Research article: An ethnography of chronic pain management in primary care

Fiona Webster and her team recently published a study investigating physicians responses to the increasing rates of opioid addiction. The paper reports on the experiences of physicians providing treatment for patients with chronic pain, with an emphasis on treating chronic pain in patients who are simultaneously navigating issues such as trauma, poverty, addiction, and unstable housing — factors that can make treatment “challenging at best, and at worst frustrating and overwhelming.”

The frustrations of health care providers are complicated by concerns that they could lose their license for inappropriate opioid prescription, “thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse.” Further exasperating this situation is the fact that even though reducing opioid dosing has become a significant focus of health care provision, alternative approaches to alleviating pain — physiotherapy, massage, and even mental health care — are unfunded, and therefore not viable options for patients with chronic pain who are also struggling with poverty.

Interpreting the results, the study suggests that the effort healthcare professionals exert to respond to their patients’ social and economic situations, rather than their distinct medical needs, contributes to increased feelings of “depersonalization, loss of job satisfaction and emotional exhaustion” among providers. “Indeed, the pervasiveness of poverty among chronic pain patients means that care providers are being asked to mediate across class lines, to help people whose problems they have not been trained to solve. This shines light on how rising social inequities impact the care environment and the medicalization of poverty that often results.

Using a social determinants of health perspective, the authors ask some critical questions. For instance, what if we stop describing it as an opioid epidemic which locates the problem in a class of drugs rathan than in systemic issues? What if, instead, we described it as an epidemic of rising social inequities? Or an epidemic of chronic pain?

Fiona is continuing her investigation with a Canadian Institutes for Health Research (CHIR) Project Grant: Understanding the social determinants of health from the standpoint of patients: an institutional ethnography of mental health, addictions and poverty in the lives of people with chronic pain.

Read the full paper

Webster F, Rice K, Katz J, Bhattacharyya O, Dale C, Upshur R (2019) An ethnography of chronic pain management in primary care: The social organization of physicians’ work in the midst of the opioid crisis. PLoS ONE 14(5): e0215148.

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