Table 2.

Example Quotes From Themes 2, 3, and 4 (Clinic Environment)

Theme	Quote
Theme 2: Patients develop their own clinician archetypes	“But a lot of people come up here for the wrong reasons: welfare, free housing, dope doctors. That’s what we call them. And there’s a lot of them still practicing here in the cities like there are, I’m sure, in a lot of other states also.” [66-year-old male] “I think a lot of clinicians just won’t even prescribe [opioids]. And it seems like every doctor or [physician assistant] has their own ceiling about them.” [59-year-old male] “Well, of course [doctors] have different viewpoints. Well, maybe not viewpoints but different methods of working with the patient. I think they each have their own strategies.” [66-year-old female]
Theme 3: Most patients are open to talking about opioid risks but have diverse preferences on how these conversations should be conducted	“Just to talk with the patient in a caring way and basically letting them know that any of this discussion is information. And so it’s not accusatory, it’s just information.” [59-year-old male] “I know some people are a little more delicate when it comes to [talking about opioids], so I would say knowing your patients and being tactful in your approach.” [33-year-old male] “Well, I guess the doctor’s personality, to start with, if he’s just going – if he’s just textbook and doesn’t seem really caring, doing it because he had to, I think that would give me a bad taste.” [66-year-old male] “If the provider was able to approach it with always positive intentions and assuming transparency and honesty, that might make it go better.” [34-year-old male] “I think dependency and addiction to me sound more like risks of the prescription, and misuse sounds more like problems I might have myself, that I might cause or that I might do to myself. So that has a slight accusatory connotation I think to it. Where the other ones feel like side effects that could be unintended. None of them seem bad.” [34-year-old male] “So when you say addicted, it’s such a negative word. And when you say misuse, it seems very deliberate when you’re telling a patient, ‘You’re misusing. You’re deliberately doing something wrong.’” [60-year-old female] “I used to feel really badly about that word [addict], actually, because I had always used it for my mom and people who I thought put themselves in a situation to become an addict. So I actually prefer the word dependent -- opiate dependent over addict, for me – to refer to me. … I guess I would rather say, ‘You can become a dependent.’ Those wordings, I guess, I like better.” [40-year-old female] “Addiction would give me a bad feeling.” [59-year-old male] “[Conversations go poorly] if there’s more of a blaming attitude to it or an assumption. If that were me, I feel distance between the doctor and myself, threatened.” [66-year-old female] “I guess for the relationship that I have with [my PCC], I go see him about everything, so if he wanted to talk about opioids he could.” [42-year-old male] “I understand [opioid problems] … coming from a family of people with addiction issues, it wouldn’t faze me personally. I would understand what they were trying to convey.” [47-year-old male] “Just by the way they would speak about [opioids] and it made me feel like if I had to take them that I’m some sort of, I don’t know, lower than them or just that, some sort of criminal or something.” [59-year-old male]
Theme 4: Primary care is an appropriate setting for these discussions	“Oh, my primary care. I trust him and his judgment more than anything.” [58-year-old male] “I think it’s 100% important [for doctor to have these conversations]. And I think all of your doctors should be in contact with each other, especially your primary care doctor should know who your other doctors are in all of your care, and any medications they’re prescribing you, like a psychiatrist or somebody doing methadone maintenance. Any doctor that’s involved in your health care, your primary should know all of them and what they’re prescribing.” [40-year-old female] “I would say it’s extremely important [for primary care doctors to talk about opioid risks]. And then your primary care physician is your interface with the system. So this is the person you rely upon for medical advice. And they know you. They have a relationship with you.” [67-year-old male] “First of all, I trust [my PCC]. I trust her ability to advise me in any fashion. Plus, she has an overall view of what I’m going through with respect to any degree of my medical history.” [61-year-old female] “And they should say, ‘Hey, you need to go see a specialist – a pain doctor – and let them do what they do to figure out how much your dosage should be.’ I don’t think a primary care one should be – he’s only got limits. That’s why they have specialists.” [64-year-old male]