.: Opioid stigma in opioid use disorder (adapted from the Health Stigma and Discrimination Framework; Stangl et al., 2019). Above are examples and are not meant to be comprehensive. OUD, opioid use disorder; MOUD, medications for opioid use disorder.1.2. Drivers and facilitators Policy restricting access to evidenced-based OUD treatment has fueled widespread opioid stigma,21 which significantly impacts those with OUD and chronic pain. Medications for OUD (MOUD; eg, methadone, buprenorphine) improve opioid craving and overdose7,101 and can also have small analgesic effects for some patients making it a useful tool for OUD and pain management.38,58 However, only 25% of patients with OUD ever receive MOUD.29 Federal policy requires methadone dispensing within opioid treatment programs, yet in 2019, 78% of US counties did not have a program leaving most patients without available treatment options.25 Opioid treatment programs are also often separated from medical facilities and use a highly regulated approach derived from carceral settings,71 which increases treatment burden and worsens outcomes. For example, when daily dosing regulations were relaxed across 8 programs during the COVID-19 emergency, treatment retention and opioid use improved without an increase in methadone overdoses.13,43 Current research50 and policy efforts87 are underway to improve methadone access by increasing availability in other outpatient settings and pharmacies. These strategies are used in other countries experiencing high rates of overdose (eg, Canada, Australia, United Kingdom20) and can reduce stigma by improving treatment access, burden, and privacy. Buprenorphine, on the other hand, is available across a range of settings, including primary care and community clinics. However, despite increased availability, access and utilization varies widely between states and urban and rural settings,23,45 driven in part by limiting state policies3 and insurance payment barriers (eg, patient cost, provider reimbursement).11 Restrictive policies and carceral practices also promote negative attitudes towards OUD and MOUD, which exist among patients,65 clinicians,60 and the public.99 A national survey of US adults (N = 947) showed that having negative attitudes toward people with OUD was associated with endorsing punitive policies towards OUD services.99 Another national survey of 361 clinicians found that a majority held stigmatizing views towards people with OUD, which was associated with stigma practices, including lower willingness to prescribe MOUD.91 Clinicians holding stigmatizing views towards MOUD (eg, “switching one opioid for the other”)1,27,36 are more likely to prematurely discontinue MOUD, increasing overdose and mortality risk.14,17,89,103 Myths are also shared within mutual support groups, which hinders recovery63 and worsens shame, depression, and isolation.27,65 Restrictive policies and opioid stigma have contributed to widespread OUD treatment inequities among women, people from racialized and rural backgrounds, and those who use intravenous methods.27,37,64,76,82 1.3. Chronic pain: an intersecting stigma Over half of people with an OUD have comorbid chronic pain,44 which can precede or follow an OUD diagnosis.47,106 Chronic pain worsens opioid withdrawal105 and increases risk for overdose,39 yet most opioid treatment programs do not offer evidenced-based pain care.34 Having an OUD diagnosis can also make it harder to access quality care in other settings,41,89 limiting pain treatment options. Fear of uncontrolled pain is also cited as a barrier to entering addiction treatment,94 highlighting the intersectional nature of pain and OUD and the need to treat both conditions. Patients report being perceived as difficult, lazy, or drug-seeking,65 especially when there is no clear medical explanation for their pain.74 Intergroup stigma is also present among people with chronic pain and OUD. Some patients who cite pain as their primary reason for developing OUD distance themselves from people who report developing OUD for other reasons (eg, seeking euphoria, relieve emotional distress), who are seen to have greater responsibility for their OUD.33,77,94 1.4. Patient experiences and outcomes A systematic review of 49 qualitative studies showed patients with comorbid OUD and chronic pain describe experiencing unfair treatment, such as having to comply with burdensome demands (eg, drug screens, pill counts, daily dosing) that reduce autonomy, self-efficacy, and sense of control, which are important predictors of health outcomes.20,65 Several qualitative studies also showed patients with comorbid chronic pain and OUD describe being perceived as morally weak, untrustworthy, drug-seeking, and orphaned by the medical system.6,9,65 As a result, pain concerns are often dismissed and undertreated.8 People from racialized backgrounds also experience harmful myths about pain (eg, higher pain tolerance) and receive inadequate pain care.98 These experiences promote mistrust and avoidance of medical treatment.8,9 Outcomes of these stigma experiences include poor physical and mental health, social support, treatment engagement, retention, and greater pain severity.4,8,9,32,57 Internalized stigma, or negative beliefs about oneself, is also associated with worse pain coping and recurrent OUD symptoms.31,86 1.5. A call to action A multilevel, health equity–orientated approach is needed to reduce opioid stigma (Table 1). The Stanford-Lancet Commission proposed an evidenced-based national policy agenda to reduce overdose deaths,46 including strategies to destigmatize opioid use and improve systems of care for people with pain and OUD. Table 1 - Multilevel recommendations to destigmatize opioid use in people with opioid use disorder and chronic pain. Topic area Recommendation Strategies Policy Improve treatment access • Reduce MOUD daily dosing requirements15,54 • Expand MOUD dispensing into pharmacies15 • Insurance reform to cover addiction and pain management services53,54 Education Increase addiction and pain workforce • Require addiction and pain management training in medical school55 • Clinician training in MOUD prescribing55–57,60 • Clinician training in stigma reduction56–58,68,69 Improve public understanding of chronic pain and addiction • National education campaign focused on pain and nonopioid treatments70 • Increase knowledge of SUD as a treatable medical condition58 • Increase awareness of SUD and pain stigma58,70 Care delivery Effectively engage patients in treatment • Shared decision making61,63 • Patient centered communication62 • Telehealth services and digital interventions59,60,81 • Integrated care models59 • Nonabstinent treatment models74 Patient coping Develop and implement effective behavioral interventions to improve coping • Motivational interviewing75,78 • Mindfulness-based relapse prevention76,77 • Peer support services86,87 • Development and tailoring of interventions to target internalized stigma66,79,80 • Develop integrated interventions target pain, SUD, and common comorbid mental health conditions MOUD, medications for opioid use disorder; SUD, substance use disorder. 1.5.1. Treatment access Increasing treatment access and provider education are crucial steps towards reducing stigma towards all forms of substance use treatment. Insurance reform and reducing MOUD regulations (eg, daily dosing)46,66,71 are necessary steps towards achieving health equity. Brief training sessions with medical residents can increase confidence, evidenced-based prescribing practices, and treatment referrals.84 Support tools, educational programming, visual campaigns, and short vignettes have also reduced clinician opioid stigma and improved access to SUD treatment.10,53 Integrated care models, telehealth services, and digital interventions can increase access and quality of medical care.46,56,68 Providers Clinical Support System offers trainings on MOUD prescribing and evidenced-based SUD and chronic pain treatment.78 Use of engagement strategies, such as patient-centered communication and empowering patient autonomy, can increase patients' understanding and confidence in their treatment plan and reduce stigma.48,92 Bringing Recovery Supports to Scale offers shared decision-making tools to help providers engage in patient-centered discussions about MOUD.95 1.5.2. Dispelling myths Stigma and shame-based messages are commonly used to raise awareness about opioid harms. However, shame-based messaging reinforces false messages of individual responsibility, contributes to overly punitive treatment policies, and causes treatment options to be inconsistently applied14 exacerbating health inequities.12 Public education designed to eliminate stigmatizing language (eg, “abuser,” “addict,” “drug-seeker”) and shame-based messaging can improve understanding of OUD as a treatable medical condition, which is crucial for reducing negative stereotypes and blame.52,60 The Opioid Response Network offers clinician resources on reducing stigma in OUD care.97 A national pain education campaign could improve understanding of pain as a biopsychosocial (as opposed to purely biomedical) phenomenon and increase use of nonopioid treatments.16 1.5.3. Supporting multiple pathways towards recovery Most opioid treatment programs use abstinence-based programming, which defines treatment success as achieving and sustaining abstinence from all substances.55 Yet, a highly cited barrier to entering SUD treatment is that patients are not ready to stop their substance use contributing to stigma and shame.96 Those who do engage in SUD treatment need 3 to 4 treatment episodes, on average, to sustain recovery.26 Given this, prior work has called for widespread integration of harm reduction models to improve stigma and treatment engagement and retention.75 These approaches conceptualize SUD treatment and recovery using a whole-person approach with goals focusing on any health behavior change. Evidence-based behavioral treatments that align with abstinent and nonabstinent goals, and are effective among pain populations, include motivational interviewing and mindfulness-based relapse prevention.2,83,85,102 1.5.4. Improve coping Behavioral interventions can improve internalized stigma and shame.62,88 Effective digital interventions for SUD and comorbid pain or mental health conditions exist.54,61,67,80,81 Peer support services can reduce distress and increase self-efficacy and social support.5,35 Development and tailoring of stigma interventions are vital to improving treatment engagement, retention, and outcomes. International100 and federal22,42,69,72,73,93 initiatives have prioritized stigma research to improve treatment access and outcomes. To create an effective multilevel approach, we must mobilize key collaborators from diverse disciplines. Most importantly, including diverse patients with lived experience is vital to ensuring efforts are patient-centered and stigma-free.51,104 Engaging experts in stigma, pain, SUD, implementation science, social science, policy, and healthcare delivery will ensure that strategies are responsive to varied clinical needs. By adopting these multilevel, patient-centered strategies, we can reduce opioid stigma and save countless lives impacted by the overdose crisis. The time to act is now; the lives of those suffering depend on our collective commitment to change. Conflict of interest statement B. D. Darnall is Chief Science Advisor at AppliedVR and she receives consulting fees for this role. B. D. Darnall receives royalties for four pain treatment books she has authored or coauthored. She is the principal investigator for two pain research awards from the Patient-Centered Outcomes Research Institute. B. D. Darnall is principal investigator for two NIH grants. B. D. Darnall serves on the Board of Directors for the American Academy of Pain Medicine, is on the Board of Directors for the Institute for Brain Potential, and is on the Medical Advisory Board for the Facial Pain Association. B. D. Darnall is a scientific member of the NIH Interagency Pain Research Coordinating Committee, a former member of the Centers for Disease Control and Prevention Opioid Workgroup (2020-2021), and a current member of the Pain Advisory Group of the American Psychological Association. The remaining authors have no conflict of interest to declare.

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