Communicating about 

Opioids for Chronic Pain: 

What Really Happens in Clinic 

Visits?

Marianne S. Matthias, Ph.D. 

Research Scientist, VA HSR&D Center for Health 

Information and Communication, Roudebush VAMC, 

Indianapolis, IN

Research Scientist, Regenstrief Institute, Indianapolis, 

IN
Pain is a significant health 

problem

• Over 100 million Americans suffer from pain

• Analgesics are second most prescribed class of 

drugs = 12% of all prescriptions in 

ambulatory office visits

• Over $600 billion/yr in health care costs and 

lost worker productivity
Communication is difficult in chronic 

pain management

• Research has described a “burdened physician- patient relationship.”

– Power struggles

– Threats to trust

Bieber C, Muller KG, Blumenstiel K et al. Long-term effects of a shared decision-making intervention on 

physician-patient interaction and outcome in fibromyalgia: a qualitative and quantitative 1 year follow-up of a 

randomized controlled trial. Patient Education and Counseling. 2006;63:357-366 

Kenny DT. Constructions of chronic pain in doctor-patient relationships: bridging the communication chasm. 

Patient Education and Counseling. 2004;52:297-305 
Effects on Patients

• Poor communication has led to adverse 

health effects: 

Patients w/ back pain who disagreed with 

physicians about cause, diagnostic plan, and 

treatment plan for back pain

– Decreased satisfaction

– Lower SF-36 scores for mental health, social 

function, and vitality (than pts who agreed with 

physicians)

Staiger TO, Jarvik JG, Deyo RA, Martin B, Braddock CH. Patient-physician agreement as a predictor of 

outcomes in patients with back pain. J Gen Intern Med. 2005;20:935-37.
Effects on Patients

• Burdened and depressed when physicians did 

not believe their pain complaints

• Interactions “strenuous,” “complicated,” 

“heavy”

Werner A, Malterud K. It is hard work behaving as a credible patient: encounters between women 

with chronic pain and their doctors. Social Science & Medicine. 2003;57:1409-1419.
Effects on Providers

• Caring for patients with chronic pain: a 

“thankless task” in which they are “confronted 

with failure every day.”

• 73% of VA providers: “major source of 

frustration”

Kenny DT. Constructions of chronic pain in doctor-patient relationships: bridging

the communication chasm. Patient Education and Counseling. 2004;52:297-305

Dobscha SK, Corson K, Flores JA, Tansill EC, Gerrity MS. Veterans Affairs primary care 

clinicians‘ attitudes toward chronic pain and correlates of opioid prescribing rates. Pain 

Medicine. 2008;9:564-571
Effects on Providers

• “Frustrating”

• “Overwhelming” 

• “Ungratifying”

• “Feeling Guilty”

• “Unsuccessful as a doctor”

Matthias MS, Parpart AL, Nyland KA, Huffman MA, Stubbs DL, Sargent C, Bair MJ. The 

patient-provider relationship in chronic pain care: providers' perspectives. Pain Medicine 

2010;1688-97.
Why is communication 

difficult?

• Subjective nature of pain

• Clinical uncertainty in pain management

• Negative provider attitudes and lack of 

training 

• Controversial treatments (e.g., opioids)
Opioids: Major Source of 

Communication Problems

• Feeling pressured to treat with opioids

–Guilt

– Fear of being “fired”

– Patient demands for opioids: “It was like 

you go to the McDonald’s drive-through and 

you order what you want, and they should 

give it to you.” 

Matthias et al., Pain Med, 2010
Opioids for Chronic Pain

• Dramatic increase in prescriptions in recent 

decades (Caudill-Slosberg et al., 2004; Compton 

et al., 2006; Zerzan et al., 2006)

• Similar increases in misuse (Warner et al., 2011)

• Opioids for chronic non-cancer pain are 

controversial

– Benefits are unclear (no long-term studies, see 

Manchikanti, 2011)

– Some observational studies raise questions about 

long-term benefits (e.g., Dillie et al., 2008; Sjogren et 

al., 2010)
Communication is Especially Important 

in Opioid Management

• Much opioid management is based on 

communication

– Decision-making about opioid treatment (opioid 

initiation, changes in dose, tapering)

– Discussion of risks and benefits of opioids

– Opioid monitoring strategies
Communicating about Opioids

• In sum, communicating about chronic pain in 

primary care can be challenging, especially if 

opioids are involved.

• Patients and providers have expressed this in 

interview studies.

• Very little research examining the actual 

communication in clinic visits that takes place 

between patients and providers about chronic 

pain.
Pilot Study 

• To better understand communication 

behaviors in clinic visits

• Setting: 5 primary care clinics at RVAMC

• Participants: PCPs and their patients. Patients 

had 1) diagnosis of chronic pain (ICD-9 codes) 

that persisted ≥6 mos , 2) at least moderately 

severe pain (≥4) recorded at their last primary 

care visit, and 3) had an appointment with 

PCP during study period
Methods

• Audio recording of regularly scheduled 

primary car visits

• Patients were told the study was about 

communication, but not about pain, so that 

pain discussions would emerge naturally.

• Patients were interviewed after PCP visit 

about their PCP, their pain experiences, and 

pain treatments.
Data Analysis

• Two data sources:

– Audio and Transcripts of PCP visit

– Audio and Transcripts of qualitative interview with 

patient

• Immersion/crystallization approach

– Iterative process

– Organized data into meaningful units

– Inductively developed categories (codes)

– 4-member analytic team
Results

• 5 PCPs participated

– All physicians

– 3 female

– Years of practice 6-23 years

• 40 patients participated

– Pain not discussed in 10 appointments, so these were dropped 

from analysis

– 4 women

– 7 African American

– Ages 27-70 (mean=57)

– Duration of pt/PCP relationship: 0 (first visit)-16 years (mean=4 

years)

– 17 low back pain; 13 arthritis
Results

1) How do doctors and patients communicate 

about opioids? 

Matthias, M.S., Krebs, E.E., Collins, L.A., Bergman, A.A., Coffing, J., & Bair, M.J. (2013). “I’m not 

abusing or anything”: Patient-physician communication about opioid treatment in chronic pain. 

Patient Education and Counseling, 93, 197-202. 

2) What influences these communication 

patterns and patients’ interpretations of 

physicians’ opioid prescribing decisions? 

Matthias, M.S., Krebs, E.E., Bergman, A.A., Coffing, J., & Bair, M.J. (2014). Communicating about 

opioids for chronic pain: A qualitative study of patient attributions and the influence of the 

patient-physician relationship. European Journal of Pain. DOI:10.1002/j.1532-2149.2013.00426.x.
1) Communicating about Opioids

• Some discussions about opioids were brief: 

renewal of an opioid, no further discussion

• Other discussions revealed 3 patterns of 

responses to uncertainties about opioids:

– Reassurance

– Avoiding Opioids

– Gathering Additional Information
Pattern 1: Reassurance

• When either patient or PCP raised an issue 

related to opioid misuse or addiction, the 

other often responded with reassurance.

• These issues were most frequently raised by 

PCPs.

• One participant, in his interview, recounted a 

discussion of reassurance with his PCP:
Reassurance

“He told me that it [the prescribed opioid] was 

addictive, and he would only give me so many 

pills at a time. And I told him that he don’t have 

to worry about it, ‘cause I’m not gonna take any 

more than I have to.”
Reassurance

• Candid clinic discussions about concerns over 

opioids:

Physician: I’m hoping we could help you to cut 

back on this other stuff, this crap that we’re having 

to give you because they’re not controlling...that 

methadone’s not good. Period. It’s not as 

dangerous as some drugs, it’s just the side effects 

and dealing with, you know...

Patient: Possibly addiction and whatnot

Physician: Yes, exactly
Reassurance

This patient goes on to reassure his doctor:

“I think I’m doing pretty good...I don’t have to 

double up [on the methadone dose] every night. 

I’m not abusing or anything.”
Pattern 2: Avoiding Opioids

• Sometimes patients and/or their physicians 

preferred to face the uncertainties presented by 

opioid treatment by avoiding the medications 

altogether.

• For patients, fear of addiction led to the desire to 

avoid opioids:

– (Interview) “They said, we’ll give you those pills...and I 

said, those are addictive. I don’t want that.”

– (Interview) “I’m trying to stay off narcotics. I don’t 

want to get addicted.”
Avoiding Opioids

• Patient/physician concordance

Physician: (to patient in clinic visit) “The more 

you can stay off these medicines—one patient 

after another are on narcotics, and once they’re 

on, can’t get ‘em off.”

Patient did not reply, but said in interview: “I’m 

really happy not taking narcotics.”
Avoiding Opioids

• The following physician expressed the desire 

to discontinue opioids and explore alternative 

treatments—did not bring up addiction 

concerns.

• The patient agreed, but emphasized in his 

interview that his concern was risk of 

addiction.
Avoiding Opioids

Physician: I’m going to give you no hydrocodone 

refills, because my goal is after your injection you’re 

not going to be having much pain.

Patient: Yeah. I don’t think I’m going to need 

anything.

Physician: I think you’re potentially going to have 

chronic back issues. If we can help you with a 

couple of things. One, weight loss, two 

strengthening your back with physical therapy, I 

think it’s going to help you in the long run.
Avoiding Opioids

In his interview, the patient agreed with his 

doctor’s approach, saying, 

“I don’t take [hydrocodone] unless I have to, 

because I don’t wanna get hooked on anything.”
Pattern 3: Gathering Additional 

Information

• Sometimes patients and physicians reacted to 

uncertainty about opioids by having extended 

conversations to gather more info.

• Sometimes more info included requests for 

urine drug screens.

• Often included candid discussions about 

opioid misuse that explored issues of trust, 

particularly when patients had history of 

substance use disorder.
Additional Info

• This physician had a candid discussion with a 

patient with history of cocaine use about the 

possibility of opioid misuse.

• First addressed with request for urine drug 

screen, then with further discussion about 

patient’s history
Physician: Have you been using cocaine 

recently?

Patient: No.

Physician: When was the last use?

Patient: Uh, I don’t remember.

Physician: Approximate.

Patient: Maybe a year, year and a half

Physician: Nothing since then?

Patient: No
Physician: Can I do a urine drug screen today?

Patient: Uh...I got a ride. I can come back 

today...I just gotta go out there and tell themPhysician: Will it be clean?

Patient: Can I come tomorrow?

Physician: Will it be clean tomorrow?

Patient: Yeah.

Physician: Okay. My general approach to 

patients that have had a positive urine drug 

screen, which I think yours was in ‘09, I require 

them to go through substance abuse treatment.
Patient: Well, I’m not going to do that, because I 

don’t think it’s necessary. I’ve been going to 

substance abuse treatments all my life.

Physician: Uh huh.

Patient: And you test me, I think you tested me 

last time for drugs.

Physician: Well, it seems like you’ve been doing 

pretty well...Why don’t we check it tomorrow? 

If it’s positive, obviously we’ll put a stop to it, 

but I’m okay renewing your hydrocodone 

[today]. 
• In the end, although the doctor was 

straightforward about his uncertainty about 

opioid misuse, he was willing to give his 

patient the benefit of the doubt.

• Even praised him for “doing pretty well” with 

his substance use.

• Despite this disagreement, they later shared 

laughter over the patient’s weight.
• In his interview, the patient acknowledged 

that he and his doctor have had 

disagreements, but put it in perspective:

“I feel I’ve got more rapport with him over time. 

We’ve had our differences and now we have a 

better relationship. But you know, everything is 

rocky sometimes when you’re dealing with 

people.”
Summary

• Three ways of communicatively handling uncertainty 

about opioids in clinic visits: 1) reassurance, 

2) avoidance, 3) gathering more info.

• Physicians and patients frequently shared concerns 

about opioids.

• Concerns about opioids most frequently revolved 

around fears of addiction or abuse (esp for pts)—most 

common with patients who had history of substance 

use disorder.

• More agreement than disagreement was observed.

http://dx.doi.org/10.1016/j.pec.2013.06.021. 
2) How does the patient-physician 

relationship influence opioid 

communication?

• Sometimes patients responded very 

differently to virtually identical physician 

behaviors and decisions regarding opioids 

(e.g., requests for urine drug screening; 

limiting, decreasing, denying, or discontinuing 

opioids).

• What accounts for these differences in patient 

reactions?
To understand this, it’s helpful to look 

at

• Patient accounts of conflicts with prior 

physicians (from interviews)

– These emerged in interviews and were discussions 

of physicians they were no longer seeing.

– Conflicts revolved around 2 concerns:

• Perceptions that a previous physician did not care 

about or believe their pain

• Disagreements over opioids, including patient’s belief 

that the physician was “withholding” opioids or 

believed the patient was “drug seeking”
Concern, Trust, and Productive 

Patient-Physician Relationships

• The majority of patients in this study believed 

their doctors listened to them and 

demonstrated genuine concern for them:

– “I feel he’s concerned about my health.”

– “Not only does she listen, but she shows her 

concern. She knew I used to drink...When she 

asked me today how my drinking was, she told me 

she was proud of the fact that I had stayed two 

years sober.”
• These patients also trusted their doctors’ 

treatment decisions about pain, even when the 

physicians were cautious about prescribing 

opioids.

• One patient, who said his hydrocodone was 

ineffective, told us he wouldn’t ask his doctor for 

additional opioid medication, explaining that he 

trusts his doctor: “I have 26 open prescriptions, 5 

psych medications. So she balances what will not 

affect the other medications.”
Attributing Decrease in Opioids to 

Concern

• In another patient’s clinic visit, he asked for an 

opioid refill, which his doctor granted 

immediately.

• Interview reveals that, in a previous appointment, 

his doctor had reduced his hydrocodone earlier 

because of concerns about liver toxicity. The 

patient noted that, even though he has more pain 

now, he believes the doctor acted in his best 

interests. When asked how satisfied he was with 

his doctor’s management of his pain, he said: 
I’m satisfied because he looks out for me, 

because he was giving strong medication, but he 

was more concerned about my liver. I could see 

that he was really concerned, so he cut [the 

hydrocodone] back. And...as long as it helps me 

out—there’s some pain you’re going to have to 

endure. But when he said he was concerned 

about my liver, I am as well. So after a while I 

adjust my mind down to what I’m getting now. 

He was concerned about me, and he brought up 

how it causes liver problems and so forth.”
Another patient credited his doctor with helping 

him to stop smoking marijuana. Recently he had 

gone to the ER and received additional 

hydrocodone. His doctor discovered this and 

decreased the patient’s hydrocodone dosage as 

a result. The patient was generally positive, 

saying in his interview:
“I was a little upset at first, but I kind of 

understood what he did, because I’ve been 

coming into the emergency room for other 

issues, and the other doctors were giving me 

stuff and they weren’t notifying him. I don’t feel 

it as punishment, but he just wanted to make 

sure I wasn’t getting overindulged in, you know, 

what I was using. So I was glad he did what he 

did. Gotta keep me in check sometimes.”
Positive sentiment reflected in clinic 

visit

Physician: How are you?

Patient: I’m doin’ well. Well, I say that. I’m getting by. 

Getting by.

Physician: Yeah, well, you know, it’s obvious the muscle 

relaxers are helpful.

Patient: Mmm hmm. When you knocked it down to 20 

on the pain killers, it didn’t quite get me through, not 

even one day. You know, I’m trying to hold off and use 

them only when needed, but there’s some days when you 

just, you almost need more than...I found myself taking 

more of the muscle relaxers because I didn’t have the 

pain killers. But other than that, I’m not feeling too bad.
This patient explained in his interview how he and 

his doctor were careful with his hydrocodone: 

“He takes me off of [hydrocodone] for a while, or 

limits me to fewer amounts, so I don’t get too 

addicted. I don’t take them as prescribed. I only 

take them when I need them...so there’s days when 

I won’t take any. I’ll wait until I absolutely can’t take 

[the pain] anymore, and then I’ll take it...And he 

understands that...They’re keeping me healthy. I 

know there’s a lot of people out there that abuse.”
Summary and Implications

• Patients interpreted similar physician decisions 

about limiting or denying opioids very differently.

– Mistrust or punishment versus their doctor’s genuine 

concern for their health

• Patients who believed their doctors were 

concerned for them adapted to lower opioid 

doses.

– Adjusting expectations for pain levels/pain relief

– Learning how to modify activities to minimize pain
Summary and Implications

• This study suggests that the nature and history of 

the patient-physician relationship influences how 

patients interpret their physicians’ decisions 

about opioid prescribing.

• In many cases patients who were positive about 

their physicians’ decisions to limit or deny opioids 

had a long history with the physicians.

• Some had even confronted substance use 

disorders with the help of their doctors.
Summary and Implications

• These findings underscore the critical role of 

the patient-physician relationship in pain 

management, particularly when opioids are 

involved.

• Patients were more accepting of limitations on 

opioids when they believed their doctors 

really cared about them.
Practice Implications

• Supports the idea of fostering a therapeutic alliance, in 

which patients and physicians have shared goals, 

mutual liking and trust—may make conflict less likely.

• A strong therapeutic alliance can lead to more positive 

responses from patients when limiting opioids by 

shifting the focus from the patient and whether he or 

she is trustworthy or “drug seeking” to the benefits 

and harms of opioids themselves (Nicolaidis, 2011, 

Pain Medicine).

• This framing emphasizes concern for the patient, which 

patients in our study highly valued.
Final Observations

• Paucity of pain discussions

• Many discussions were very brief (“Need a 

renewal?” “Yes.”)

• Contrasts with recent study (Henry and Eggly, 

2012, JGIM) in which 1/3 of clinic time was 

spent discussing pain.

– However, those were not necessarily repeat 

appointments
Final Observations

• It is possible that patient and physician perceptions 

about the difficulty of pain conversations led to 

avoiding them when possible.

• Many physicians might have avoided asking about the 

patient’s pain unless the patient mentioned it.

• Visits were often dominated by discussions of 

conditions such as diabetes or hypertension, which 

physicians are likely to prioritize because poor 

management of these conditions can lead to serious 

complications—this may have crowded out pain 

discussions.
Final Observations

• Conflict was infrequent in our sample

– Could be selection bias: contentious patients (or 

physicians with contentious patients) might have 

declined to participate in study

– Although we were hoping to learn more about 

conflict, we found that there is a lot to learn from 

conversations about pain and opioids that go well, 

which can serve as a foundation for a welltargeted communication intervention.
Limitations

• Single VAMC, select sample

– Intent not to generalize but to gain a richer, more 

detailed understanding about how patients and 

physicians actually communicate about pain

• We captured only a single PCP appointment in 

the context of an ongoing relationship

– We missed other conversations that occurred in 

other appointments (Interviews provided insight 

into some of these conversations)
Future Research

• Longitudinal research is needed to better 

understand pain communication patterns over 

time.

• Future research should seek to understand 

what factors influence presence and extent of 

pain discussions (e.g., pain intensity, 

psychiatric comorbidities, the patient-provider 

relationship, others?).
Acknowledgements

• Study Team

– Matt Bair, M.D., M.S.

– Erin Krebs, M.D., M.P.H.

– Alicia Bergman, Ph.D.

– Jessica Coffing, M.P.H.

– Linda Collins, B.S.

• Funding

– VA HSR&D CDA 10-034 (Matthias, PI)

– Indiana Institute of Medical Research (Matthias, PI)

• No conflicts of interest