When Topics are Off Limits to Talk About in Pain Management

The Institute for Chronic Pain (ICP) recently published a content piece on the roles that shame play in the experience of pain, particularly in persistent pain. It’s an under-reported topic in the field of pain management. In fact, we don’t tend to talk about it at all.

There are actually a number of topics that we don’t tend to talk about with each other — whether it’s between professionals in the healthcare community or between healthcare professionals and their patients. While no means a conclusive list, topics that remain off limits to talk about in pain management, and the subsequent alternative topics that we tend to talk about instead, are the following:

• The role that fear-avoidance plays in pain and disability from pain.

• It’s often easier with patients, for example, to talk as if objective findings, such as on MRI scans, are highly correlated with disability.

• The fact that stress, as well as anxiety, depression and trauma, can cause pain.

• It’s often easier, for example, to talk as if stress and mental health problems are solely the consequence of pain.

• The role that opioid dependency has in the long-term use of opioids, even in people who use opioids exactly as prescribed.

• It’s often easier, for example, to talk as if there is a distinct, categorical difference between opioid dependency and addiction, and not one phenomenon that occurs along a spectrum of severity.

• The role that coping has in determining whether someone uses opioids for the long-term management of pain or the role that coping has in whether one experiences pain as intolerable and therefore disabling or not.

• It’s often easier, for example, to talk as if the use of opioids or disability are the natural and inevitable consequence of severe pain for which it is impossible to engage in any other response.

• The fact that pain is not just physical, but rather is a subjective, biopsychosocial experience.

• It’s often easier, for example, to talk as if objective findings on exam, such as on MRI scans, are the sole reason for experiencing pain.

• How pain is not solely the result of things that happen to you through no fault of your own, but rather can also be the result of lifestyle and health behaviors. 

• It’s often easier to talk about how to surgically respond to objective findings, such as on MRI, than the obesity and sedentary lifestyle, for example, that can also contribute to low back or joint pain.

These topics are difficult to discuss. They often sound like blaming the patient for the pain that patients have or its problematic impact that pain has on their life. Topics related to the bi-directional relationship between pain, on the one hand, and stress, mental health, coping, lifestyle or health behaviors, on the other hand, all imply that patients have some, if only modest, degree of control. That is to say, if patients are not entirely powerless and helpless to affect their pain and overall well-being, then choices, health behavior, and lifestyle have a role in the onset and maintenance of pain, disability and the use of opioid medications. 

This conversation can be had in a productive and hopeful manner — for who doesn’t want to at least potentially, if not actually, have some control over one’s health, including pain, disability and use of opioids? Such control is, after all, a good thing, given the alternative of having no ability to affect one’s health and well-being. Nonetheless, these conversations are sensitive, and can come across as blaming. For after all, if we do in fact have some degree of control over our health and well-being, including pain, disability and use of opioids, then we must be responsible, at least in part, for our health and well-being. If we find ourselves in rough shape, then, are we not, at least in part, responsible for it? Might there not always be in the background an implied criticism of ‘why haven’t you already done something about it?’ If you haven’t, the implied criticism, lurking out there, is ‘maybe, you just want to be in pain [or on disability or on opioids].’ Thus, the acknowledgement that patients may have some degree of control over their health and well-being can take a turn of perspectives in the course of a healthcare visit and come to be seen as a blaming and stigmatizing.

Given the potential for these conversations to go poorly, it is often easier to just not have them and instead focus on those aspects of pain, such as objective findings on exam, that presumably patients have no control over. The focus of office visits thus becomes, not the sedentary lifestyle, or obesity, or ineffective coping responses, but rather the osteoarthritic changes in the joint. Thus, patients leave with only part of the story. The account of the pain, impairment or need for opioid medications as solely the inevitable consequence of a physical ailment is reassuring in its incompleteness. There’s no potential for blame because there’s no capacity for patients to feel, be or do otherwise.

Shame is the underlying factor in these topics that are off limits to talk about. It’s also the driving force in providers and patients finding something else to talk about instead. Shame is the most off limits topic of all the off limits topics. 

The Institute for Chronic Pain has a long history of discussing sensitive topics in as approachable ways as we can achieve. We do so with every effort to share and explain information in thoughtful and inclusive ways. We anticipate when topics can be taken in the wrong way and are careful to explain the non-judgmental perspective from which the reader might more accurately understand. We recognize the persistent role of stigma and write about it frequently, as we also write about ways to overcome stigma. 

We do so with the intent to educate the pain community — patients, family, and providers — on topics related to pain management and pain rehabilitation. We provide scientifically accurate health information that is approachable to all. Our hope is that the information shared on this site is approachable in two ways: one, that it translates scientifically complex material into information that is readily understandable by all; two, that the information is provided in a sensitive manner, which allows us to talk openly about topics that we need to discuss as a pain community, but that we do so without judgement, criticism or stigma.

We hope that the new content piece on Shame & Pain is helpful to you.

Date of Publication: January 30, 2022

Date of Last Modification: January 30, 2022

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.