Introduction   Patients have many of the same misconceptions regarding opioids that health care providers have.  This Fast Fact discusses common reasons that patients do not take appropriately prescribed opioids, thus resulting in unnecessary pain and suffering. 

Fear of “addiction”   Many patients are afraid of “becoming hooked”; they confuse physical dependence with psychological dependence (addiction or opioid use disorder).  The public health crisis of increased opioid overdose deaths (see Fast Fact #80) may increase these fears. Patients may refer to the media (“Hasn’t fentanyl been in the news lately? I don’t want that drug”) or familial experience (“My cousin was addicted to oxycodone”).  As a result, patients may limit their intake and/or wait until the pain is severe before using opioids.   

Fear of tolerance   Patients often worry about taking pain medicine “too early” in their disease course.  They believe that if the pain gets worse, they will have already taken the “best” medicine and thus have severe pain during the dying process.  A related belief is that if they take the medicine on a regular basis, their body will “get used to it” and thus the pain medicine will no longer be effective. 

Opioid toxicity   Patients are concerned about opioid-related side effects, especially mental impairment, nausea, sleepiness, and constipation. 

Pain as a symptom   Patients may dichotomize treating the symptom rather than the cause of the pain (e.g., treating the underlying cancer) as a bad idea, rather than understanding that often both can be done at the same time.  Patients may worry that pain management may mask their disease’s progression so that future medical decisions are not made in a timely manner.   

The good patient   Patients frequently do not want to ‘worry’ their clinician or ‘bother’ them with symptom complaints. Particularly with pain, they may feel their report of pain is a criticism. Patients may believe that “good” patients do not complain about pain or ask for more medicine.  Our society traditionally has had a very ambivalent view towards pain and pain treatment, some even believe that it is heroic or noble if patients are “strong” or “tough” and minimize their symptoms (see Fast Fact #78). 

The meaning of pain   Patients may view their pain as a punishment for past bad deeds or view the pain experience as an opportunity for growth or personal redemption.  When present, such beliefs lead patients not to discuss their pain with their health care team and to defer using analgesics. 

Mistrust in allopathic medicine   The financial aspects of medicine have contributed to news reports of pharmaceutical companies influencing clinicians prescribing patterns. This can create ongoing mistrust that can cause patients to be suspicious of their clinician’s motives for prescribing medications. 

Other reasons   Cost concerns, polypharmacy concerns (“If I take the morphine than I’m going to have to start a medication for constipation”), clinical misunderstandings, and mental health issues such as anxiety and depression are all recognized factors for patients not taking their prescribed medications.   

Patient Assessment Tips  Patients often want to please their clinicians. Thus, simply asking them, “Are you taking your medicine?” is likely to result in the patient saying “Yes.”   To better understand the patient’s beliefs regarding pain medicine and how they are taking their medicine one should: 

• Use non-judgmental phrasing.  “Tell me exactly how you take your pain medicine.”  Often it is easier for patients to tell you that they are not taking the medicine the way they were prescribed if you acknowledge how hard it is to take the medicine; “It must be really hard to take all these pills. How often, in the last week, have you found that you forget one or two?” 
• Normalize the patient’s concerns.  “Some patients worry that if they take the pain medications, they will become addicted. Do you have this worry?” 
• Explicitly ask about their health beliefs regarding opioids.  Ask what they know about morphine or whether they have any family members who have taken morphine and what the experience was like. 
• Ask about side effects at every visit in the same way that you ask about pain.  Moreover, ask about whether the patient notices any other changes that s/he believes might be caused by the opioids. 
• Proactively prepare patients about opioid-related side effects that are transient or treatable such as sedation, nausea, and constipation.  

References 

1. Cleeland CS.  Clinical cancer: 31. Barriers to the management of cancer pain: the roles of patient and family.  Wis Med J. 1988; 87(11):13-15. 
2. Ersek M. Enhancing effective pain management by addressing patient barriers to analgesic use. J Hospice Pall Nursing. 1990; 1(3):87-96. 
3. Ward SE, Goldberg N, et al.  Patient-related barriers to management of cancer pain. Pain. 1993; 52(3):319-24. 
4. Gunnarsdottir S, et al. Patient-related barriers to pain management: The barriers questionnaire II (BQ-II).  Pain. 2002; 99:385-396. 
5. AMA. 8 reasons patients don’t take their medications.  February 22, 2023.  Available at: https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications#:~:text=Mistrust-,Mistrust,trust%20can%20support%20medication%20adherence. Last accessed 2/29/24. 

Version History:  This Fast Fact was originally edited by David E Weissman MD. 2nd Edition was edited by Drew A Rosielle MD and published October 2007; 3rd Edition June 2015. 4th Edition in February 2024.
Conflicts of Interest: None to report.