The Marginalization of Chronic Pain Patients on Chronic Opioid Therapy

The realities of treating chronic pain do not reflect the attention that marginalization of patients taking opioids has received. Physicians continue the same prejudices and biases that were present decades ago. One theory proposed to explainthis poor treatment has been titled, the “barriers to pain management.” Thebarriers are not treated as moral issues, but rather as clinical aberrations and donot explain continued poor treatment. However, the barriers do not explain certain types of cases where there appears to be specific unfounded concerns related to a specific class of medications, e.g, opioids. Four cases are presented, fromthe authors experience, illustrating the marginalization of chronic pain patientson chronic opioid therapy admitted to a tertiary care hospital. These types ofcases have not been presented in the literature previously and illustrate the failure of the barriers to explain marginalization. In each of these cases mental status changes was the presenting problem. However, in each of these cases, thesechanges were not related to their opioids, but were explained by clear reasons,other than opioids. Regardless, in each case, the attending physician blamed theopioids, without further workup and stopped them reflexively. It is proposed thatthere may be more complex psychosocial issues involved in the marginalization ofchronic pain patients. This case series illustrates a ubiquitous problem demandingfurther examination and discussion. It is hoped that this case series will create interest in further research in this area.Key words: Chronic pain, opioids, marginalization, bias, barriers