The impact of opioid stigma on patient-provider interaction and decision-making in cancer pain management: a qualitative meta-synthesis

Abstract

Context

Clinical guidelines recommend opioids for moderate-to-severe cancer pain, yet undertreatment remains common. In the context of the opioid crisis and increasingly restrictive regulatory policies, communication and decision-making around cancer pain management have become more challenging. Opioid stigma may be an overlooked influence on how patients and healthcare providers communicate and make treatment decisions.

Objectives

To explore how opioid stigma influences patient-provider interaction and decision-making through a qualitative meta-synthesis.

Methods

This qualitative meta-synthesis followed PRISMA and ENTREQ and was registered in PROSPERO (CRD420261329320). We searched PubMed, CINAHL, Embase, PsycINFO, Web of Science, the Cochrane Library, WanFang, and CNKI from database inception to 1 March 2026. We included qualitative studies examining stigma, interaction, and decision-making in cancer pain management. Findings were synthesized using thematic synthesis, and confidence was assessed using CERQual.

Results

Twenty studies were included. Most had moderate methodological limitations, particularly in reflexivity and positionality. A total of 145 findings were extracted and grouped into 10 descriptive categories and 4 analytical themes. Opioid stigma was shaped by sociocultural narratives and institutional processes. Patients internalized this stigma as shame and fear, which could reduce pain expression and help-seeking. Clinicians faced tension between adequate analgesia and risk management, contributing to conservative prescribing. In clinical encounters, patients often felt compelled to justify the legitimacy of their pain, whereas clinicians responded defensively to perceived risks.

Conclusions

Opioid stigma shapes patient-provider interaction and decision-making in cancer pain management and may reinforce undertreatment. Multilevel efforts to reduce stigma may improve communication, support shared decision-making, and promote more appropriate opioid-related decision-making in cancer pain management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-026-02197-8.

Introduction

Pain is a highly prevalent and distressing symptom among people living with cancer. Approximately 30%-50% of patients experience moderate-to-severe pain, and the prevalence may be as high as 75% in advanced cancer [1, 2]. Poorly controlled cancer pain is associated with physical functional decline, sleep disturbance, psychological distress, impaired social and role functioning, and reduced quality of life [3, 4]. Effective pain management is therefore a core component of comprehensive cancer care.

Opioids remain the treatment of choice for moderate-to-severe cancer pain [5, 6]. Cancer pain differs from chronic non-cancer pain because it may arise from active disease, cancer treatment, advanced illness, or survivorship-related sequelae [6]. Accordingly, opioid prescribing expectations in oncology and palliative care differ from those in general chronic pain management [7]. The 2022 CDC opioid prescribing guideline also states that its recommendations do not apply to cancer-related pain, palliative care, or end-of-life care [8]. When used appropriately, opioids can relieve suffering and help maintain daily functioning [5]. However, despite established guideline recommendations, approximately 51% of patients with cancer still do not receive adequate pain control [9]. Increasing evidence suggests that persistent undertreatment cannot be explained solely by inadequate knowledge or poor adherence [10, 11]. The intensified regulatory climate associated with the opioid crisis, particularly in North America, may also be an important contextual factor shaping cancer pain management [12, 13].

Historically, patients with cancer were widely regarded as a legitimate population for opioid therapy in policy, guidelines, and clinical practice [6]. As a result, they were often exempt from restrictions applied to patients with non-cancer pain. This landscape has shifted in the context of the opioid crisis, media portrayals of addiction and overdose, increased regulatory scrutiny, and more restrictive prescribing policies [14, 15]. These forces may strengthen the association of opioids with addiction, misuse, drug-seeking, and moral blame, thereby shaping attitudes toward opioid use even in the setting of cancer pain [16]. Drawing on general stigma theory and Bulls et al.’s Opioid Stigma Framework for cancer pain [16, 17], opioid stigma was defined in this review as negative labeling, stereotyping, and devaluation associated with prescribed opioid use in cancer pain management. Prior literature suggests that opioid stigma may be shaped by sociocultural, institutional, and regulatory contexts and reflected in anticipated judgment, shame, or fear related to opioid use [16, 18, 19].

Opioid stigma adds complexity to cancer pain management, which requires ongoing pain assessment, dose titration, opioid rotation, patient education, effective communication, and mutual trust between patients and healthcare providers [16]. Existing studies have examined opioid stigma in patient experiences, clinicians’ attitudes, and chronic non-cancer pain contexts, but most have focused on either patients or healthcare providers separately [20–22]. Less attention has been paid to how opioid stigma affects communication and shared decision-making (SDM) between patients and clinicians in cancer pain management [23]. Patients’ views about opioids may vary according to prior opioid experiences, family beliefs, and exposure to opioid-related media narratives, underscoring the need for individualized communication [14, 15]. However, evidence regarding differences across age groups or generations remains limited. This evidence gap is important because opioid stigma may erode the trust that underpins SDM. There has been no systematic synthesis of how opioid stigma shapes communication and decision-making in cancer pain management. In addition, the roles of family members, pharmacy staff, and institutional processes within this context remain insufficiently understood. Individual qualitative studies are often limited by small samples and context-specific findings, making it difficult to draw more explanatory conclusions about these complex interactional processes. Therefore, this qualitative meta-synthesis [24] aimed to synthesize how opioid stigma influences patient-provider interaction and decision-making in cancer pain management in the context of the opioid crisis. The findings may help explain persistent undertreatment and inform more targeted communication strategies and pain-management approaches.

Methods

This qualitative meta-synthesis was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement (PRISMA 2020) [25] and the Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement (ENTREQ) [26]. For additional information, see Supplementary Material 1. This systematic review has been registered in PROSPERO (CRD420261329320).

Search strategy

The final search strategy was developed around four concepts: cancer, opioid stigma, patient-provider interaction, and qualitative research. These concepts were used to search eight databases: PubMed, CINAHL, Embase, PsycINFO, Web of Science, the Cochrane Library, WanFang, and CNKI. We searched for qualitative studies examining interactions between patients and providers in the management of cancer pain against the backdrop of the opioid crisis. The searches were conducted from database inception to 1 March 2026. No lower date limit was applied because opioid-related stigma, fear of addiction, and concerns about opioid prescribing may have been discussed in cancer pain literature before the term “opioid crisis” became widely used. This approach was intended to avoid excluding earlier qualitative evidence relevant to the phenomenon of interest. The searches employed both subject headings and free text keywords. Many studies did not specifically use broad terms to describe the interaction in their titles or abstracts, and thus some relevant content could be found in the participants’ quotations. To increase recall, the search strategy included specific keywords related to interactive behaviors, such as ‘trust’, ‘conflict’, ‘distrust’, and ‘dilemma’. To supplement database searches, we conducted backward citation searching by screening the reference lists of all included studies and relevant reviews. Forward citation tracking of included studies was also conducted using Web of Science. Records identified through citation searching were imported into EndNote and screened using the same eligibility criteria. Detailed search strategies are provided in Supplementary Material 2.

Selection criteria

Inclusion and exclusion criteria were established in accordance with the PICoS framework [27]. The detailed inclusion and exclusion criteria are presented in Table 1. Cancer pain was conceptualized broadly as pain related to active cancer, cancer treatment, advanced or palliative cancer care, chronic cancer-related pain, or survivorship-related sequelae. Studies published in English or Chinese were included because these were the languages in which the review team could reliably screen, appraise, interpret, and synthesize qualitative findings.

Table 1.

Inclusion and exclusion criteria

PICoS element	Inclusion criteria		Exclusion criteria
Population	1.Adult cancer patients (aged ≥ 18 years). 2.Stakeholders directly involved in cancer pain management, including healthcare providers, informal caregivers, community workers, and regulators.
Phenomenon of interest	Phenomena relating to stigma, fear and mistrust associated with opioids, and an exploration of their impact on communication, help-seeking, prescribing or decision-making processes in cancer pain management.	No qualitative evidence was provided regarding stigma, interactions, communication or decision-making.
Context	1.Against a backdrop of the opioid crisis, intensified opioid-related regulatory oversight and restrictive prescribing policies. 2.Study settings include oncology departments, palliative care units, pain clinics, pharmacies and relevant community settings.	Studies were excluded if the opioid-related context was outside cancer pain management, such as general non-cancer pain, postoperative pain unrelated to cancer care, or opioid use disorder treatment without a cancer pain context.
Study type	Qualitative studies or the qualitative component of mixed-methods studies, including descriptive qualitative research, phenomenology, grounded theory, etc.	systematic reviews, scoping reviews, qualitative syntheses, concept analyses, research protocols, editorials, commentaries, case reports, and conference abstracts were excluded. Full-text reports that could not be accessed. Duplicate publications. Literature published in languages other than English or Chinese.

Study selection

Two master’s-level nursing researchers (YXC and RY), both trained in evidence-based practice, independently screened titles and abstracts against the eligibility criteria. The full texts of potentially eligible records were then independently assessed by the same two reviewers. Disagreements were resolved through discussion and, when needed, consultation with a third reviewer (XLZ). All retrieved records were managed in EndNote for duplicate removal and screening.

Quality appraisal

The methodological limitations of the included studies were independently appraised by YXC and RY using the 2016 version of the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research [28]. Disagreements were resolved through discussion and, when needed, consultation with XLZ. The quality assessment of each included study consisted of 10 items rated as ‘Yes’, ‘No’, ‘Unclear’ or ‘Not applicable’. The pattern of responses across the 10 items was summarized narratively to identify common methodological limitations across the included studies. No study was excluded solely on the basis of methodological appraisal; instead, appraisal results were used to inform the CERQual assessment of confidence in the review findings.

Data extraction

Data were extracted into Excel spreadsheets by the two researchers (YXC and RY). Extracted information included author and year of publication, country or region, study type, phenomenon of interest, data collection method, data analysis method, research context or recruitment setting, participant and clinical characteristics, and key findings relevant to opioid stigma, communication, and decision-making. Clinical characteristics included cancer type, disease stage or cancer trajectory, survivorship status, pain type, and opioid-related context where reported. Disagreements in data extraction were resolved through discussion and, when needed, consultation with XLZ. To enhance transparency in data extraction and analysis, relevant quotations from the included studies were tabulated in Supplementary Material 4, together with the corresponding perspectives (i.e., patients, healthcare providers, or caregivers) and first-order codes.

Data synthesis

Data from the included studies were summarized and synthesized using Thomas and Harden’s thematic synthesis [29]. Initial line-by-line coding was conducted by YXC and RY using NVivo 14. Codes were compared and grouped into descriptive categories through iterative discussion among YXC, RY, MX, and XLZ. Analytical themes were then refined by the same team until consensus was reached.

Confidence in the findings

The Confidence in the Evidence from Reviews of Qualitative Research (CERQual) tool [30] was used to evaluate the level of certainty about synthesized results across four dimensions: methodological limitations, relevance, coherence, and adequacy of data. Overall confidence was graded as high, moderate, low, or very low.

Reflexivity and positionality

The research team members had backgrounds in oncology nursing, evidence-based practice or qualitative research. Some had clinical or research experience in cancer symptom management, which may have sensitized the team to issues of undertreatment, communication, and opioid-related concerns. To minimize the influence of individual assumptions, study selection, quality appraisal, data extraction, and initial coding were conducted independently by two reviewers. Disagreements were resolved through discussion. Throughout synthesis, we repeatedly returned to the original studies, participant quotations, and authors’ interpretations to ensure that analytical themes remained grounded in the included evidence.

Results

Study selection

Database searches identified 3,532 records. After removal of 527 duplicates, 3,005 database records were screened by title and abstract, and 2,893 were excluded. A total of 112 reports were sought for retrieval, of which six could not be obtained. The remaining 106 full-text reports were assessed for eligibility, and 86 were excluded because of ineligible populations, study types, phenomena of interest, or contexts. Citation searching identified 21 additional records; all were assessed for eligibility, but none met the inclusion criteria. Finally, 20 studies were included in this review. The study selection process is shown in Fig. 1.

Fig. 1.

PRISMA flow diagram illustrating literature search and selection

Study characteristics

This review identified 20 studies [21, 31–49] published between 2019 and 2025, of which 18 were published in or after 2020 [21, 33–49]; 16 studies were conducted in the United States, with the remainder being conducted in Vietnam, Australia, Qatar, and Cyprus [31, 33, 36, 48]. No Chinese-language study met our eligibility criteria. Some studies were conducted across more than one type of setting. Five studies involved academic or tertiary cancer centers [32, 35, 37, 44, 45], five involved oncology outpatient clinics or oncology practice settings [34, 37–39, 44], four involved palliative care settings or services [34, 37, 43, 46], four involved primary care settings [36, 38, 43, 46], and three recruited through community-based survivorship organizations [40, 41, 49]. Three studies also incorporated broader health-system or regulatory perspectives [43, 47, 48].

The included studies used qualitative designs or qualitative components of mixed-methods studies [21, 31–49]. The most common data-collection method was semi-structured interviews [21, 32, 34–49] and focus groups [31, 33]. Patient participants were represented across different cancer trajectories, including advanced cancer [21, 37, 42], active cancer care [21, 34, 37, 42, 44, 45, 48], post-treatment survivorship [40, 41, 43, 46, 47, 49], and remission [46]. Pain contexts included active cancer pain, cancer-related pain [21, 31, 33, 34, 37, 39, 42, 44, 45, 48], chronic cancer-related pain [32, 35, 43, 46, 49], and survivorship-related pain [40, 41, 43, 46, 47, 49]. The included studies did not use a single standardized definition of cancer pain; instead, the concept was operationalized according to the populations and clinical contexts examined. Most studies involved mixed or unspecified tumor types [21, 31–43, 45–49], whereas one study focused specifically on patients with hematologic malignancies [44]. Several studies focused on opioid-related contexts, including long-acting or long-term opioid therapy [32, 35, 38, 43, 45, 46], opioid prescribing and dispensing [31, 33, 38, 39, 43, 46], barriers to opioid access [31, 48], and cancer pain management among patients or survivors with a history of opioid use disorder (OUD) [42, 47]. Non-patient participants included informal caregivers or support persons [21, 34, 42, 48], general practitioners [36], medical oncologists [39], other healthcare professionals or clinicians [31, 33–35, 38, 40, 43, 46–48], regulators [48], and community stakeholders [40, 47]. Table 2 describes the key characteristics of the included studies.

Table 2.

Characteristics of the included studies (n = 20)

No.	Author/Year	Region		Study Type	Phenomenon of Interest	Data Collection Method	Data Analysis Method	Research Context/ Recruitment Setting	Participants and clinical characteristics
1 [32]	Wright, 2019		USA	Qualitative component of a mixed-method study	Opioid use patterns and adherence perceptions among patients with chronic cancer pain	Semi-structured interviews	Framework analysis	Academic medical center	Patients with chronic cancer pain on long-acting opioids (n = 17)
2 [31]	Charalambous, 2019		Cyprus	Qualitative component of a mixed-method study	healthcare providers’ perceptions of and barriers to opioid use for cancer pain	Focus group interviews	Phenomenological analysis	Primary and secondary healthcare settings in Cyprus; in the context of cancer pain management and opioid availability	Healthcare professionals (n = 28)
3 [35]	Giannitrapani, 2020		USA	Qualitative study	Signature informed consent for long-term opioid therapy in patients with cancer	Semi-structured interviews	Content analysis	Two large academic-affiliated Veterans Affairs medical centers	Patients with cancer on long-term opioid therapy (n = 20); opioid prescribers (n = 20)
4 [36]	Luckett, 2020		Australia	Qualitative study	Risk of opioid misuse in patients with cancer and related clinical considerations	Semi-structured telephone interviews	Integrative analysis	Primary care setting	General practitioners (n = 22)
5 [33]	Al-Masri, 2020		Qatar	Qualitative study	healthcare providers’ perceptions of law, culture, and fear related to opioid use for cancer pain	Focus group interviews	Thematic analysis	Cancer care settings in Qatar	Healthcare professionals (n = 36)
6 [34]	Brooks, 2020		USA	Qualitative descriptive study	The role of palliative care in cancer pain management during the opioid crisis	In-depth interviews	Content analysis	Single outpatient cancer center; outpatient palliative care setting	Patients with cancer, caregivers, and oncology healthcare professionals (n = 44)
7 [37]	Azizoddin, 2021		USA	Qualitative study	Cancer pain self-management and opioid stigma among patients with advanced cancer in the context of the opioid epidemic	Semi-structured interviews	Thematic and framework analysis	Dana-Farber Cancer Institute; outpatient/inpatient oncology and palliative care settings	Patients with advanced cancer using opioids (n = 26)
8 [40]	Tyson, 2021		USA	Qualitative study	Perceptions of prescription opioids and the impact of the opioid epidemic in the context of cancer survivorship	Semi-structured interviews	Thematic analysis	Community organizations and cancer center-related settings	Healthcare providers (n = 24); community stakeholders (n = 6); cancer survivors (n = 25)
9 [38]	Giannitrapani, 2021		USA	Qualitative study	Cross-disciplinary role coordination in long-term opioid prescribing for cancer	Semi-structured interviews	Thematic analysis	Two large academic-affiliated Veterans Affairs medical centers and associated community outpatient clinics	Primary care and oncology-based providers (n = 20)
10 [39]	Schenker, 2021		USA	Qualitative descriptive study	Opioid prescribing challenges for patients with cancer-related pain	Semi-structured telephone interviews	Thematic analysis	Eighteen oncology practice sites in Western Pennsylvania, USA	Medical oncologists (n = 26)
11 [41]	Chavez, 2022		USA	Qualitative study	Fear of addiction to prescribed opioids among cancer survivors	Semi-structured interviews	Thematic analysis	Community organizations and cancer center-related settings	Cancer survivors prescribed opioids (n = 25)
12 [21]	Bulls, 2022		USA	Inductive qualitative descriptive study	Manifestations of opioid stigma among patients with advanced cancer	In-depth semi-structured interviews	Thematic analysis	Cancer center/advanced cancer care setting	Patients with advanced cancer (n = 20); support persons (n = 11)
13 [49]	Marshall, 2023		USA	Exploratory qualitative study	Barriers to pain control and perceptions of opioid use among cancer survivors	In-depth qualitative interviews	Thematic analysis	Community-based cancer survivorship organizations	Cancer survivors with persistent pain (n = 25)
14 [42]	Bulls, 2023		USA	Inductive qualitative descriptive study	Attitudes toward opioid use disorder among patients with advanced cancer and their supporters	In-depth semi-structured interviews	Thematic analysis	Advanced cancer care setting	Patients with advanced cancer pain (n = 20); support persons (n = 11)
15 [43]	Bulls, 2024		USA	Inductive qualitative descriptive study	Opioid prescribing decision-making for chronic cancer pain in survivorship	In-depth telephone interviews	Thematic analysis	Single health system; oncology, palliative care, primary care, and pain specialty settings	Clinicians (n = 20)
16 [45]	Yeager, 2024		USA	Qualitative descriptive study	Pain experiences of Black patients with cancer taking long-acting opioids	Semi-structured interviews	Content analysis	Large urban public hospital cancer center and tertiary cancer center	Black patients with cancer on long-acting opioids (n = 14)
17 [44]	Nabulsi, 2024		USA	Qualitative study	Perceptions of prescription opioids among marginalized patients with hematologic malignancies in the context of the opioid epidemic	Semi-structured interviews	Framework analysis	Urban academic medical center; hematology-oncology outpatient clinic	Patients with hematologic malignancies (n = 20)
18 [47]	Chavez, 2025		USA	Secondary qualitative analysis	Pain management among cancer survivors with co-occurring opioid use disorder	Semi-structured interviews	Thematic analysis	Healthcare and community care settings	Healthcare providers (n = 24); community stakeholders (n = 6)
19 [46]	Bell, 2025		USA	Qualitative study	Opioid stigma among survivors with chronic cancer pain in remission	In-depth telephone interviews	Content analysis	Single institution; oncology, palliative care, pain management, and primary care settings	Survivors in remission with chronic cancer-related pain (n = 17); clinicians (n = 20)
20 [48]	Nguyen, 2025		Vietnam	Qualitative descriptive study	Barriers to safe opioid access for cancer pain relief	Semi-structured interviews	Content analysis	Multiple regions in Vietnam	Healthcare providers (n = 5); patients with cancer or caregivers (n = 6); regulators (n = 6)

Quality assessment

The methodological quality of the 20 included studies was assessed using the JBI Critical Appraisal Checklist for Qualitative Research. Overall, the included studies showed moderate methodological limitations, mainly related to incomplete reporting of philosophical positioning and researcher reflexivity. The most frequently identified concerns were limited reporting of the philosophical foundations underpinning the studies, researchers’ cultural or theoretical positioning, and the influence of researchers on the research process. Specifically, only one of the 20 studies explicitly articulated a philosophical foundation consistent with the research methodology [31]. Eleven of the 20 studies [21, 31–33, 35, 40

Synthesis findings

The 20 included studies yielded 145 relevant findings related to the review question. The research team conducted line-by-line coding of the 145 findings and developed first-order codes. These codes were then grouped into 10 descriptive categories and further consolidated into four analytical themes. The synthesis indicates that, in the context of the opioid crisis, cancer pain management was shaped by regulatory processes, sociocultural narratives, patients’ opioid-related concerns, and clinicians’ prescribing responsibilities. These factors were reflected in patients’ pain expression and help-seeking, clinicians’ prescribing judgments, and patient-provider interactions around the legitimacy of pain and opioid use. The main barriers identified across different levels and the detailed analytical themes are summarized in Supplementary Material 5.

Theme 1: institutional and sociocultural sources of opioid stigma

Presumptions of mistrust embedded in policies and institutional processes

Opioid stigma emerged through institutional arrangements and broader sociocultural meanings, particularly through policies, regulations, and clinical workflows surrounding opioid use. Some findings suggested that patients with a history of OUD could be treated as potentially untrustworthy within policies, documentation requirements, and institutional workflows related to opioid prescribing: “The papers that the pain clinic sent me……when I read them, they were already assuming that I was addicted” [46]. Routine risk-monitoring procedures such as urine drug testing (e.g., urinalysis) were also experienced by some patients as implying mistrust: “The default is you’re suspicious of them…having to pee in a cup every time they come in” [39]. In addition, pharmacy-related practices could create barriers to opioid access for some patients. For example, one patient described being told that information about OxyContin availability could not be provided by telephone: “I called another pharmacy and asked did they you know have Oxycontin. she said Well, actually we can’t give you that information over the phone” [45].

Opioid fears shaped by media and community narratives

Several included studies described how media reports and community experiences of overdose shaped participants’ perceptions of opioid risk. One participant described media-related fear of overdose: “I didn’t want to be the person on the news that died of an overdose” [40]. “My neighbor died from opioids in the basement. Everybody knew she was drug addict.” [44]. Some participants associated opioids with criminal behavior or illicit drug use: “When I hear opioid, I think street drug, illegal use by somebody who does not have a prescription for it” [41]. Some participants associated morphine with end-of-life care. The idea that morphine signaled approaching death could trigger fear or resistance among patients and families: “.morphine has been identified as a means of therapy that indicates a terminal status.” The patient asks, “Is this the end?” [31]. Together, these findings suggest that opioids were often associated with addiction, illicit drug use, overdose, or end-of-life care in participants’ accounts.

Theme 2: internalized shame and fear reducing pain expression and help-seeking

Shame and fear of addiction

Several studies described internalized shame related to prescribed opioid use. For example, one patient stated, “I’m absolutely embarrassed. You know, I don’t tell anyone I have them” [46]. In addition, internalized stigma may affect how patients take their medications by generating feelings of self-blame, guilt, and self-scrutiny: “I felt guilty because I prided myself in getting down to the 10 milligrams. And now I have to go up to the 20” [21]. Some patients also described feeling ashamed or guilty when filling opioid prescriptions at pharmacies. A patient explained, “I even feel a little guilty going to the pharmacy to pick it up, like, ‘Oh, there’s an addict right there’” [21]. The psychological burden of self-stigma can be substantial for patients with a history of OUD. The anxiety associated with potential relapse may intensify psychological stress while patients are using prescribed opioids: “I have a history of an opiate use disorder. I’m very scared about starting this medication” [47].

Reduced pain expression and delayed help-seeking

Some studies suggested that concerns about being perceived as drug-seeking could lead patients to downplay pain or avoid asking for help. Marshall reported that some patients stopped attending hospital appointments because they feared being perceived as “seeking drugs” [49]. Some patients described tolerating pain rather than using opioids: “I didn’t want to use them (opioids). I wanted to tolerate as much pain as I could” [49]. Some patients described hiding their pain from others: “Because I don’t want it to look like I’m a drug addict” [21]. Some patients described using sleep to cope with residual pain after taking prescribed opioids: “If I take [my prescription opioids] and there’s a little bit more pain, then you know what I try to do? Go to sleep” [42].

Theme 3: clinicians’ balancing of analgesia, risk, and responsibility contributing to conservative prescribing

Widespread skepticism toward patients’ pain and medication requests

Several included studies suggested that healthcare policies and external pressures were associated with a stronger emphasis on risk management when clinicians evaluated patients’ pain reports and medication requests. Some clinicians described concerns that patients who actively requested pain medication might be perceived as drug-seeking: “I think a lot of people automatically assume someone who’s asking for pain medication is a drug seeker. It’s easier sometimes to just slap a label onto someone” [46]. For patients with a history of drug use or substance use disorder, one study reported that medication requests could be viewed through a drug-seeking lens: “I’ve seen people be like, ‘They have a history of drug use. They are just drug seeking’” [47]. One study suggested that such skepticism was reflected in some patients’ sense that they were treated like others seeking opioids, regardless of their cancer diagnosis: “they treat everybody the same way, whether you’re a cancer patient or not” [34].

The dilemma between analgesia and risk management

When prescribing opioids to patients with cancer, clinicians described a dilemma between relieving pain, managing opioid-related risks, and fulfilling their duty of care. This dilemma was reflected in three ways. First, clinicians who prescribe opioids often find themselves under peer scrutiny: “I feel like there’s been this weird judgment thing that’s happened [to] the prescribers. there just seems to be a lot of stigmas associated with. being a prescriber” [43]. Second, prescribers described having to balance patients’ need for pain relief against concerns about addiction risk and their professional duty of care. This balancing act may be particularly difficult when caring for patients with a shortened life expectancy: “it’s even harder to have the difficult conversation with someone who has a shortened life expectancy” [36]. Finally, clinicians’ perceived lack of preparedness to address both pain and addiction added to this dilemma: “A lot of the clinicians. don’t feel prepared to address the addiction problem with the pain problem” [47].

Conservative prescribing under regulatory pressure

In our study, conservative prescribing refers to more guarded opioid prescribing, including reluctance to prescribe opioids, to increase doses or provide longer prescriptions, and to take responsibility for ongoing opioid prescribing. In several studies, regulatory scrutiny, licensing concerns, and perceived legal liability contributed to this pattern. As one participant stated, “The providers are scared too. They are scared of the DEA, they are scared of losing their license, so they start undertreating the patients” [40]. Some clinicians stated: “I’m not covering their narcotic regimen. I’m going to be deferring to my colleagues” [43]. “No one, it seems a lot of times other providers don’t want the liability of prescribing that to ya know our cancer patients” [39]. One included study also described the tension between prescribing caution and pain control: “It’s just a delicate balance. what the clinicians are willing to prescribe does not take care of their pain” [47].

Theme 4: patients’ efforts to legitimize pain claims and clinicians’ defensive responses potentially contributing to undertreatment

Mutual wariness in clinical interactions

Patients described concern that their pain reports might be interpreted as evidence of a signs of addiction or drug-seeking. This concern could affect how they communicated in clinical settings. Patients described this sense of caution clearly: “I try to be very careful with how I ask. I don’t want to sound too desperate, because desperation looks like addiction to them” [40]. At the same time, some findings suggested that clinicians may interpret persistent pain reports or medication requests through a lens of skepticism. In Marshall [49], one patient described how persistent pain beyond the expected recovery period was questioned: “I kept telling them that I’m still in pain and they’re like, ‘It’s been 6 weeks. Why are you still in pain?’” [49].

Patients’ efforts to legitimize pain and medication needs and clinicians’ defensive responses

Some patients described feeling that they needed to justify both the credibility of their pain and the legitimacy of the medications they were receiving, both during clinical appointments and when obtaining medications at the pharmacy. Examples included stating that cancer caused the pain, explaining the purpose of the medication, or providing documentation to support pain-related claims. Some patients also described having to justify themselves when encountering skepticism at the pharmacy: “.they looked at me like I was a drug addict. And I’m like, ‘Listen. Read this prescription. It says oncology. I’m not your typical—walking up here needing pain medication to get these opioids. I have cancer’” [21]. Some patients described feeling the need to provide visible proof of pain: “I feel like I have to prove that I’m in pain. I have to show my scars or my records just so they don’t think I’m just trying to get a high” [40]. Some patients tried to build trust with the pharmacy by providing copies of medical letters from their clinicians or trying to communicate with the pharmacy to establish rapport: “This pharmacy had asked if I could get a letter from my doctor just stating that I was her patient and cancer, stage four. So just talking with them and trying to make a partner with them so that they weren’t concerned” [37].

Clinicians also used written agreements and procedural requirements to manage the professional risk of prescribing opioids. Patients often viewed written agreements and procedures as a way for clinicians to protect themselves: “.you know, I might have gotten upset. I’m in pain and you want me to sign all this crap and stuff. It’s like they’re [providers] trying to cover their ass” [35]. Some patients also described dose limits by issuing lower doses or by asking patients to make their medication last longer: “He [the doctor] wrote the script for ten days past where I was going to run out of pain meds and told me to stretch it. And that was after he found out I had cancer again” [34].

Three-way interactions involving patients, families, and clinicians

Family involvement might turn opioid-related communication into a three-way interaction between patients, family members, and clinicians. In some narratives, family members supported more restricted opioid use because they were concerned about continued requests for pain medication or possible addiction: “.the family does not want us to give him much, so that he does not continually ask for it. so he does not become a drug addict” [31]. In other narratives, family members joined with patients and advocated for appropriate pain relief: “I kept stomping my feet. She has cancer. She’s not being treated. She needs pain medicine. I don’t understand why we’re having to fight about it” [34]. In addition, family member concern or misunderstanding of strong opioids could shape their support for patients’ pain management choices: “They [family members] were like, ‘That’s too strong. Maybe you should ask for another medication or not take it.’” [49].

CErqual summary of the review findings

CERQual was used to assess confidence in the four synthesized themes. Overall confidence in all four themes was moderate. The main concerns across included studies were methodological limitations, particularly insufficient reporting of researcher positionality and reflexivity. Nevertheless, the four themes showed good coherence across studies, were supported by adequate data, and were highly relevant to the review question. Detailed CERQual assessments are provided in Supplementary Material 6.

Discussion

This qualitative meta-synthesis identified opioid stigma in cancer pain management as a multilevel and interactional process. It was shaped by sociocultural narratives and institutional practices, internalized by patients as fear and shame, and translated by clinicians into risk-focused and conservative prescribing. These processes affect clinical communication and decision-making, potentially weakening trust and contributing to undertreatment of cancer pain.

Our synthesis aligns with the Opioid Stigma Framework proposed by Bulls et al. [16], which describes opioid stigma among patients with cancer pain in terms of stigma contributors, intersecting stigmas, stigma manifestations, proximal outcomes, and long-term effects. The synthesis builds on this framework by explaining how these stigma processes operate within patient-provider interactions and opioid-related decision-making. The included studies showed that institutional procedures, risk-monitoring practices, and pharmacy-related barriers were important sources through which opioid stigma entered the care process. These sources may reinforce patients’ anticipated stigma, making them worry that pain expression or medication requests will be interpreted as drug-seeking. Such expectations may then be internalized as shame, guilt, and self-scrutiny. Thus, the synthesis further illustrates how stigma extends from institutional and sociocultural contexts to patients’ communication behaviors and opioid-related decision-making in cancer pain management.

From the patient perspective, opioid stigma shaped patients’ pain expression, help-seeking, and medication-use behaviors. Patients in the included studies described concerns about being judged, shame, fear of addiction, and reluctance to disclose pain or request additional analgesia or opioid adjustment. This finding is consistent with Bean et al.’s study, which showed that people with chronic pain may be disbelieved because pain is invisible, be perceived as drug-seeking, and conceal or manage pain to avoid stigmatizing situations [50]. These behaviors are clinically relevant in the context of cancer pain. When patients underreport pain, delay help-seeking, restrict medication use, or avoid discussing opioid-related concerns, clinicians may receive incomplete information about pain severity, treatment response, and patients’ concerns. These behaviors should not be treated simply as poor adherence. Rather, they may represent stigma-avoidance strategies through which patients try to avoid being seen as drug-seeking and preserve the legitimacy of their pain and need for pain relief. Stigma theory further suggests that stigma threatens those aspects of identity, value and relationships which people identify as central to their lives in the social world [17]. In this synthesis, patients often sought to demonstrate the legitimacy of their pain and medication needs by emphasizing that they had cancer-related pain rather than seeking opioids for non-medical reasons. In this way, opioid stigma may reflect a threat to patients’ understanding of themselves and the perceived legitimacy of their need for pain relief [16].

From the clinician perspective, our findings help explain why opioid prescribing for cancer pain may become more cautious or defensive. Conservative prescribing should not be interpreted simply as clinicians’ unwillingness to relieve patients’ pain. Instead, it reflects the difficulty of striking an appropriate balance between adequate analgesia and opioid-related risks, regulatory scrutiny, and individual responsibility for ongoing opioid management [51]. This difficulty may be particularly pronounced in chronic cancer-related pain and survivorship contexts, where long-term opioid therapy is less well studied and clinicians face challenges in balancing chronic pain control with opioid safety [52]. Additionally, opioid-related public policy and legal concerns may inadvertently create barriers to appropriate cancer pain management [51, 53]. Because the 2022 CDC guideline explicitly states that its recommendations do not apply to cancer-related pain, palliative care, or end-of-life care [8], general chronic pain opioid regulations should not be applied rigidly to cancer pain contexts. These findings suggest that improving opioid-related decision-making requires clearer guidance for chronic cancer-related pain and interprofessional support for balancing analgesia and opioid-related risk.

The interactional findings suggest that opioid stigma may change the focus and tone of clinical communication. Clinical interactions should ideally focus on pain assessment, treatment goals, and opioid treatment planning. In the context of opioid stigma, however, these interactions may become shaped by competing concerns: patients’ need to establish the legitimacy of their pain and medication needs, and clinicians’ need to manage the safety and accountability of opioid prescribing. Although information exchange, clarification of patients’ values, discussion of treatment options, and mutual trust were not analyzed as independent outcomes in this review, they are recognized components of shared decision-making [54]. The interactional findings therefore suggest that stigma-related tensions may weaken some of the conditions supporting shared decision-making. Existing studies that have explored the experience of people with OUD in hospital-based care find that “drug-seeking” language or being seen not to take pain seriously may contribute to distrust and avoidance of care, while respectful communication and shared decision-making can foster trust and openness [55]. Therefore, the interactional pathway identified in this synthesis helps explain how opioid stigma may disrupt communication and opioid-related decision-making in cancer pain management. Family members and pharmacy practices also shaped opioid-related communication, revealing that cancer pain management involves not only clinical teams but also caregivers, pharmacy systems, and institutional policies.

Implications for practice and research

The results of this study suggest that efforts to reduce opioid stigma in cancer pain management should go beyond patient-level education or reassurance and address factors related to patients, clinicians, healthcare organizations, and regulatory contexts [16, 18]. The main practice implications are summarized in Table 3.

Table 3.

Practice implications for reducing opioid stigma in cancer pain management

Level	Practice implications
Patient and family	Ask about pain-control goals, functional goals, previous opioid experiences, family beliefs, treatment preferences, and concerns about stigma, dependence, addiction, or being perceived as drug-seeking.
Clinician	Use non-stigmatizing language; avoid labels such as “drug-seeking”; explain the distinctions among tolerance, physical dependence, opioid use disorder, and undertreated pain.
Interprofessional team	Clarify responsibilities for opioid prescribing, risk monitoring, pharmacy communication, and referral to palliative care, pain specialists, or addiction medicine when needed.
Organization and pharmacy	Explain risk-monitoring procedures as routine safety practices; strengthen communication between clinical teams and pharmacies to reduce dispensing-related misunderstandings.

In clinical communication, clinicians should ask about patients’ pain-control goals, functional goals, prior opioid experiences, family concerns, treatment preferences, and concerns about stigma, dependence, addiction, or being perceived as drug-seeking [6]. Risk-monitoring procedures such as urine drug testing, opioid treatment agreements, prescription checks, and follow-up visits should be explained as routine safety practices rather than as indications that a patient is untrustworthy [56, 57]. Clinician education may include cancer pain guidelines, stigma-free language, distinctions among tolerance, physical dependence, opioid use disorder, and undertreated pain, and communication skills for discussing opioid-related risks without labeling patients as drug-seeking [6, 58].

At the organizational level, interprofessional pathways should clarify responsibilities for opioid prescribing, risk monitoring, pharmacy communication, and referral to palliative care, pain management, or addiction medicine when needed. Such teams may include oncology clinicians, palliative care clinicians, pain specialists, nurses, pharmacists, mental health professionals, and addiction medicine specialists [59–61]. Strengthening communication between clinical teams and pharmacies may reduce dispensing-related misunderstandings and barriers to obtaining prescribed opioids for cancer pain. For patients with co-occurring OUD or a history of substance use disorder, early joint assessment by palliative care and addiction medicine teams may be considered [62].

This synthesis also points to directions for future research: First, future studies could develop or adapt opioid stigma assessment tools specific to cancer pain management. Existing opioid stigma measures have largely been developed for people with OUD or chronic pain [63, 64]. Cancer-specific tools may need to capture issues such as legitimate analgesic need, survivorship-related pain, palliative care, family involvement, pharmacy-related barriers, and clinician-related risk concerns. Second, future research should examine opioid stigma across different cancer trajectories and pain contexts, including active cancer treatment, advanced cancer, remission, chronic cancer-related pain, survivorship status, and a history of OUD. Third, intervention studies are needed to evaluate multilevel destigmatization strategies that target patients and families, clinicians, interprofessional teams, organizational procedures, and pharmacy communication. Such research should assess whether these strategies improve communication, reduce stigma-related distress, and support more appropriate opioid-related decision-making in cancer pain management.

Strengths and limitations

This study has several strengths. First, we move beyond explanations of barriers to cancer pain management that focus exclusively on the patient or provider. By integrating insights from patients, caregivers, healthcare providers, pharmacists, and other stakeholders, this review demonstrates how opioid stigma shapes cancer pain management across institutional, patient, clinician, and relational pathways. Second, our findings provide a clearer basis for practical improvements, such as non-stigmatizing communication about pain and opioid use, clearer explanations of risk-monitoring procedures such as urine drug testing and opioid treatment agreements, and interprofessional support for opioid-related decision-making in cancer pain management.

This study also has several limitations. First, most included studies were conducted in the United States, where cancer pain management occurs within an opioid crisis and regulatory environment specific to the US health system. The transferability of the findings to other healthcare, regulatory, and cultural contexts should therefore be considered cautiously. Second, there was insufficient evidence to examine how opioid stigma may vary across age groups or generations, patients with a history of OUD, or patients at different stages of the cancer trajectory. Third, because most included studies were cross-sectional qualitative studies, longitudinal research is needed to examine how opioid stigma changes across the cancer trajectory, including active treatment, advanced disease, and end-of-life care. Finally, some primary studies provided limited information about researchers’ backgrounds and reflexive processes. This made it difficult to fully assess how researchers’ perspectives may have shaped data interpretation.

Conclusion

This meta-synthesis indicates that opioid stigma influences patient-provider interaction and opioid-related decision-making in cancer pain management through institutional, patient, clinician, and interactional pathways. Opioid stigma may foster mistrust between patients and clinicians, lead patients to report or disclose pain more guardedly, promote more conservative prescribing, make the legitimacy of pain and opioid use a central tension during clinical encounters, and potentially contribute to the undertreatment of cancer pain. Future efforts should focus on reducing opioid stigma in clinical communication, explaining risk-monitoring and prescribing processes more clearly, and supporting shared decision-making through interprofessional care.

Authors’ contributions

YXC and RY contributed equally to this work. YXC, RY, MX, and XLZ contributed to the conception and design of the study. YXC and RY conducted the literature search, study selection, quality appraisal, data extraction, and initial coding. YXC, RY, MX, YZ, WYH, and XLZ contributed to data interpretation, refinement of the analytical themes, and revision of the manuscript. YXC drafted the manuscript. XLZ supervised the study. All authors read and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

All data supporting the findings of this review are derived from previously published studies, as cited in the reference list. No new datasets were generated or analyzed during this study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.