Persistent pain, long-term opioids, and restoring trust in the patient-clinician relationship

The erosion of trust in the patient-clinician relationship is an underappreciated, and vital, component of the prescription opioid crisis. Drawing from lived experience of patients and clinicians, and a narrative evidence review, this report discusses how opioid use for persistent pain can impact the patient-clinician relationship from the vantage points of the patient and the family physician. For patients, the stress of dealing with persistent pain, misalignment with clinicians regarding goals of care, experiences of disrespect and stigma, fear of abrupt tapers, and frustration with a fragmented health system, all combine to breed a lack of trust. Clinicians, for their part, experience challenges due to inadequate resources for pain management and opioid safety, pressure to deprescribe opioids rapidly, inconsistent prescribing practices of colleagues, 'policing' opioid prescriptions when concern arises for opioid use disorder and adversarial relationships with frustrated patients wary of clinician intentions. As a result, many clinicians struggle to maintain a therapeutic relationship with patients in great need of empathy and healing. To support implementation of evidence-based guidelines and achieve public health goals of safer prescribing and reducing harm from prescription opioids, we recommend steps health systems and clinicians can take to rebuild trust in the patient-clinician relationship, enable patient-centered pain care, and embed patient perspectives into opioid safety processes. PERSPECTIVE: Erosion of patient-clinician trust is a barrier to implementing evidence-based guidelines that aim to improve opioid safety. This paper explores lived patient and clinician experiences and recommends steps for health systems and clinicians to rebuild this trust as a strategy to actualize the benefits of adherence to these guidelines.