Guilty until proven innocent: a qualitative study of the management of chronic non-cancer pain among patients with a history of substance abuse

Introduction: Physicians are often reluctant to prescribe strong opioids for chronic non cancer pain (CNCP). No study has qualitatively examined physicians' beliefs about prescribing opioids for CNCP to patients with a history of substance abuse (PWHSA).

Aims: To describe physicians' attitudes and experience of prescribing opioids for CNCP to PWHSA.

Design, setting and participants: Nineteen individual interviews and two focus groups were conducted with GPs, Addiction Specialists, Pain Specialists and Rheumatologists.

Results: Physicians were "reluctant" to prescribe opioids to PWHSA experiencing CNCP for fear of addiction, misuse or diversion of medications. Many exhibited "distrust" that such patients were experiencing "genuine pain", resulting in patients often being considered guilty until proven innocent. Such negative regard towards these patients was based on previous manipulative "drug seeking" encounters and often resulted in the under treatment of pain. Potential "flags" were identified that alerted physicians to the potential for abuse or diversion of their prescription including: doctor shopping. loosing prescriptions, frequent attendance and early requests for repeat prescriptions. Physicians reported different management approaches and stricter prescribing regimes for PWHSA to limit the potential of addiction, misuse and diversion. Examples of poor pain management were described where drug users had been under treated as a result of negative attitudes or inexperience of staff.

Discussion: Applying the chronic disease model to comorbid addiction and CNCP would ensure a health and social care system that makes it difficult to stigmatise patients experiencing these conditions and would facilitate the prescribing of opioid pain medication to patients who could benefit.