Opioid Treatment: Bridging the Gap Between Doctors and Patients
"Uncover the surprising differences in how doctors and patients perceive the risks of opioid therapy, and how this disconnect impacts safety and treatment outcomes."
Chronic pain affects millions, and opioid prescriptions are a common treatment, especially in primary care settings. However, for patients with a history of substance use, this treatment path becomes more complex. Safety-net clinics, which serve low-income populations, often face the challenge of managing chronic non-cancer pain (CNCP) and substance use without specialized resources.
Recent research has uncovered a significant disconnect between how primary care practitioners (PCPs) and their patients perceive the risks associated with chronic opioid therapy. This difference in understanding can hinder effective communication, impact treatment adherence, and potentially compromise patient safety.
This article explores these differing perceptions, drawing from a study of PCPs and patients in San Francisco Bay Area safety-net clinics. We'll delve into the specific concerns of both groups and discuss strategies for bridging the gap to create safer, more effective opioid treatment plans.
Chronic Pain and Its Impact
The CDC’s report, “Chronic Pain and High-impact Chronic Pain in U.S. Adults, 2023,” describes chronic pain and high-impact chronic pain—pain that often restricts life or work activities—as common reasons adults seek medical care. The report links these conditions with decreased quality of life, opioid misuse, increased anxiety and depression, and unmet mental health needs. Its accompanying summary reports that 20.4% of adults had chronic pain in 2019; the provided excerpt does not give the corresponding figure for high-impact chronic pain.
Guidance for Safer Prescribing
The CDC’s 2016 guideline aims to improve clinician-patient communication about opioid therapy’s risks and benefits, improve the safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid use, including opioid use disorder, overdose, and death. It recommends urine drug testing before starting opioid therapy for chronic pain and consideration of testing at least annually. A 2026 article says gaps in evidence for specific clinical populations and opioid formulations contributed to guidelines taking a one-size-fits-all approach across pain conditions, despite differences in pain etiology and biological variation.
How Opioid Use in Pain Care Expanded
Since the 1990s, opioid consumption has risen dramatically, alongside increased prescribing to people with chronic pain and other injuries, according to “The Opioid Crisis: Roots, Evolution, and Contributors.” In the 1980s, cancer pain specialists Russell Portenoy and Kathleen Foley supported long-term opioid therapy, initially for cancer pain and later for severe chronic pain, with intensive physician involvement as an ethical way to help patients regain meaningful quality of life. A later presumption that opioids were safe and effective for chronic pain contributed to overreliance and a significant reduction in multidisciplinary pain centers across the United States.
The Divide: How Doctors and Patients See Opioid Risks Differently
A study was conducted involving interviews with 23 PCPs and 46 of their patients, all of whom had a history of both CNCP and substance use. The results revealed key differences in their perceptions of opioid risks.
- Doctor's Main Concerns: PCPs primarily worried about causing harm through unintentional overdose, patient addiction, and community harm via opioid diversion. They also expressed concerns about legal repercussions related to prescribing opioids, especially to patients with substance use histories.
- Patient's Main Concerns: Patients, however, did not highlight the adverse health consequences of opioids as much, except for the fear of addiction. But they fear being labeled as addicts and being targeted by monitoring policies because of their histories of substance use. They expressed concern about medicolegal issues and how it might change their policy.
- Shared Concerns: Both PCPs and patients were concerned about PCPs' medicolegal risks related to opioid prescribing.
Patient Experiences and Prescribing Limits
A 2023 qualitative study titled “Cookbook medicine” examines how legislation limiting opioid prescribing affects clinical practice and patient experiences. Its authors report that prescribing legislation has been linked to clinicians viewing patients who take opioids with greater suspicion, stigmatizing them as “addicts,” and restricting their autonomy in treatment decisions. A separate San Francisco Bay Area study interviewed 22 patients with chronic non-cancer pain and a history of substance use, along with 7 primary care clinicians, from March through July 2020, to examine telehealth in safety-net primary care.
Opioids, Alternatives, and Breathing Risks
The Lancet-linked article explains that opioid activation of mu opioid receptors in brainstem respiratory centers can reduce the brain’s responsiveness to carbon dioxide and impair breathing; this is respiratory depression. It describes non-addictive pharmacological alternatives to opioids as a growing research area. A 2025 review lists non-opioid medications, interventional techniques, physical therapy, psychological interventions, complementary therapies, and cannabinoids as alternatives to consider in comprehensive chronic-pain management.
Bridging the Gap: Towards Safer and More Effective Opioid Treatment
The study's findings underscore the importance of open and honest communication between PCPs and patients. To improve the informed consent process for opioid therapy, it's crucial that both parties have a shared understanding of the risks and benefits.
Balancing Evidence on Benefits and Harms
A 2021 analytic review of clinical literature on opioids for chronic non-cancer pain in the United States concludes that substantial, though not definitive, scientific evidence supports opioid effectiveness for pain treatment. It also emphasizes high variability in opioid dose requirements and side effects. A separate systematic review and meta-analysis compared opioid with nonopioid treatment for chronic noncancer pain, assessing pain intensity, physical function, and vomiting, while an evidence report addressed benefits and harms, dosing strategies, and risk assessment and mitigation.
Precision and Safer Pain Management
A 2025 review of four decades of chronic-pain management describes progress in interventional techniques, safer pharmacologic practices, and multidisciplinary care. It identifies opioid misuse, patient variability, and equitable access as continuing challenges, and highlights precision medicine, technology integration, and safety-centered innovation as future directions. Separately, researchers have proposed studying whether κ-opioid receptor antagonists can reduce pain intensity or pain-related disability in people with chronic pain and thereby reduce opioid-misuse risk; this remains a question for future studies.
Pain, Treatment Access, and Opioid Use Disorder
A 2026 NEJM perspective states that pain interferes with daily activities and can undermine people’s ability to engage in treatment for opioid use disorder, while barriers to pain assessment and treatment persist. A 2019 review argues that examining pain-related allostatic changes across the four opioid systems is necessary to understand how pain interacts with liability for opioid misuse. A 2026 editorial also draws attention to pediatric chronic pain management, which it says is often absent from media coverage and policy proposals despite its prevalence, economic impact, and relevance to the opioid epidemic.
Individualized Care and Ongoing Monitoring
A 2021 case report describes concerns about chronic-pain opioid analgesics, including limited evidence of effectiveness and risks of tolerance, dependence, addiction, and side effects. The CDC guideline topics listed in a case-study resource include when to initiate or continue opioids, opioid selection and dosage, treatment duration, follow-up and discontinuation, and assessing and addressing risks. The resource also emphasizes identifying evidence-based non-opioid options, weighing opioid risks and benefits, managing ongoing therapy, and recognizing behaviors that may be associated with opioid use disorder.
Here are some actionable steps that clinics and practitioners can take:
<ul> <li><b>Open Dialogue</b>: Facilitate discussions that promote patient autonomy and safety, allowing patients to voice their concerns and perspectives without fear of judgment.</li> <li><b>Address Stigma</b>: Develop communication strategies that educate patients about opioid risks while reducing experiences of stigma and discrimination.</li> <li><b>Comprehensive Education</b>: Provide thorough education on the risks of overdose, addiction, and diversion, tailored to the patient's individual circumstances.</li> <li><b>Naloxone Co-Prescription</b>: Consider co-prescribing naloxone, an opioid antagonist, to patients at high risk of overdose, and educate them on its use.</li> </ul> By addressing these issues, clinics can create a more collaborative and supportive environment for managing chronic pain and substance use.