"I can't take in every stray puppy": How U.S. pain specialists purify pain management through opioid-related gatekeeping.

U.S. pain specialists have always rallied against their profession being cast as "dirty work" - work that is undesirable, socially stigmatized, and morally questionable - due to both its object of study (chronic pain) and one of its primary treatment modalities (prescription opioids). This paper demonstrates that U.S. outpatient pain specialists purify pain management through opioid-related gatekeeping practices that differ depending upon their role as a physician or an advanced practice provider (APP). Drawing from abductive analysis of semi-structured interviews with 21 pain specialists and participant observation at three pain management conferences conducted between 2023 and 2024, I found that higher-status pain specialist physicians often delegated the dirtiness of opioid prescribing and surveilling patients downwards to lower-status APPs. These physicians simultaneously consolidated their own authority through interventions (i.e., procedures, such as nerve blocks and radiofrequency ablations), which purified chronic pain through its biologization. These findings suggest that higher-status professionals' techniques for cleansing dirty work not only avoid status damage but also enhance their power and amplify intra-professional hierarchies. APPs served as a protective funnel through which only deserving patients passed - determinations often based on racialized assumptions, like criminal justice system involvement. This also provided pain specialist physicians with more time to elevate their own status through interventional work. In purifying pain management, however, APPs and physicians' opioid-related gatekeeping practices often functioned to separate substance use disorder from chronic pain, reinforcing racially constructed boundaries between these conditions.