Stigma and bias in pain care are real, and even inadvertently, clinicians can contribute to that stigma through language, documentation and treatment approaches.
“Pain is always a personal experience and can change, and a person’s report of an experience as pain should be respected,” said Tanya Uritsky, PharmD, the opioid stewardship coordinator at Penn Medicine, in Philadelphia, during a session at the ASHP Midyear 2024 Clinical Meeting & Exhibition, in New Orleans.
Dr. Uritsky and Jessica Geiger, PharmD, MS, BCPS, CPE, the facility pain management, opioid stewardship and PDMP coordinator at the VA Illiana Health System, which has several locations throughout Illinois, discussed best practices in pain care. They focused on how clinicians can overcome internal biases and minimize stigma through connection, positive language, and a holistic approach to both chronic pain management in the outpatient setting and acute pain care for inpatients.
The medical literature identifies several types of stigma, said Dr. Geiger, including structural and internalized stigma. “Factors that can contribute to stigma in pain conditions include absence of clear medical advice, the invisibility of pain symptoms, subjectivity of pain assessment, deviation from expected norms in medical and social settings, opioid use and other forms of substance use, and difficulty understanding the mind–body connection,” she said.
Pain is one of several stigmatized conditions, which also include obesity, mental illness and substance use disorders. People with any of these conditions can be perceived as being “at fault,” Dr. Geiger said. “It seems as if they have control over it, and they really don’t. When you have a condition like chronic pain, most of the time it controls you.”
After an extended period in which they may be told that the pain is not real and are blamed and dismissed for their condition, people with chronic pain can internalize that stigma, feeling a loss of control, confidence and self-worth, blaming themselves for not getting better, and believing their value as a person is somehow less, Dr. Geiger said.
Clinicians should avoid any labels that turn people into “things,” she said. “Language is very important. If we want to protect something, we call it a flower. If we want to kill it, we call it a weed.”
In medical terms, saying a person has a substance use disorder or a chronic pain condition suggests that the person has a problem that can be addressed. “If, on the other hand, you call someone a drug abuser or a drug seeker, it assumes that the person is the problem,” she said. “Flipping the script can help [sidebar]. Are we conflating the patient with their diagnosis? Are we making it worse than it really is and then contributing to their potential anxiety or depression?”
Data Show That With Pain, Words Count
A 2022 study examining stigmatizing language in the medical record underscores the power of language when managing pain patients (JAMA Network Open 2021;4[7]:e2117052).
Using natural language processing to analyze 48,651 admission notes written by 1,932 clinicians at a large, urban academic medical center, the investigators found that 2.5% of notes contained stigmatizing language, including 6.9% for patients with diabetes, 3.4% for patients with substance use disorders and 0.7% for patients with chronic pain.
“Some of the negative themes they found included questioning patient credibility, expressing disapproval of patient reasoning or self-care, stereotyping by race or social class, portraying the patient as difficult, and emphasizing physician authority over the patient,” said Jessica Geiger, PharmD, MS, BCPS, CPE, the facility pain management, opioid stewardship and PDMP coordinator at the VA Illiana Health System, in Illinois. “But positive themes were also identified, such as compliments, approval, self-disclosure of positive feelings about patients, minimizing blame, personalization and noting patient authority for their decisions. That’s encouraging.”
Impact on Treatment Decisions
The use of stigmatizing language can affect not only how a patient feels about the care they receive, but actual treatment decisions, Dr. Geiger added. In a randomized vignette study of two chart notes employing stigmatizing versus neutral language to describe the same hypothetical patient with sickle cell disease, exposure to the stigmatizing language note was associated with more negative attitudes toward the patient (P<0.001) and less aggressive management of the patient’s pain (P=0.003) (J Gen Intern Med 2018;33[5]:685-691). (For more tips on managing sickle cell disease, see sidebar below.)
Positive language can also be very powerful, Dr. Geiger noted. “How many of you have had someone come in and say, ‘My scans show wear and tear’ or ‘My joints are breaking down’? Those are often things they might have heard from someone else interpreting an x-ray or an MRI,” she said. “You can redirect those thoughts.”
For example, when a patient says, “My scans show wear and tear,” you can say, “The body continuously wears and repairs throughout life. Just like wrinkles on the skin, joints also show wear over time.”
Dr. Geiger often sees this dynamic play out with veterans whose families say they are taking too many medications. “I use that as an opportunity to go through their medication list with them and say, ‘We’re doing these things to manage your different disease states. And if there are [interventions] you feel aren’t working from a pain perspective, we can talk about that. But there is a purpose in all of this, and research strongly suggests that pain is best managed in an integrated, collaborative way.” She added that it’s always important to mention nonpharmacologic options during those discussions.
Drug-Seeking or a Sickle Cell Crisis? Bias May Affect the Answer
In the second episode of the new medical drama series “The Pitt,” set in the emergency department (ED) of a fictional Pittsburgh trauma hospital, a Black woman is admitted screaming in pain, and both paramedics and a young medical student display implicit bias and stigma by making the assumption that she is seeking opioids for reasons other than pain.
One of the ED physicians, however, recognizes that the patient is having an exacerbation of sickle cell disease (SCD), sometimes referred to as sickle cell crisis. She explains to the student, “Blood cells get caught and plug up your capillaries and deprive all your cells of oxygen. It’s been described as an electrical stabbing pain that feels like it’s breaking your bones and flushing glass through your body.”
As the script accurately notes, patients with SCD are frequently accused of opioid misuse in the healthcare system, which leads to insufficient analgesia (J Gen Intern Med 2023;38[14]:3247-3251).
“I care for many patients with sickle cell disease who have had their pain dismissed,” said Jessica Geiger, PharmD, MS, BCPS, CPE, the facility pain management, opioid stewardship and PDMP coordinator at the VA Illiana Health System, in Illinois. “Patients do present with very mixed pain syndromes, with a lot of possible etiologies for their pain. Unfortunately, we end up giving a lot of opioids, which do not target the inflammation, the organ damage or the vascular dysfunction. They’re kind of a [bandage], but they’re the best thing we’ve got.”
The American College of Emergency Physicians’ recommendations for managing sickle cell exacerbations in the emergent setting include:
- Treating pain within 30 minutes of triage/60 minutes of registration.
- Using intermittent opioids.
- Reassessing/redosing every 15 to 30 minutes until adequate pain control is achieved.
- Admitting patient if pain is uncontrolled at six to eight hours.
- Using patient-controlled analgesia (PCA) to prevent lapse in dosing.
- Using around-the-clock nonsteroidal anti-inflammatory drugs if not contraindicated.
“No matter what modality you choose, the important thing is to remember how long these drugs last,” Dr. Geiger said. “If the only thing you are giving someone is an IV opioid bolus every four hours, you are leaving them with an hour or two without any real analgesia on board because the duration of that bolus is two hours. Oral opioids last longer, so if we can use oral as a backbone and use IV as breakthrough, that’s a far better therapeutic approach.”
Patient-controlled analgesia is standard of care for patients with SCD, Dr. Geiger added. “If you manage acute pain exacerbations using PCA for someone with cancer pain, why would you not do that for someone else experiencing an acute pain exacerbation?”
A 2021 study of patients in sickle cell crisis found that those who received PCA had a 1.2-day decrease in hospital length of stay (LOS) compared with those who did not (HCA Healthc J Med 2021;2[4]:303-309). A study in children found that early PCA was associated with a median LOS reduction of 3.4 days, and was also associated with a reduced time to adequate analgesia (–41.0 hours) in a subset of patients for whom those data were available (J Pediatr Pharmacol Ther 2021;26[6]:615-623).
“People may say, ‘Well, if you’re using PCA, you’re using more opioids,’” Dr. Geiger said. “I am not actually concerned about that in these cases because it is a very short-lived, acute situation. If you get better pain control under those circumstances, I’m happy with that.”
Turning to the basic science behind pain, Dr. Geiger stressed that pain is more than nociception—that is, the way the nervous system processes noxious stimuli such as tissue injury. Pain also is the subjective experience one feels as a result of the activation of nociception pain pathways, Dr. Geiger explained. “We have to be open to the person’s description of the pain they are experiencing and believe them,” she said. “I’m not saying to believe blindly, but pain is a very personal experience that can change over time, and we need to go in with an open mind.”
A final, important consideration is the shift away from numerical pain scales to functional measures, Dr. Geiger noted. “Instead of trying to achieve an improvement in a pain score, which may or may not change, we can highlight what patients are able to do now that they were previously unable to do. ‘When I first saw you, you weren’t able to do X, Y or Z. But now today, you walked in with a cane instead of in a wheelchair.’ If they are doing things they weren’t able to do before, that’s huge.”
The sources reported no relevant financial disclosures.
This article is from the April 2025 print issue.