I vividly recall the expression on Tim’s face during his initial visit to my exam room. Rather than relief, he exhibited suspicion. After enduring years of chronic pain, Tim had been referred to me, an interventional physiatrist, and had come to perceive a referral to “pain management” not as an opportunity for assistance, but as a judgment. He feared I would regard him not as a patient in need, but as a problem to be managed, or worse, as a potential drug seeker.
For trainees and clinicians meeting pain patients for the first time, it is important to recognize these fears and respond with empathy and nonjudgmental communication. Starting visits with open-ended questions such as “Can you tell me about your pain journey so far?” or “What are your main concerns today?” helps patients feel heard. Affirming the reality of their experience, by acknowledging the challenges of living with chronic pain and clarifying that your role is to support, not to judge, can begin to build the trust that is essential for effective care.
After more than thirty years in this specialty, I have found that fears like Tim’s are among the most common I encounter in practice. These fears are rarely irrational; rather, they are learned through experience.
Patients frequently arrive at my office believing their referring physician has quietly abandoned them. Many harbor an even greater concern: that accepting treatment for chronic pain, especially when it involves opioids, will result in being perceived as having an addiction by their physicians, employers, and families. This fear is not merely imagined. Qualitative research on patients undergoing opioid tapers describes them as feeling stigmatized, judged by clinical systems that interpret typical pain behaviors as signs of dishonesty. A widely cited 2018 essay in the Canadian Medical Association Journal highlights how individuals with chronic pain are routinely labeled as complainers, malingerers, or drug seekers. Such framing influences their treatment long before any clinical evaluation occurs.
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This stigma extends beyond patients’ perceptions. Survey data indicate that a significant proportion of physicians express reluctance to treat patients already receiving opioid therapy. Additionally, a national secret shopper study found that approximately 40 percent of primary care practices declined to accept new patients undergoing opioid treatment for chronic pain. Researchers have observed that, while stigma toward individuals with substance use disorders is widely acknowledged, a parallel and under-recognized stigma affects those living with pain. Surveys of pain patients reveal tangible consequences: difficulty securing a willing physician, involuntary tapering of effective medications, and a persistent sense of abandonment by a health care system that once pledged support.
Families are also affected by this dynamic. Patients managing chronic pain for extended periods, particularly with prescribed opioids, frequently encounter subtle skepticism from relatives who question the legitimacy of their pain or fear potential dependence. This doubt intensifies feelings of isolation. Patients often report feeling judged, misunderstood, and abandoned not only by the health care system but also by those closest to them, precisely when support is most needed.
Stigma has direct clinical consequences. Patients who feel shame may underreport pain, skip follow-up visits, or stop treatment early. Physicians, fearing external scrutiny, may hesitate to provide individualized care. Both situations lead to declining function. Untreated pain can result in disability, depression, and the dependence that stigma aims to prevent.
I have witnessed alternative outcomes. When Tim first presented, he was bedridden, and his obesity was so severe that safe anatomical landmarks for spinal injections were unidentifiable. Nearly twenty years later, now in his late seventies, he has lost hundreds of pounds, works daily with a physical therapist and personal trainer, and is regaining the strength to ride his motorcycle. This progress was not achieved by treating him as a diagnosis to be managed cautiously, but by recognizing his pain as genuine, developing a comprehensive plan centered on movement and multiple modalities, including acupuncture, massage, and meditation, and restoring his trust in the treatment process.
Diana provides another illustration. She has been under my care for fifteen years, following a history of significant injuries, including a broken leg, being struck by a car, two knee surgeries, and a car accident severe enough to detach the rearview mirror from her head. Recently, at age seventy-nine, she went skydiving for the second time. Throughout her treatment, we discontinued an opioid medication that was subtly causing memory impairment previously mistaken for Alzheimer’s disease, underwent a cervical fusion surgery successfully, and transitioned her long-term management to physical therapy, epidural injections, and radiofrequency ablation. Diana exemplifies the potential of individualized, nonjudgmental pain care.
Neither Tim nor Diana required protection from their own treatment. They needed a physician willing to look beyond the referral label and recognize the individual behind it. This begins with how referring physicians and specialists communicate the purpose of a pain management referral. It should not be portrayed as a transfer to someone who merely monitors drug-seeking behavior, but rather as an escalation of care to a clinician trained in a comprehensive array of interventions, including injections, regenerative techniques, physical therapy, behavioral health, and, when appropriate, judicious medication management.
For example, when writing a referral, clinicians might say: “I am referring my patient for specialized pain management to explore additional treatment modalities that may improve function and quality of life.” Or “This patient has complex chronic pain that has not responded fully to current management, and would benefit from comprehensive assessment and multidisciplinary interventions.” Using nonstigmatizing language like this shifts the focus toward collaboration and individualized support, rather than suspicion or surveillance.
We owe patients transparency about the evidence. Most people with chronic pain, including those on long-term opioids, are not addicted; they are in pain. Confusing these conditions in records, discussions, or nonverbal cues causes real harm.
I assure my patients and their families that fear of being labeled should never prevent them from being heard. My role is not to restrict relief, but to offer every possible option and support my patients throughout their journey, however long it may be.
Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness.
Dr. Torres was born in Spain and grew up in Puerto Rico. He graduated from the University of Puerto Rico School of Medicine. Dr. Torres performed his physical medicine and rehabilitation residency at the Veterans Administration Hospital in San Juan before completing a musculoskeletal fellowship at Louisiana State University Medical Center in New Orleans. He served three years as a clinical instructor of medicine and assistant professor at LSU before joining Florida Spine Institute in Clearwater, Florida, where he is the medical director of the Wellness Program.
Dr. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine. He is a prolific writer and primarily interested in preventative medicine. He works with all of his patients to promote overall wellness.
