Background & Aims
Chronic low back pain (CLBP) is highly prevalent and is often comorbid with negative affective disorders including depression and anxiety. This subpopulation of people with CLBP and negative affect (NA) experience worse pain, function, and treatment outcomes. CLBP (and associated opioid medication use) and NA are also associated with stigma, a devaluation of identity within a particular social context. Intersectional health-related stigma (IHRS), occurring when multiple stigmatized health conditions converge, is associated with depression, lack of engagement in health behaviors, and poor treatment adherence and outcomes. However, IHRS has not been examined at the intersection of CLBP and NA, especially among those using opioid pain medications. The aim of this study was to examine IHRS among patients with CLBP and NA to better understand the experience of IHRS and inform the development of interventions for reducing the impact of IHRS on pain and related outcomes.
Methods
We capitalized on a pragmatic trial in which 215 people (63% female, 90% non-Hispanic, 77% White) with CLBP and NA were randomized to receive antidepressant treatment (AD), enhanced fear-avoidance physical therapy (EFAR), or the combination of the two (AD + EFAR). For the current study, participants completed measures of pain (Pain, Enjoyment of Life and General Activity; PEG [1]), depression (Patient Health Questionnaire-4; PHQ-4 [2]), chronic pain stigma (Internalized Stigma of Chronic Pain; ISCP [3]), mental health stigma (Self-Stigma and Perceived Public Stigma Measures; SSPPS [4]), and opioid medication stigma (Brief Opioid Stigma Scale; BOSS [5]). A subset of participants (N=55) completed a semi-structured qualitative interview about their experiences with public stigma, their own stigmatic beliefs, causes and sources of stigma, and how stigma can be addressed. We used descriptive statistics to analyze quantitative data and thematic analysis to analyze qualitative data.
Results
Descriptive analyses indicated participants endorsed moderate levels of chronic pain stigma especially alienation, and social withdrawal. Regarding mental health-related stigma, they experienced moderate levels of both perceived public stigma from those around them as well as self-stigma. Participants were very aware of stigma related to opioid medication use though they were less likely to endorse agreeing with these stigmatizing beliefs. During qualitative interviews, several themes were identified including: (1) public pain-related stigma occurs because others do not understand or believe that the pain is exaggerated or is not real; (2) providers exacerbate effects of stigma because they do not listen and do not understand chronic pain; (3) stigma results in worsen negative affect including depression, anxiety, and frustration; and (4) stigma can best be addressed through advocacy, education, perspective taking, and sharing one’s own experience.
Conclusions
Patients with CLBP and NA experience moderate levels of IHRS including stigma related to their chronic pain, mental health, and opioid medication use. This stigma comes from the general public, friends and family, healthcare providers, and is internalized. The results of IHRS include worsened negative affect and isolation. However, patients believe there are important ways to help reduce IHRS for people with CLBP and NA including providing education as well as perspective-taking interventions which have also been shown to help improve implicit bias and discrimination.
References
1. Krebs, E.E., et al., Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. Journal of general internal medicine, 2009.
2.Kroenke, K., et al., An ultra-brief screening scale for anxiety and depression: the PHQ–4. Psychosomatics, 2009.
3.Waugh, O.C., D.G. Byrne, and M.K. Nicholas, Internalized stigma in people living with chronic pain. The journal of pain, 2014.
4.Kendra, M.S., J.J. Mohr, and J.W. Pollard, The stigma of having psychological problems: Relations with engagement, working alliance, and depression in psychotherapy. Psychotherapy, 2014.
5.Yang, L.H., et al., A new brief opioid stigma scale to assess perceived public attitudes and internalized stigma: Evidence for construct validity. Journal of substance abuse treatment, 2019.
Presenting Author
Samantha Meints
Poster Authors
Topics
- Mechanisms: Psychosocial and Biopsychosocial