Opioid analgesics, stigma, shame and identity

Richard J. Cooper

Introduction

Opioid analgesics represent a well-recognised class of medicines that have gained increasing notoriety through concerns about their addiction potential (Vowles et al., 2015) increasing prescribing trends (OECD, 2019), and related harms (British Medical Association, 2017) particularly associated with their long-term use such as for chronic pain. The ubiquity of prescribed opioids is reflected in a recent analysis which found that around one in eight adults in England had been prescribed an opioid at least once annually (Marsden et al., 2019). This has been viewed as a significant public health concern and termed an ‘opioid epidemic’ with a significant risk of harm and mortality. In terms of scale, in the United States during 2017 there were estimated to be around 17,000 deaths related to prescription opioids (Centres for Disease Control and Prevention, 2017), and in the United Kingdom in 2019, there were over 9,000 hospital admissions linked to non-heroin opioids such as codeine and morphine (NHS Digital, 2019). As well as concerns about deaths and overdose, other clinical manifestations arise in relation to loss of therapeutic effect and tolerance over time, hyperalgesia and addiction itself (Deyo et al., 2015). Between 2005 and 2017 in England, there was a 91% increase in presentations of individuals to formal drug and alcohol treatment services where an opioid analgesic only was involved (Public Health England, 2018)

In this chapter, my aim is to move beyond these dominant clinical and public health foci on harm and mortality, to explore the significant psychosocial problems related to the consumption of prescription and over-the-counter (OTC) opioid analgesic medicines. 1 argue that affected individuals might experience significant stigma and shame through problematic use of opioid medicines themselves. In addition, such medicine use impinges on important aspects of identity, and challenges notions of coping and the management of often chronic conditions. As Eaves notes:

Consumption of goods, including medications, is a visual and tangible means of communicating social values, performing notions of self and establishing social relationship... Pharmaceutical consumption is part of constructing individual and social identity.

(Eaves, 2015, p. 147)

Issues of stigma, shame and identity have been represented in the literature relating to conditions like chronic pain and associated illness narratives (Asbring &. Narvanen, 2002; Denny, 2017; Frank, 2013; Newton et al., 2013; Werner & Malterud, 2003); however, my aim in this chapter is to show that despite the importance of such studies, they have neglected the additional impact of the consumption of opioid analgesics and its effect on stigma, shame and identity.

Patients and medicines

Much has been written about patients and insights into their illnesses and associated narratives and biographies as part of the ‘narrative turn’ in recent decades (Polkinghorne, 1988); while the sociological literature in particular has offered important and influential framing of patients and illness in terms of identity, shame and stigma among others, there is a relative lack of corresponding constructs in the more specific area of patients’ consumption of medicines. This was recognised more than two decades ago by Vuckovic &. Nichter (1997) who recognised the dearth of research and literature that went beyond traditional compliance debates and failed to capture important issues such as ‘self-identity’. In an authoritative review of previous research on how individuals use (and more specifically) resist medicines, Pound et al. (2005) suggested that patients were often cautious in the use of medicines, and adopted either active or passive strategies and at times sophisticated lay testing strategies to evaluate medicines. The authors identified key concerns also around identity and stigma and in particular anxieties around dependence and addiction. Of particular note, however, was that this occurred not just for medicines with recognised addiction or tolerance properties - such as opioids - but with other therapeutic groups such as antihypertensives and proton pump inhibitor medicines also. Of note, however, was that identity issues were often not specifically related to addiction fears and arose more in terms of non-acceptance of a medical condition, or associated stigma, that is, preventative asthma medicines were not taken to support patients’ denial that they had a significant and chronic illness (Adams et al., 1997) or antiretroviral medicines were not taken regularly as they highlighted a stigmatised condition (Pound et al., 2005).