“我感觉自己像被打上了红字”：慢性非癌痛患者在接受阿片类药物递减治疗时反复经历结构性耻辱。
"I felt like I had a scarlet letter": Recurring experiences of structural stigma surrounding opioid tapers among patients with chronic, non-cancer pain.
机构信息
Clinical Addiction Research and Evaluation Unit, Section of General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, Boston, MA, 02118, USA.
Michigan Medicine, Department of Internal Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA; VA Center for Clinical Management Research, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.
出版信息
Drug Alcohol Depend. 2021 May 1;222:108664. doi: 10.1016/j.drugalcdep.2021.108664. Epub 2021 Mar 18.
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.
背景
为了解决阿片类药物过量致死问题，人们采取了各种措施来逐渐减少（即减少或停止）阿片类药物的处方，尽管对患者的体验了解有限。
方法
在 2019 年至 2020 年间，我们招募了在波士顿医疗中心或密歇根医学中心的过去两年中经历过阿片类药物日剂量减少≥50%的慢性非癌性疼痛患者。参与者完成了半结构化访谈，探讨了健康史、阿片类药物使用和减少剂量的经历。基于结构污名的理论概念化的归纳分析确定了新出现的主题。
结果
在 41 名参与者中，在参与者的生活中发现了三个结构性污名的要素。首先，参与者认为自己是美国阿片类药物危机中被忽视的对象，经历了过度处方、随后对阿片类药物使用的污名化和监测（例如毒理学筛查、“药丸计数”）以及各种减少剂量的举措。其次，在疼痛治疗过程中，参与者感到受到文化规范的污名化，这些规范将慢性疼痛与不诚实行为的刻板印象联系起来（例如，“寻求药物”）。最后，在减少剂量期间和之后，机构政策和计划进一步增加了参与者的边缘化感，产生了多种意想不到的后果，包括减少获得医疗护理的机会和感到“被系统抛弃”。
结论
阿片类药物减少剂量可能会加剧慢性疼痛患者的社会产生和污名负担，尤其是当这些过程被认为否定了疼痛、认可刻板印象并将以前有效和可接受的治疗贴上不适当的标签时。研究结果强调了各种减少剂量的举措如何强化了患有慢性疼痛的人的贬值地位，同时也降低了患者对医疗系统的幸福感和信心。
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