Applying sociological stigma theories to re-interpret studies of opioid deprescribing in primary care

Context: Recent guidelines and policy changes emphasize deprescribing opioids for people with chronic, non-cancer pain in primary care. Tapering opioids is challenging. Stigmatization of opioid use has intensified.

Objective: To re-interpret existing research exploring the perspectives, concerns, and experiences of opioid tapering of people prescribed opioids for non-cancer chronic pain, or clinicians in primary care or related settings, by applying sociological theories of stigma.

Study Design and Analysis: Narrative review, involving a systematic search of three databases and a team approach to screening for inclusion. Our analysis was iterative, including coding of articles into broad topics, analytic memoing, and team discussions to map the literature to multiple sociological stigma theories.

Dataset: 39 articles met inclusion criteria.

Population: primary care practitioners and clinicians working in similar settings and/or people taking prescribed opioids for chronic, non-cancer pain.

Intervention/Instrument: n/a.

Outcome Measures: n/a.

Results: Only two studies explicitly integrate stigma theories into their analyses, though more use the phrase. In multiple studies, people prescribed opioids are aware that they risk being treated ‘as an addict’ in health care – a member of a stigmatized group, stereotyped as dishonest and undeserving. This risk is heightened in this time of surveillance requiring strict adherence. They recognize that to be labeled ‘drug-seeking’ could result in lost access to the medication, and all that follows. To manage, many distanced themselves from the stereotyped group through tactics like cautious communication with health care professionals. Thus, tapering conversations can be understood as a situation of ‘stereotype threat’ for patients. Clinicians recognize opioid tapering conversations as loaded. They describe the misalignment of structural de-prescribing pressures (e.g. state policies and guidelines) with the realities of patients’ lives and clinical care. Intersecting forms of stigma were occasionally implied but not developed.

Conclusions: Opioid tapering challenges patient-centered and relationship-oriented primary care. Stigma and coercive structural pressures complicate this work. Stigma and related discrimination theories have relevance but are underutilized.