Appendix: The effects of physician stigma and hesitancy with opioids on patient pain care in the United States: A survey study

Objectives: Determine if physician stigma toward patients with chronic pain or opioid use disorder or physician hesitancy prescribing opioids adversely affects patient pain care. Explore the demographics associated with stigma and hesitancy. Design: Survey, 25 questions. Setting: Physician faculty at medical schools (80 percent), private physician Facebook® groups (15 percent), and others (5 percent), all specialties. Participants: N = 352 attending United States physicians. Main outcome measure: Physician self-reported patient pain care quality. Results: Subjectively worse patient pain care was not found to be associated with stigma but had a borderline association with hesitancy (p = 0.046). Subjectively worse pain care was associated with less knowledge and experience with opioids (odds ratio [OR] 4.1, 95 percent confidence interval [CI] 3.0-5.6), practicing in the Midwest region (OR 2.1, 95 percent CI 1.2-3.4), and specialty: emergency (OR 53, 95 percent CI 20-139), other internal (OR 15, 95 percent CI 6.6-34), and general medicine (OR 12, 95 percent CI 5.4-26) compared to pain medicine. Physician stigma was more likely to be high in males (OR 2.5, 95 percent CI 1.5-4.3) and medium in physicians over 55 (OR 2.5, 95 percent CI 1.5-4.5). Compared to medium stigma, those with low stigma (General Linear Model (GLM) 0.35, 95 percent CI 0.18-0.52) and high stigma (GLM 0.22, 95 percent CI 0.01-0.44) were both more hesitant to prescribe opioids. More hesitancy was associated with less knowledge and experience (GLM 0.14, 95 percent CI 0.05-0.22) and physicians under 55 (GLM 0.24, 95 percent CI 0.08-0.40). Conclusions: Although physician stigma was not found to affect patient pain care adversely, self-reporting bias and/or questionnaire issues may account for this. Physician specialty and knowledge and experience with opioids were important factors.