“I Refused to Get Addicted to Opioids”: Exploring Attitudes About Opioid Use Disorder in Patients With Advanced Cancer Pain and Their Support People

Abstract

Patients with advanced cancer are commonly prescribed opioids, yet patient attitudes about opioid risks (eg, opioid use disorder, or OUD) are understudied. Our objective was to use in-depth qualitative interviews to understand perceptions of opioid prescribing and OUD in patients with advanced, solid-tumor cancers and their support people. We conducted a qualitative study using a rigorous inductive, qualitative descriptive approach to examine attitudes about OUD in patients with advanced cancer (n = 20) and support providers (n = 11). Patients with cancer hold 2 seemingly distinct views: prescription opioids are addictive, yet OUD cannot happen to me or my loved one. Participants described general concerns about the addictive nature of prescription opioids (“My biggest concern… would just be the risk of getting addicted to the medication or even like, overdosing it”), while separating cancer pain management from OUD when considering prescription opioid risks and benefits (“They need to make sure they get the right ones, when they’re taking it away from you.”). Finally, participants identified personal characteristics and behaviors that they felt were protective against developing OUD (commonly control, willpower, and responsibility). This rigorous qualitative study demonstrates that patients with advanced cancer and their support people simultaneously hold concerns about the addictive nature of prescription opioids, while distancing from perceptions of OUD risks when using opioids for cancer pain management. Given high rates of opioid exposure during advanced cancer treatment, it is important to explore opportunities to promote a balanced understanding of prescription opioid use and OUD risks in this population.

Introduction

Patients with cancer, especially those with advanced disease, are exposed to prescription opioids at high rates. Prescription opioids are considered standard, guideline-concordant care for moderate-to-severe cancer pain, and many policies and clinical guidelines exempt patients with cancer from opioid prescribing restrictions.^3,8,15,37,51 These exemptions may be motivated in part by a common perception that patients with advanced cancer are nearing the end of life. However, as treatments evolve and prognosis improves for many types of advanced cancer, finding balance between pain management and opioid risks (eg, opioid use disorder, or OUD) is a more complex and salient issue.^2,18,38,39

From recent evidence, it is clear that patients with cancer have a complex relationship with opioid pain management. They are prescribed and accept opioid prescriptions at high rates, yet many also under-use their prescription opioids and express fear, guilt, and shame about their prescription opioid use and report systemic barriers to access.^{5,7,10,11,25,28} Understanding OUD risk is important when making decisions about opioid pain management, yet there is little evidence to guide patients with cancer and their prescribers. Though it is difficult to pinpoint rates of opioid misuse and OUD in patients with active disease, it is generally assumed that opioid misuse/OUD rates are similar to the general population and carry significant potential risks for patients using prescription opioids for cancer pain.^12,41,52

In the absence of clear, compelling evidence to direct decision-making, patient attitudes and beliefs about prescription opioids (including perceptions of OUD) carry important implications about how patients engage in cancer pain care. For example, patients with cancer who believe prescription opioids to be uniformly addictive may hesitate when offered guideline-concordant, clinically indicated opioids, resulting in under-managed pain. Additionally, for the subset of patients who do develop opioid misuse/OUD during the course of cancer pain management, negative attitudes about OUD may deter them from seeking necessary care. Negative oncologic outcomes that may accompany an OUD diagnosis include impaired relationships with clinicians and personal support systems, which can then result in reluctance to treat cancer and/or cancer-related pain.^13,35

Interviewing patients directly is critical to understand how perspectives about two common occurrences—opioid pain management and OUD—intersect in the context of advanced cancer pain. Research indicates that active patient engagement in their own care, and particularly perceptions of self-efficacy and self-advocacy, is associated with improvements in pro-healthy behaviors and decreased negative outcomes.^17,34,48 Support people are often centrally involved in advanced cancer care and pain management and provide critical support, including day-to-day medication management, attending appointments, and procuring medications.^{29,32,33,42,45} Support people may have direct experiences with systemic barriers to effective pain care that the patients themselves do not, depending on how they provide support (eg, if the support person picks up all medications from the pharmacy). Unfortunately, the lack of clear guidance on the benefits and risks of opioids extends to support people, and there is reason to believe that their attitudes about prescription opioids can directly impact the patient. For example, evidence suggests that family hesitancy to use analgesics is associated with suboptimal medication adherence in patients with cancer.³⁰ Thus, it is important to include support people in cancer pain management research to ensure a robust understanding of challenges. In this study, our objective was to use in-depth qualitative interviews to understand patient and support person perceptions of opioid prescribing and OUD in the context of cancer pain management.

Methods

Here, we present a secondary analysis of in-depth qualitative interviews with patients with advanced cancer and their support people. This analysis focused on the topic of opioid pain management and OUD in the context of advanced cancer pain, while a prior analysis of this dataset focused on manifestations of prescription opioid stigma in this population.¹⁰ The eligibility criteria, recruitment methods, and qualitative analysis approach has been presented in detail elsewhere.¹⁰ Relevant details for the current analysis are described below. This study was approved by the University of Pittsburgh Institutional Review Board and all participants provided informed consent.

Inclusion/Exclusion Criteria

Eligible patients were adults with advanced (stage III or IV) solid tumors currently receiving care from a UPMC Hillman Cancer Center medical oncologist. All participants were required to report current or prior experience with prescription opioid pain management. Participants were eligible for the study if they were prescribed opioids that they were currently taking for moderate-to-severe pain related to cancer or its treatment, or if they had been offered prescription opioids for moderate-to-severe pain (even if they did not choose to use them at the time of interview). Eligible support people were adult family members or friends of a participating patient, who were identified by the patient as the person most involved in their care. Inclusion criteria for patients and support people included 1) ability to participate in an in-depth interview, 2) telephone access for study contact, and 3) ability to respond to questions in English.

Recruitment Approach

UPMC Hillman Cancer Center medical oncologists who participated in a prior qualitative study on pain management in patients with advanced cancer identified and approached potentially eligible patients under their care and obtained permission for study team contact.⁴⁴ A study team member approached patients in person during a regularly scheduled clinical visit or via phone at a time convenient for the patient to explain the study and document verbal consent. Once identified by an eligible patient, support people were approached in person (if present in the clinic with the patient) or via phone. Patients were not required to identify a support person, though they were encouraged to include a friend or family member with knowledge of their care if available.

Qualitative Interview Methods

We used an established inductive, qualitative descriptive approach to analysis in this study.^27,43 The PI developed initial interview guides, which were refined for clarity by the qualitative methodology team. This secondary analysis focused specifically on participant perceptions of OUD in context of cancer pain management. Interviews lasted approximately 45 minutes. All interviews were conducted by trained qualitative interviewers via phone (patients: F.C., support people: R.W.). Interviewers reported preliminary findings to the study team throughout data collection. Each interview was recorded, transcribed verbatim, and identifying detailed redacted prior to analysis. Sample size was determined by the concept of thematic saturation (eg, the point at which conducting additional interviews does not result in new insights). We planned to interview 20 patients and 10 support people in anticipation of reaching thematic saturation. Interviewers kept detailed notes during data collection to facilitate the decision point as to when thematic saturation was reached.

Data Analysis

Established procedures for thematic analysis were followed in the data analysis phase.^6,21 One interviewer (R. W.) served as the primary coder and analyst for both patient and support person interviews. Transcripts were reviewed by the primary analyst (R.W.) and the lead qualitative methodologist (M.H.) as they were produced in order to create inductively derived codebooks tailored to each set of interviews. To ensure consistency in coding, 2 experienced qualitative coders (R.W., B.K., supervised by M.H.) coded 16 of 20 patient transcripts and all of the support person interviews (11) and resolved coding differences as necessary. The remaining 4 interviews were coded independently by the primary coder (R.W.). Once coding was finalized, the primary coder reviewed the coding to conduct both content and thematic analyses of both sets of data.²³ The content and thematic analyses were presented to the PI and the rest of the study team for review and refinement as a form of investigator triangulation.

Results

A total of 20 patients and 11 support people participated in the interviews (March 2020–May 2021). Participant characteristics are summarized in Table 1. Patients were 50% female, 100% non-Hispanic and 90% White, located in urban areas (75%), and had an average age of 66.2 years (range 41–95). Support people were primarily female (73%), all non-Hispanic white, located in urban areas (64%), and had an average age of 50.5 (26–74). Most patients reported being diagnosed with their current cancer 1 to 2 years prior to the interview, with an initial diagnosis range of 1 month to 12 years. The majority used 1 or more prescription opioids to manage cancer-related pain (16/20).

Table 1.

Participant Characteristics

	Patients (N = 20)	Support providers (N = 11)
Age: M (Range)	66.2 (41 – 95)	50.5 (26 – 74)
Gender: N (%) female	10 (50%)	8 (73%)
Race: N (%)
African-American/Black	1 (5%)	0 (0%)
Asian	1 (5%)	0 (0%)
White	18 (90%)	11 (100%)
Ethnicity: N (%)
Hispanic	0 (0%)	0 (0%)
Non-Hispanic	20 (100%)	11 (100%)
Location: N (%)
Urban	15 (75%)	7 (64%)
Rural	5 (25%)	4 (36%)
Primary cancer diagnosis: N (%)
Lung	5 (25%)	-
Prostate	3 (15%)	-
Renal	3 (15%)	-
Anal	2 (10%)	-
Breast	2 (10%)	-
Esophageal	2 (10%)	-
Colorectal	2 (10%)	-
Stomach	1 (5%)	-

Percentages rounded to the nearest whole number.

Of the 31 total participants, 9 were patient/support person dyads. Eleven patients did not identify a support person. In two cases support people were referred by consented patients and completed the interview, but the patients were lost to follow-up despite repeated contact attempts.

A total of 19/20 patients interviewed indicated that their pain was managed by an oncologist or radiologist, with 3 patients reporting comanagement by a PCP. One participant did not know the role of the provider who prescribed their pain management medications. No patient participants reported current or past OUD. One support person described a distant history of heroin addiction in the referring patient, who was lost to follow-up. Nearly half of the sample (14/31) endorsed personal exposure to OUD in family relationships, friendships, or other relationships, including 6 of 20 patients and 8 of 11 support people.

In addition to quotes below, additional exemplary quotes for each theme are shown in Table 2. Stigmatizing language is used in the quotes, and this language is replicated only to remain true to the interviewee’s words.

Table 2.

Selected Exemplary Quotes

Theme 1: Participants described general concerns about the addictive nature of prescription opioids.
“…that’s something she always wanted to shy away from, and then whenever you start talking OxyContin, you’re talking a whole different animal there, especially with all the people that get addicted to it and everything. With that reputation it gets almost scary. … Getting hooked on it. That would be a situation that I would be scared of, because you see how it affects a lot of good lives.”
Support Person 11
“No, it’s a very bad drug and there are a lot of good people that are hooked on it that have no control from– actually, they’re taking more than what they should be taking…”
Patient 10
“Again, my concern with that would just be the risk of getting addicted to the medication or even like overdosing it, God forbid, but that would be my biggest concern.”
Support Person 6
Theme 2: Participants distanced cancer pain management from opioid use disorder when considering their own perceptions of opioid risks and benefits.
“I think it’s just because of so much abuse has happened with the opioids, and being highly addictive. They’re just, they just seem to be really cautious about wanting to prescribe the opioid type medications. Which I understand, however, he has cancer. So, it’s like there’s not a kind of a line drawn for someone that has cancer to receive these medications, versus someone that doesn’t have cancer, but still needs some type of pain management, or those that don’t really have pain, that say they do, and are just addicted to the opioids. I just feel that there should be a stronger acknowledgement of cancer pain and what should be prescribed versus others that don’t have cancer that also need pain management.”
Support Person 7
“…[I wish people understand that cancer] is painful and that just because people are taking oxycodone doesn’t mean they’re a drug addict. People are not drug addicts. People that have cancer, who have cancer pain, need to manage their pain to function. And there’s obviously a stigma associated with opioids. … Somebody who has an addiction issue as opposed to someone who has cancer and is trying to manage a very difficult situation the best way the doctors and science know how. It makes them feel like– I think it probably makes them feel sometimes like people have a perception that they’re the person on the street looking to score a few more pills or something, as opposed to, “No, I have pain, and this is how I manage it.”
Support Person 9
“… It’s none of the people that need it that’s the problem. Like for me, my situation, that isn’t the problem. It’s the drug addicts that’s causing this situation. Wherever they’re getting the drugs and selling them. Because people who are dying left and right. …I’m sure there’s people out there that are taking it that get prescriptions. They make it up. They make up reasons to get– go say their back hurts to try to– something that they can’t pinpoint, so they can get medicine, like whiplash. I don’t know. I don’t think you can pinpoint whiplash. But they give you medicine for. Those kind of people, yeah, they’re abusing it. It’s the people who abuse it that’s the problem.”
Patient 12
Theme 3: Participants conceptualized opioid use disorder as a choice, and identified personal characteristics and behaviors that they felt were protective against developing OUD.
“[The patient] seems, she’s a very strong willed person. And she’s determined to not abuse it. I know that it’s sometimes out of your control when you’re taking drugs, but, she seems to be with it, as far as the pain medication’s concerned.”
Support Person 1
“My household would not abuse medications… Well, I said anybody that I could control wouldn’t abuse medications… this business about an opioid crisis and it leading to addiction is nonsense, because it’s just a matter of choice. …from a woman who has had her fair share and opportunity to use the medication as it’s prescribed or to go ahead and have a party with it, there is no freaking need if you care enough about yourself. There is no need to do that.”
Support Person 5
“…I’m using it for my pain, where I think a lot of these drug people just use it, like I said, they get high, or whatever they happens to them. … I just think [members of her family] were, they wanted to be dopers. That’s awful to say, but it’s just the people they ran with, and the way that they were. It seemed like they liked it.”
Patient 4
“I really wasn’t one to be addicted to anything, and I sure don’t want this. Actually, I refused to get addicted to these opioids.”
Patient 7

Theme 1: Participants Described General Concerns About the Addictive Nature of Prescription Opioids

Patients and their support people commonly understood that prescription opioids can be highly addictive. As one support person noted, “the only concern I would have is, you know, the possibility of getting addicted to them… I know it can be easy to get addicted to those types of medications sometimes.” (SP6). Concerns were general, commonly noting that anyone can get addicted to prescription opioids in light of the opioid crisis. Occasionally, participants endorsed wariness of prescription opioids specific to cancer pain management, stating that they found prescription opioids “kind of scary.” As 1 support person described,

“If [patient] wasn’t as careful as she was, I’d probably be a little more nervous about again, it being addicting. I mean, we live in an area where a lot of people take those type of medications illegally, so. We know what it’s like, we’ve seen it.

… It just seems like a lot of people end up addicted, and like it just ruins their entire life.”

(SP3)

When considering their concerns about OUD, several participants simultaneously highlighted the need to effectively manage cancer pain. For example,

“Gosh, the addiction factor is there. So that’s the biggest concern, and which is I suppose why doctors are hesitant to prescribe them in the first place. But, there doesn’t seem to be anything else. So it’s a needed medication with that kind of double edged sword.”

(SP7)

Many patients described hesitancy on the part of their non-specialist providers (ie, their PCPs) to prescribe prescription opioids, and nearly all patients in the sample who were using opioids to manage their pain were doing so under the care of an oncologist or radiologist, as noted above. Indeed, despite their concerns about OUD, participants felt that cancer pain could be severe enough to warrant the use of opioids to control it, as discussed below in theme 2.

Theme 2: Participants Distanced Cancer Pain Management From OUD When Considering Their Own Perceptions of Opioid Risks and Benefits

While participants endorsed concerns about prescription opioids, they also considered the risks and benefits of prescription opioids for advanced cancer pain to be unique. In their view, the unique benefits for treatment of cancer-related pain outweighed the risks. Cancer pain was defined as “real” pain for which opioid pain management was typically justified (“trying to manage a very difficult situation the best way the doctors and science know how”).

Participants typically distinguished between cancer pain and OUD, with little to no overlap. Rather, participants identified several “other” groups they perceived to be responsible for the opioid crisis and its ripple effects to patients with cancer pain. These “other” groups were spontaneously mentioned by most participants in response to a general prompt about what they know about the opioid epidemic, and included young people who use the medications recreationally, the government, pharmacists who dispense opioid prescriptions, and clinicians who over-prescribe opioids. As one patient commented, “I think [the opioid crisis] needs to be taken under control. But, you know, hey, some people are abusing it big time, and some aren’t. So they need to make sure they get the right ones, when they’re taking it away from you.” (Pt2).

Here, Pt 4 describes their experience working at a pharmacy:

“… we got a lot of druggers. You know, it was, it’s sad what happens to them… a lot of them would start out with some, a type of pain. And then they would, they’d get so hooked on it. And, and they must have been taking more and more and more… I mean it was sad that you would get that hooked on something that…”

However, when this participant was asked if these observations influenced their views on prescription opioids for their cancer pain, the patient responded:

“No… Because I feel that I’m responsible…. And I’m using it for my pain, where I think a lot of these drug people just use it, like I said, they get high, or whatever.”

(Pt4)

While most participants felt that opioid therapy was appropriate for management of their pain, and that careful use of opioids as prescribed would prevent OUD, a few participants reflected on the potential overlap between patients with cancer and OUD. One participant noted that developing a substance use disorder can be “out of your control when you’re taking drugs,” (SP1) while another commented on the potential to become addicted to opioid medication even when it was taken for the purposes of pain management:

“…And the addiction of [prescription opioids] is, it is really easy to get addicted to it. I mean if you’re not one to be careful, and let your guard down, and I mean, a lot of people I know as soon as they get a slight bit of pain, they’ll take them every two hours, or every hour. And then, they’re out buying them off the street, so …”

(Pt7)

Even in this quote illustrating awareness of the possibility to become addicted to opioids when taken for pain management, though, the participant indicates that this can happen easily but only if you “you’re not careful” or “let your guard down,” indicating personal responsibility for the problem. Thus, while there was some participant awareness of the possibility of being addicted to opioids, the benefits of opioid pain relief for cancer-related pain were perceived to outweigh the risks, and participants generally believed that taking opioids as-prescribed (ie, being “responsible”) was protective against the risk of OUD.

Theme 3: Participants Conceptualized OUD as a Choice, and Identified Their Own Personal Characteristics and Behaviors That They Felt Were Protective Against Developing OUD

The majority of participants conceptualized OUD as a choice, not a disease. Participants used several stigmatizing terms to describe people with OUD, including “drugger,” “doper,” “junkie,” and “pill popper.” In contrast, most participants perceived patients managing cancer with prescription opioids, to have protective characteristics like personality (“I’m not one to get addicted to things”), personal responsibility, caring about oneself, and willpower (“I refused to get addicted”). As one participant commented,

“[People with OUD] didn’t follow things. They got addicted. That’s not my fault. It’s no one’s fault except their own. We all have free will… It’s just everyone has to take responsibility for themselves…

… I take it for pain, not if I’m doing okay. Again, there’s that free will. See, I could have took it, could get addicted and blame someone, but I didn’t take it because I didn’t need it.

…I preach to [people in their personal life] on free will. You can be a junkie if you want to, but you don’t have to be. Congress made it, “You take one or two pills. Now you’re hooked.” No, you’re not. It’s all in how you take it.”

(Pt16)

Participants also described behaviors they viewed as protective against the risk of OUD. Many participants emphasized the need to carefully control opioid medications, take them exactly as prescribed, and never take more than necessary. In 1 case, a participants described under-using their medications and suggested alternate behaviors in lieu of opioid use. For example, Pt 10 stated “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. That’s the best I can tell you.” Most participants, however, relied on simply taking them exactly as prescribed.

Their conceptualization of OUD as a choice, and of themselves as choosing not to become addicted, was reflected in participants’ descriptions of themselves as comfortable discussing pain management and their opioid use with their oncologists. One participant worried that their provider might “look at me like I’m an addict” if they felt the need to ask for more opioid medication, and thus planned never to do so. However, nearly all participants felt that because their opioid use was within the limits prescribed by their oncologists for the purpose of alleviating “real” pain (as described in Theme 2), there was no reason to feel uncomfortable discussing it with their prescribing clinicians. Thus, participants largely felt that they, as cancer patients with cancer-related pain, were not susceptible to OUD as a result.

Discussion

This qualitative study explored patient and support person perspectives on opioid prescribing for cancer pain management and attitudes about OUD. Findings suggest that patients with cancer are acutely aware that opioids carry potential for OUD, yet they do not necessarily connect perceived opioid risks to cancer pain management. This study contributes to the literature by examining the intersection of 2 complex issues, opioid pain management and OUD, in a population commonly exposed to prescription opioids during routine cancer pain care.

Our prior work found that patients with advanced cancer and their support providers endorse manifestations of opioid stigma in pain management, including negative internalized attitudes, direct stigmatizing experiences with clinicians (primarily outside of oncology, including pharmacists and other specialties/disciplines), and anticipated worry about stigma in the future.¹⁰ Here, we note that patients may also hold stigmatizing views of their own about people with OUD and make efforts to distance themselves from these perceptions. Participants held 2SIX seemingly distinct views – prescription opioids are addictive, yet OUD cannot happen to them or their loved ones with cancer. Differentiating cancer pain from other pain etiologies is common in scientific literature, medical practice, and in the public sphere (eg, exemptions to laws regulating opioid prescribing for patients with cancer).^3,8,16,40 Arguably, distinctions between patients with cancer and others may also be influenced by empathy for those with pain due to a serious, possibly life-limiting condition like advanced cancer. It may be commonly assumed that patients with advanced cancer are near the end of life, which has changed over recent years for many cancers as interventions improve. One possible explanation for the distancing observed in this study is that patients and their support people are aware of their exempt status and wish to preserve ongoing access to opioid pain management. Another reasonable possibility is that cancer exemptions lead people to assume there is solid evidence that patients with cancer are not at risk for misuse and OUD. In reality, there is little literature specifically examining rates of OUD in patients with advanced cancer, nor how risks and benefits may shift for those with lengthy prognoses. Current estimates often rely on inferences from the general population that may not be representative of patients with advanced cancer. Additionally, little is known about how lengthening prognoses and evolving cancer treatments may influence pain rates and perceived opioid benefits and risks in ths population. Thus, research to identify precise rates of OUD and risk factors for co-occurring OUD and cancer pain, including the potential clinical implications of novel treatments and clinical outcomes, is critically needed.

Participants described several personal characteristics and behaviors they perceived as protecting against personal OUD risks. Many participants focused on control, in which they felt confident in their ability to take medications exactly as prescribed and described themselves as responsible and careful. It is unclear whether these characteristics and behaviors are actually effective at reducing OUD risks, and some behaviors may actually have unintended negative consequences (eg, under-treated cancer pain). However, it is possible that patients may be open to learning evidence-based risk mitigation strategies for opioid pain management (eg, education about prescription opioids and OUD risk, improving patient-centered strategies for opioid monitoring, complementary/behavioral management strategies to maximize pain control).^22,24,36,47 Future studies should seek to develop interventions that reduce OUD risk and optimize pain management in this complex population.

Another notable finding from this study is that participants used stigmatizing language to describe people with OUD, including charged terms like “druggers” and “dopers,” and conceptualized OUD as a moral failing. These attitudes mirror a pervasive cultural stigma around OUD, despite efforts to shift to a disease-based model.^1,49,50 Addiction stigma is a well-established barrier to effective medical care.^1,49,50 In that context, patients may be highly motivated to quash any perceptions that OUD could develop because of their opioid pain management. Patients who completely distinguish between cancer and OUD may also feel risk-mitigation strategies are unnecessary, then later fail to recognize concerning behaviors should they develop. This perception may be falsely reinforced by clinicians, who may also view risks as minimal and not assess opioid behaviors routinely throughout cancer care. Additionally, patients with co-occurring cancer pain and OUD may feel pressure to hide their current or past OUD, minimize symptoms, and avoid care altogether for fear of judgment and rejection. Future clinical efforts should focus on destigmatizing OUD, maximizing access to OUD care, and providing education about how OUD develops. From a policy perspective, future directions of this work could include 1) revision of national guidelines to discuss evidence-based management approaches for co-occurring OUD and cancer pain, and 2) updated state and federal opioid prescribing policies to optimally balance cancer pain management and OUD risk, along with expanded access to OUD treatments, for patients with advanced cancer.

Limitations to this study must be acknowledged. One limitation of our study is that our sample is lacking in racial and ethnic diversity, and primarily resided in urban areas. Disparities in access to guideline-concordant opioid pain management are well-documented in underserved groups, especially for people of color.^{4,9,14,19,20,26,31,46} Our sample was limited in part by a sampling strategy that relied on oncologist referral without specifying specific goals for patient attributes, combined with a primarily non-Hispanic White patient population. Thus, future research must focus on perspectives from diverse, underserved communities to inform robust and broadly inclusive interventions. Other limitations to transferability include the fact that most of our participants had their pain managed by their oncologists, which is not always the case and may reflect a sample with particularly supportive oncologist-patient relationships. These limitations are offset by the considerable strength of being the first study to investigate these concepts in depth.

In summary, this qualitative study provided evidence that patients with advanced cancer and their support people simultaneously hold concerns about the addictive nature of prescription opioids, while distancing from perceptions of OUD risks when using opioids for cancer pain management. Given the high rates of opioid exposure during treatment for advanced cancer, it is important to optimize prescription opioid behaviors and cancer pain management, minimize OUD risk, and destigmatize OUD care for patients with advanced cancer. Future research should examine opportunities to develop new, innovative strategies to promote effective pain management in this complex population.

Perspective:

Though prescription opioids carry risk of OUD, there is little data to help guide patients with advanced cancer. Findings suggest that there is a need to develop new, innovative strategies to promote effective pain management and minimize opioid risks in this complex population.