Healthcare provider knowledge, beliefs, and attitudes regarding opioids for chronic non-cancer pain in North America prior to the emergence of COVID-19: A systematic review of qualitative research

Figures & data

Figure 1. Flow diagram depicting article inclusion and exclusion along with reasons.

Table 1. Characteristics of included studies.

First author (year)	Provider characteristics	Objective of interview	Type of interview/qualitative analysis	Constructs	Themes relating to opioid prescribing
Barry (2010)	N = 23 Internal medicine (n = 10), infectious disease (n = 4), addiction medicine (n = 3), psychiatry (n = 2), FM (n = 1), did not report (n = 3) Incentive: None	Examine attitudes and experiences about treating CNCP	Semistructured/grounded theory	Self-efficacy managing pain with opioids; concerns for society (diversion); short appointment duration; alternative resources; patient–provider relationship	1. Absence of objective or physiological measures of pain impedes pain management (refer to subtheme 1.1) 2. Concern over drug diversion reduces the patient–provider trust (refer to subtheme 2.2) 3. Providers have a difficult time challenging patients in fear of rupturing the patient–provider alliance (refer to theme 4) 4. Limited alternative resources (i.e., specialty pain management clinics) resulted in prescribing opioids to alleviate pain (refer to subtheme 5.1) 5. Providers noted that there was too little time to adequately assess multifactorial nature of pain and complete paperwork (refer to subtheme 5.2) 6. Providers used toxicology screening to support their decision to discontinue opioid prescriptions (refer to theme 9) 7. Providers questioned the motivation for some patients’ requests for opioids for their pain (refer to subtheme 10.1)
Buchman (2016)	N = 6 FM (n = 1), internal medicine (n = 2), psychiatry (n = 3) Incentive: None	Examine how adults with CNCP negotiate trust and demonstrate trustworthiness with clinicians	Semistructured/grounded theory	Fear of professional sanction or liability; patient–provider relationship	1. Providers feel that if there is something that objectively describes pain, it changes their approach to their patient (refer to subtheme 1.1) 2. The ultimate fear for providers was for the safety of their patients and society (refer to subtheme 2.1) 3. The potential harm that could occur from the patient diverting opioids was considered distressing (refer to subtheme 2.2) 4. Prior negative experiences with patients bias future interactions (refer to subtheme 3.2) 5. Preexisting positive relationships counteract the antagonistic attitude (refer to subtheme 7.2) 6. Risks associated with prescribing opioids provide a defensible position of distrust and adoption of an “investigator” role that impacts the development of a patient–provider alliance (refer to theme 4 and subtheme 10.1)7. Observing colleagues lose jobs over prescribing results in fear of opioid prescribing and impacts their prescribing behavior (refer to subtheme 10.2)
Calcaterra (2016)	N = 25 GP (n = 25) Incentive: None	To understand physicians’ attitudes, beliefs, and practices toward opioid prescribing during hospitalization and discharge	Semistructured; open-ended/mixed inductive and deductive approach	Fear for patients; institutional pressure; patient-related salient events; self-efficacy managing pain with opioids	1. Perceived self-efficacy to appropriately prescribe opioids is lower when the objective pain is lacking (refer to subtheme 1.1) 2. Physicians were concerned that by increasing the amount of opioids, they may inadvertently be contributing to opioid dependence or addiction (refer to subtheme 2.1) 3. Physicians expressed concern surrounding opioid diversion to supplement income as some patients had perceived limited resources (refer to subtheme 2.2) 4. Salient negative events (e.g., overdose) bias future prescribing practices for physicians, which results in developing strategies in attempt to prevent such events (refer to subtheme 3.2) 5. Physicians reported little opioid-specific training during residence. As such, opioid prescribing was shaped by their previous experiences (refer to subtheme 5.3) 6. The ability to verify prescription history in PDMPs improves comfort in prescribing opioids (refer to theme 9)
Chang (2017)	N = 23 GP (n = 18), NP (n = 4), PA (n = 1) Incentive: $50 gift card	Capture experiences interpreting and implementing guideline recommendations for patients with CNCP and substance use	Semistructured/content analysis method	Alternative resources; patient–provider relationship; patient–provider communication	1. Management plans and UTSs were useful tools to facilitate patient–provider communication about the expectations and risks of opioid therapy (refer to theme 9)
Chang (2016)	N = 12 Anesthesia (n = 6), GP (n = 5), surgeon (n = 1) Incentive: None	Assess experiences, perspectives, and attitudes toward the Canadian opioid guideline, elicit barriers and facilitators	Semistructured interview guide with open-ended questions/thematic analysis of verbatim transcripts	Patient–provider communication; education	1. Providers were concerned that it is too easy to turn to opioids to manage CNCP and were concerned about the opioid-related harms for their patients (e.g., dependence; refer to subtheme 2.1) 2. The use of guidelines helps to improve patient–provider communication (refer to subtheme 7.1) 3. Some providers felt that the guidelines were helpful for decision-making processes, whereas others felt that the volume of information deters updating of prescribing guidelines (refer to theme 11)
Click (2018)	N = 32 GP (n = 22), osteopath (n = 2), NP (n = 4), pharmacist (n = 2), other (n = 2) Incentive: None	Determine what factors lead to prescribing controlled drugs for CNCP through the use of focus groups	Semistructured/iterative process; transcripts combined and compared analysis of transcripts	Institutional pressure; provider-related salient events; patient–provider relationship	1. Providers are reluctant to prescribe opioids due to significant issues of abuse (refer to subtheme 2.1) 2. Providers recall previous negative events and are concerned for their and their staff’s safety when prescribing opioids (refer to subtheme 3.1) 3. Access to alternative therapies is difficult for various reasons (e.g., uninsured patients; refer to subtheme 5.1) 4. Providers report a higher level of comfort prescribing opioids when they have a good and/or long-standing relationship with their patient (refer to subtheme 7.2) 5. Treatment agreements are beneficial for setting boundaries, rules, and standards with patients (refer to theme 9)
Desveaux (2019)	N = 22 FM (n = 22) Incentive: None	Understand perceived barriers and facilitators to guideline-adherent opioid prescribing	Semistructured/content analysis	Patient–provider relationship; self-efficacy managing pain with opioids; fear for patients; short appointment duration; alternative resources	1. Providers struggled with the objectivity versus subjectivity of pain. Objective results helped make the diagnosis more clear, but subjective results complicated the ability to establish a diagnosis (refer to subtheme 1.1) 2. Providers expressed concern that de-prescribing opioids could lead to an increase in use of stimulants or alcohol (refer to subtheme 2.1) 3. Discussions over opioid prescribing adversely impact the working relationship, subsequently impacting the decision to discuss opioids (refer to theme 4) 4. Lack of accessible nonpharmacological options related to the perceived inability to manage pain (refer to subtheme 5.1) 10. Time constraints in family practice create a barrier for providers to appropriately educate patient about pain and opioids (refer to subtheme 5.2) 5. Having strong communication with the patient and a trusting relationship improves confidence prescribing opioids (refer to subtheme 7.1) 6. Running a practice where patients are well known reduces concerns surrounding prescribing opioids (refer to subtheme 7.2) 7. Providers used tools to help monitor opioid prescribing (i.e., contracts, random urine drug screening; refer to theme 9) 8. Challenging experiences with previous patients led providers to experience fear when patients requested opioids during appointments (refer to subtheme 10.1) 9. Guidelines were helpful summaries of evidence but did not provide tangible tools to assist with prescribing or monitoring practice (refer to theme 11)
Elder (2012)	N = 18 GP (n = 10), PA (n = 8) Incentive: None	Understand differences in pain management among adults with CNCP who are and are not prescribed opioids	Semistructured/transcribed and entered into NVivo 8 qualitative software	Patient–provider relationship; self-efficacy managing pain with opioids	1. Providers find that communication with patients about drug screens/contracts is intimidating (refer to theme 4) 2. Providers noted insufficient time to discuss important patient-related information that arose during conversations between patients and medical assistants (refer to subtheme 5.2) 3. Patients are more forthcoming in conversations over opioids when there is a long-standing relationship (refer to subtheme 7.2) 4. Providers reported benefit from the use of tools to help with drug monitoring (e.g., urine drug screening, using contracts; refer to theme 9) 5. Distrust, skepticism, and suspicion of patient motives increase ambivalence toward prescribing opioids (refer to subtheme 10.1)
Esquibel (2014)	N = 16 Resident physician (n = 10), attending physician (n = 6) Incentive: None	Understand the effects of COT on the doctor–patient relationship	Semistructured/multistep iterative approach; immersion/crystallization process	Fear for patients; patient–provider relationship	1. Providers express difficulty addressing, evaluating, and caring for the patient when the pain is subjective (refer to subtheme 1.1) 2. Providers have concerns over lack of evidence of providing relief and improving function (refer to subtheme 1.2) 3. Providers have concerns over consequences of addiction from prescribing opioids (refer to subtheme 2.1) 4. Providers note that it is easier to prescribe opioids to patients who report using opioids to engage in pain self-management (e.g., exercise; refer to theme 6) 5. Patients who are straightforward and have honest communication facilitated continued opioid prescribing (refer to subtheme 7.1) 6. Providers adopt a defensive role whereby they feel compelled to list concrete reasons for prescribing (e.g., terminal illness, poor prognosis; refer to subtheme 10.1)
Fischer (2017)	N = 96 GP (n = 96) Incentive: $200	Assess effect of patient requests for specific opioid pain medication on suspected drug seeking and prescribing practices	Semistructured/thematic content analysis; interviews coded quantitatively and analyzed statistically	Fear for patients; patient–provider relationship	1. Knowing the patient well, knowing their history, and believing that the patient’s symptoms were genuine contributed to decision making regarding opioid prescribing (refer to subtheme 7.2)
Fontana (2008)	N = 9 NP (n = 9) Incentive: None	Examine social and political factors affecting opioid prescribing for CNCP	Semistructured/dialectical analysis	Concerns for society (diversion); institutional pressure; patient-related salient events; education; fear of professional sanction or liability; fear for patients	1. Likelihood of prescribing opioids decreased significantly when objective indicators or pain were not present (refer to subtheme 1.1) 2. Fear of causing addition impacted prescribing practices (refer to subtheme 2.1) 3. Nurses placed restrictions on patients in efforts to control behavior because they felt responsible to help the government prevent illegal abuse and diversion of drugs (refer to subtheme 2.2) 4. Media coverage of overdose and death due to oxycontin reduced willingness to prescribe (refer to subtheme 3.1) 5. Lack of formal education led to prescribing practices being formulated by practices they saw around them (refer to subtheme 5.3) 6. Providers enter relationship with mistrust and suspicion, especially with patients who present with specific drug seeking characteristics (refer to subtheme 10.1) 7. Nurses felt the need to protect themselves from risk to professional licensure (refer to subtheme 10.2) 8. Nurses will refer out if they believe that complying with patient requests will require them to go off protocol (refer to subtheme 10.3)
Harle (2015)	N = 15 FM (n = 9), internal medicine (n = 6) Incentive: None	Understand the decision to prescribe opioids for CNCP in primary care	Semistructured with funneling approach/iterative, open coding analytic approach	Short appointment duration; patient–provider relationship	1. Providers are less willing to prescribe opioids when the subjective pain is out of proportion to the physical examination of pain (refer to subtheme 1.1) 2. Providers struggle with weighing the potential benefits of opioids versus the risk, such as dishonesty, risk of abusing or misusing opioids (refer to subtheme 2.1) 3. Negative past experiences of patients abusing medication lead providers to avoid prescribing altogether (refer to subtheme 3.2) 4. The high-volume environment of usual care did not permit sufficient appointment times to assess and manage pain amidst other assessments (refer to subtheme 5.2) 5. Physicians prioritize improvement in physical function over improvement in pain and are more willing to prescribe opioids when the goal is to improve function (refer to theme 6) 6. Providers base their trustworthiness of a patient off the long-standing relationship, which helps their decision making for prescribing opioids (refer to subtheme 7.2) 7. Providers noted the importance of identifying red flags that might indicate a patient is medication seeking (refer to subtheme 10.1)
Hulen (2018)	N = 6 Attending physician (n = 3), medical residents (n = 2), health psychologist (n = 1) Incentive: None	To identify sources of provider stress about prescribing opioids to manage CNCP	Semistructured/exploratory, content-driven approach to applied thematic analysis	Provider-related salient events; alternative resources	1. Providers express difficulty in assessing patients when the pain is subjective (refer to subtheme 1.1) 2. New evidence casting doubt about the effectiveness of opioids and changing guidelines contributed to difficulties surrounding opioid prescribing (refer to subtheme 1.2) 3. Previous salient events contributed to provider reluctance toward opioid prescribing (refer to subtheme 3.1) 4. Providers found conversation related to opioid harms to be fraught with tension, uncertainty, and hopelessness (refer to theme 4) 5. Insufficient appointment duration forced providers to complete risk assessment tools after the appointment, resulting in retrospective bias (refer to subtheme 5.2) 6. Having someone with experience in working with people with CP helped less-experienced providers improve their ability to complete assessments of patient social context (refer to theme 8)
Hurstak (2017)	N = 23 GP (n = 18), NP (n = 4), PA (n = 1) Incentive: $50 gift card	Understand perceptions of risk of opioid therapy to improve informed consent process	Semistructured/grounded theory	Fear for patients; fear of professional sanction or liability	1. Providers feared that discontinuing opioids could potentially lead to patients seeking opioids illicitly, potential overdose, misuse, dependence, or diversion. They felt a personal responsibility to prevent this through disciplined prescribing (refer to subtheme 2.1) 2. Providers recognized the harm that can come from diversion (e.g., substance use, violence) and, as such, felt responsible for limiting diversion and diversion-related overdoses (refer to subtheme 2.2) 3. Negative past experiences of patients (e.g., overdose attempts) abusing medication leads providers to avoid prescribing altogether (refer to subtheme 3.2) 4. Providers expressed fear over being responsible for their patient’s death and subsequently losing their license (refer to subtheme 10.2)
Kang (2019)	N = 40 Physician (n = 15), pharmacist (n = 25) Incentive: None	Explore physician and pharmacist perspectives on the opioid crisis and the possibility of physician and community pharmacist collaborations to manage CNCP	Semistructured/applied thematic analysis	Education; alternative resources	1. Providers report the need to have more alternative therapies (refer to subtheme 5.1) 2. Providers felt that they have not been provided sufficient education on managing CNCP in the context of opioid prescribing (refer to subtheme 5.3) 3. Providers relied on PDMP, urine screens, and patient history to mitigate abuse and diversion (refer to theme 9)
Kennedy (2017)	N = 40 GP (n = 34), NP (n = 3), other (n = 3) Incentive: Meals	Assess experiences of opioid tapering with patients on long-term opioid therapy	Semistructured in-person focus groups/mixed inductive–deductive method	Fear for patients; goal setting; short appointment durations; alternative resources; patient–provider relationship; patient–provider communication; education	1. Providers struggle to prescribe opioids safely while keeping patients satisfied with their pain care (particularly at higher doses; refer to subtheme 2.1) 2. Providers find conversations about opioid tapering emotionally exhausting, challenging, and draining and will often avoid or postpone having these conversations (refer to theme 4) 3. Providers noted there was not enough time during a clinic visit to discuss tapering and additionally not enough time and resources to support opioid tapering (refer to subtheme 5.2) 4. Providers sought their own training related to managing complex chronic pain, because it was not taught to them during school or residency (refer to subtheme 5.3) 5. Providers reported benefit in discussing unpleasant, common side effects (e.g., low testosterone, erectile dysfunction, memory loss) to help engage patients in opioid tapering (refer to subtheme 7.1) 6. Providers are concerned that patients may not entirely share pain-related symptoms or opioid-related adverse effects for fear that the provider will taper their opioids (refer to subtheme 10.1)
Knight (2017)	N = 23 GP (n = 18), NP (n = 4), PA (n = 1) Incentive: None	Explore the educational, clinical, and social factors that contribute to opioid prescribing	Semistructured/iterative process; inductive and deductive coding	Concerns for society (diversion); patient–provider relationship; education; self-efficacy managing pain with opioids	1. Providers expressed reluctancy toward using opioids because they feel there is not enough evidence demonstrating efficacy (refer to subtheme 1.2) 2. Providers were encouraged to evaluate evidence for effectiveness more thoroughly and weigh this against potential dangers (patient safety became a more prominent concern; refer to subtheme 2.1) 3. Concern over drug diversion was a prominent decisional factor and decreased providers’ willingness to prescribe opioids (refer to subtheme 2.2) 4. Providers were concerned that having patients sign PDMP contracts could create a climate of mistrust that might threaten the therapeutic alliance (refer to theme 4) 5. Given that few alternative options were present, providers felt that treating people’s pain with opioids was the right thing to do (refer to subtheme 5.1) 6. Providers felt relief from the introduction of pharmacovigilance measures (UTS, PDMPs, pain agreements) to help with diversion and misuse of prescribed opioids (refer to theme 9) 7. Clinicians describe their education as their responsibility to be attentive, to be nonjudgmental regarding pain, and to believe their patients regardless of the amount of morphine they need instead of adopting a defensive stance (refer to subtheme 10.1) 8. Providers feel supported by clinic policies because they help to depersonalize and legitimize clinicians’ decision-making practices regarding opioids (refer to subtheme 10.3)
Liddy (2017)	N = 26 FM (n = 25), other (n = 1) Incentive: None	Identify themes emerging from exchanges between PCPs and specialists regarding patients with chronic pain	eConsult service between PCP and specialist/thematic analysis of cases using a constant comparison approach	Self-efficacy; alternative resources	1. PCPs sought advice from pain specialists about treatment strategies (refer to theme 8)
Militello (2018)	N = 10 PCP (n = 10) Incentive: None	Identify patient, social, and provider factors that influence how providers assess and manage CNCP	Critical decision method interviews/thematic analysis using framing and anchors	Education; goal setting	1. Providers expressed uncertainty regarding the efficacy of opioids for people with CNCP (refer to subtheme 1.2) 2. Lack of available alternative nonopioid therapies, housing insecurity, transportation, and social support systems contribute to provider decision making for treatments for patients (refer to subtheme 5.1) 3. Some providers note that urine drug tests do not detect all relevant substances and instead think that a blood test may better meet the spirit of the guidelines (refer to theme 9) 4. Providers feel that guidelines are diffuse and require interpretation and that they may not be able to meet recommended guidelines in their clinic (refer to theme 11)
Penney (2017)	N = 25 GP (n = 25) Incentive: None	Identify practical issues patients and providers face when assessing alternatives to opioids	Structured; focus group/iterative process using inductive and deductive coding	Short appointment duration; alternative resources; self-efficacy; managing pain with opioids	1. Almost all providers framed opioids as problematic because of the risk of dependence and believed that they would not be able to get patients off of opioids (refer to subtheme 2.1) 2. Providers report difficulty treating patients with narcotic drugs because of the challenges that come along (i.e., diversion; refer to subtheme 2.2) 3. Providers feared that suggesting changing prescriptions would harm the rapport with their patients when they were resistant to trying anything other than opioids (refer to theme 4) 4. Despite efforts to discourage the use of opioids, providers felt that this was often the only option available (refer to subtheme 5.1) 5. Providers report that having 10 min per patient is an inadequate amount of time to explore things other than drugs for people with chronic pain (refer to subtheme 5.2) 6. Providers liked using the health plan that was introduced because it includes urine drug screening and implementation and signing of written opioid therapy plans that helped to reduce and better manage the use of opioid medications (refer to theme 9)
Robertson (2014)	N = 6 FM (n = 5), other (n = 1) Incentive: None	To understand the impact of a point-of-care opioid tool called Opioid Manager on clinical practice	Semistructured/thematic analysis; content analysis; code–recode technique used to verify content validity	Self-efficacy managing pain with opioids; patient–provider communication; education; education on tools	1. Involving the patient in conversations surrounding opioid prescribing facilitated willingness to prescribe (refer to subtheme 7.1) 2. Keeping things open with their patients facilitates a strong therapeutic alliance (refer to subtheme 7.2) 3. Some providers will use opioid management tools on all of their patients to allow the same amount of scrutiny for everyone, whereas others will use it with some patients but not others (depending on the level of risk of the patient; refer to theme 9) 4. Providers likened regulatory scrutiny to tax audits, saying it may be a growth experience, but it is not fun (refer to subtheme 10.2) 5. Providers felt like they were flying by the seat of their pants when prescribing and did not feel like they had any guidelines to go by (refer to theme 11)
Satterwhite (2019)	N = 23 Physician, NP, physician assistant Incentive: None	Identify contextual factors that contribute to time scarcity and its effects on quality of care when prescribing opioids in primary care	Semistructured and open-ended/grounded theory	Short appointment durations; alternative resources	1. Providers feel that dealing with pain management is time draining, takes up a significant amount of their schedule, takes time away from other patients, and may take time away from the specific patient to address any other health concerns (e.g., mental health; refer to subtheme 5.2) 2. Establishing functional goals with new or inherited patients being prescribed opioids was viewed as an important method for facilitating a long-term strong working alliance (refer to theme 6)
Spitz (2011)	N = 26 Physician (n = 23), NP (n = 3) Incentive: None	Identify attitudes and perceived barriers and facilitators to prescribing opioids among older adults	Focus group; semistructured/content analysis	Patient-related salient events; patient–provider relationship; fear for patients	1. Providers were skeptical about patients and were reluctant to prescribe opioids when patients’ pain scores did not correspond with their behaviors during the visit (refer to subtheme 1.1) 2. A minority of providers mentioned that opioids are effective when used in the “right” older patient (e.g., one who can understand the regimen and can anticipate the side effects and were not considered front-line treatment; refer to subtheme 1.2) 3. Providers reported the fear of causing harm to older patients (refer to subtheme 2.1) 4. Fear of causing harm to patients was related to previously experienced events (refer to subtheme 3.2) 5. Few physicians were concerned about the possible legal or regulatory sanctions of opioid prescribing. Nurse practitioners reported concern over regulatory scrutiny for writing high-volume scripts for patients when their physician was away from the practice (refer to subtheme 10.2)
Tong (2019)	N = 16 PCPs (n = 16) Incentive: None	Understand provider factors that inform the use of opioids for CNCP in primary care	Semistructured/template and emergent coding processes	Short appointment duration; alternative resources; institutional pressure	1. Providers note that there are limited alternative therapies for pain management (refer to subtheme 5.1) 2. Providers lack time to appropriately manage chronic opioids (refer to subtheme 5.2) 3. Providers have greater willingness to prescribe when risk of abuse is low and opioids help improve function (e.g., ability to work; refer to theme 6)
Wyse (2018)	N = 24 Physicians (N = 18), NP (N = 4), physician assistant (N = 2) Incentive: None	To learn about the methods PCPs used to address prescription opioid misuse and aberrant opioid-related behaviors	Semistructured/content analysis	Alternative resources	1. The mismatch between the needs of patients on long-term opioid therapy evidencing aberrant behaviors or symptoms of opioid use disorder and the substance use disorder treatment offerings that were available was noted by providers (refer to subtheme 5.1) 2. Time constraints were faced because the consent procedure can be lengthy and the consent was located in the electronic medical record, making it difficult to access (refer to subtheme 5.2) 3. Providers would sometimes turn to pharmacists to help design opioid tapers. They also appreciated knowing that they can rely on external resources to share responsibility about opioid tapering (refer to theme and subtheme 10.3)
Wyse (2019)	N = 24 Physicians (N = 20), NP (N = 4) Incentive: None	Identify provider strategies for managing aberrant medication behaviors among patients prescribed chronic opioid therapy	Semistructured/content analysis	Goal setting; short appointment duration; provider-related salient events; patient–provider relationship	1. Providers feel that conversations with patients were unpleasant, with one provider recalling violent reactions from patients when their opioid prescriptions were changed (refer to subtheme 2.1) 2. Clinicians found it difficult to be on the receiving end of complaints regarding their perceived lack of concern for patients’ pain, when they believed that their actions were ultimately in the patients’ best interest (refer to theme 4) 3. Providers report that conversations about opioids were time consuming and appreciated that nurses provided group education visits so they do not have to do this individually with each patient (refer to subtheme 5.2) 4. Providers reported benefit from the use of a treatment agreement when making decisions about restricting opioids following aberrant behaviors (refer to theme 11)

COT = chronic opioid therapy; CPG = clinical practice guideline; ED = emergency department; EMR = emergency medical record; FM = family medicine; GP = general practitioner; LPN = licensed practical nurse; NP = nurse practitioner; PCP = primary care physician; RN = registered nurse; TA = treatment agreement; UDT = urine drug test.

Table 2. Summary of findings.

Theme	Contributing studies	Description of review finding	CERQual assessment	Explanation of CERQual assessment
Barriers
Theme 1: Uncertainty toward subjectivity of pain and efficacy of opioids led to provider reluctance toward prescribing opioids
1.1 Inability to perform an unbiased evaluation of pain and identify objective explanation decreased providers’ willingness to prescribe	^Citation33–35,Citation41,Citation43,Citation44,Citation51–53	Providers questioned the veracity of self-reported pain in the absence of objective markers, which resulted in discomfort with prescribing opioids	High confidence	Moderate concerns about methodological limitations
1.2 Providers who questioned the perceived efficacy of opioids were reluctant to prescribe	^Citation41,Citation47,Citation51,Citation53,Citation55	Uncertainty about the effectiveness of providing relief and improved function from opioids for CNCP contributed to difficulties prescribing opioids	Moderate confidence	Moderate concerns about methodological limitations and adequacy
Theme 2: Concern for patient and community safety resulted in reluctance to prescribe opioids for CNCP
2.1 Concern over patient safety resulted in caution when prescribing opioids	^Citation34,Citation35,Citation37,Citation38,Citation39,Citation41,Citation43–47,Citation49,Citation51,Citation52,Citation58	Providers wanted to do the right thing by helping patients manage pain but were concerned for patient safety (e.g., addiction, overdose), which resulted in caution when prescribing opioids for CNCP	High confidence	Moderate concerns about methodological limitations
2.2 Concern over drug diversion resulted in caution when prescribing opioids	^Citation33–35,Citation43,Citation45,Citation47,Citation49	Concern over potential adverse effects of drug diversion within the community results in caution when prescribing opioids for CNCP. Examples of potential adverse effects of drug diversion included violence, poor pain management, overdose, and damaging provider–patient trust	Moderate confidence	Serious concerns about methodological limitations. Moderate concerns about adequacy
Theme 3: Past negative experiences resulted in reluctance to engage in conversations surrounding opioid prescribing
3.1 Negative personal-related events decreased willingness to prescribe opioids	^Citation39,Citation43,Citation53,Citation58	Providers reported a reduced willingness to prescribe opioid analgesics to manage CNCP due to the experience of negative salient personal events, including perceived blame for opioid-related patient overdose deaths and angry or aggressive interactions with patients	Moderate confidence	Serious concerns about methodological limitations. Moderate concerns about adequacy
3.2 Negative patient-related events decreased providers’ willingness to prescribe opioids	^Citation34,Citation35,Citation44,Citation45,Citation51	Provider’s previous negative patient-related events (e.g., patients misusing opioids or patient death) led to provider biases against prescribing opioids in the future	High confidence	Moderate concerns about methodological limitations
Theme 4: Providers expressed difficulty having conversations surrounding opioid prescribing and feared these conversations would harm the therapeutic alliance
	^Citation33,Citation34,Citation36,Citation40,Citation46,Citation47,Citation49,Citation52,Citation53,Citation58	Most providers found conversations related to opioid use, harms (e.g., side effects, misuse, hyperalgesia), tapering, and drug screening/contracts to be fraught with tension, uncertainty, and fear of rupturing the patient–provider alliance	Moderate confidence	Serious concerns about methodological limitations
Theme 5: Organizational barriers such as a lack of opioid alternatives, appointment time constraints, and inadequate medical education limited CNCP management strategies
5.1 Unavailability of opioid alternatives facilitated opioid prescribing	^Citation33,Citation39,Citation47,Citation49,Citation52,Citation54,Citation55,Citation57,Citation59	Most providers reported that insufficient availability of opioid-alternative pain management resources for patients (e.g., specialty pain management services or services focusing on co-occurring addiction and pain management) was positively associated with opioid prescribing	Moderate confidence	Moderate concerns about methodological limitations
5.2 Appointment time constraints limited thoughtful prescribing practices and patient education surrounding opioid treatment	^Citation33,Citation40,Citation44,Citation46,Citation49,Citation52,Citation53,Citation56–59	Providers reported that brief appointment durations did not provide sufficient time to prescribe opioids, including assessment, education, enacting a treatment agreement, and documentation	Moderate confidence	Serious concerns about methodological limitations
5.3 Inadequate formal education during medical school or residency resulted in unstandardized prescribing practices	^Citation35,Citation43,Citation46,Citation54	Physicians perceived a lack of formal education on prescribing opioids for the management of CNCP during medical school or residency. Some providers allowed personal experiences and interactions with clients to shape their prescribing habits, whereas others took the initiative to seek continuing medical training	Moderate confidence	Moderate concerns about methodological limitations
Facilitators
Theme 6: Prioritizing improvement in function increased providers’ willingness to discuss opioid prescribing
	^Citation41,Citation44,Citation56,Citation57	Providers prioritize improvement in function over remittance of pain and reported greater willingness to discuss opioid prescribing and discontinuation when the goal was to improve patient function	Moderate confidence	Moderate concerns about methodological limitations, adequacy, and relevance
Theme 7: A strong therapeutic alliance increased discussions surrounding and willingness to prescribe opioids
7.1 Strong patient–provider communication facilitated open and willful conversations surrounding opioid prescribing	^Citation37,Citation41,Citation46,Citation50,Citation52	A strong working alliance, candid communication, and shared decision making improved provider willingness and confidence to prescribe and taper opioids for CNCP	Moderate confidence	Moderate concerns about methodological limitations
7.2 Long-standing patient–provider relationship and trust increased willingness to engage in opioid discussions	^Citation34,Citation39,Citation40,Citation42,Citation44,Citation50,Citation52	Having a long-standing relationship with a patient was viewed as improving trust, communication, working alliance, and subsequent willingness to engage in discussions around prescribing opioids for CNCP	High confidence	Moderate concerns about methodological limitations
Theme 8: Interprofessional support or mentorship improved provider willingness and confidence to engage in patient discussions surrounding opioid prescribing
	^Citation48,Citation53,Citation59	Mentorship and support from specialists, experienced colleagues, or allied health professionals improved PCP willingness and confidence to engage patients in discussions around prescribing opioids for CNCP.	Low confidence	Serious concerns about methodological limitations, adequacy, and relevance. Moderate concerns about coherence
Theme 9: Use of PDMPs for risk management contributed to providers’ confidence in opioid prescribing and discontinuation
	^Citation33,Citation35,Citation36,Citation39,Citation40,Citation47,Citation49,Citation50,Citation52,Citation54,Citation55,Citation58	The use of PDMP, UDTs, and patient history were perceived as beneficial to decision making for opioid prescribing, better management of medications, and the prevention of opioid abuse and diversion	Moderate confidence	Moderate concerns about methodological limitations and coherence
Mixed
Theme 10: External policies and tools increased providers’ confidence in decisions to prescribe or discontinue opioids. Meanwhile, external pressures decreased willingness to prescribe
10.1 Providers adopted a defensive stance when prescribing opioids	^Citation33,Citation34,Citation40,Citation41,Citation43,Citation44,Citation46,Citation47,Citation52	Most providers adopt a position of distrust, or a “defensive stance,” when entering a patient–provider relationship and prescribing opioids. Inconsistencies or red flags (e.g., inconsistency of objective vs. subjective findings) may result in avoiding prescribed opioids altogether	Moderate confidence	No/minor concerns about coherence, adequacy, and relevance. Serious concerns about methodological limitations
10.2 Concern over regulatory scrutiny decreased willingness to prescribe opioids	^Citation34,Citation43,Citation45,Citation50,Citation51	Concern over regulatory scrutiny or being held liable for a patient overdose or death results in fear and reduces willingness to prescribe opioids for CNCP	Moderate confidence	Moderate concerns about adequacy. Serious concerns about methodological limitations
10.3 Institutional policies reduced subjectivity of prescribing opioids and were perceived as beneficial	^Citation43,Citation47,Citation58,Citation59	Providers reported that institutional policies around opioid prescribing and tapering set by an organizational opioid safety committee or ethics board reduced subjectivity and increased confidence in decision making	Moderate confidence	Moderate concerns about adequacy. Serious concerns about methodological limitations
Theme 11: Some providers struggled to enact guidelines, especially among complex patients. Contrarily, some providers felt the guidelines were helpful for making decisions and setting boundaries
	^Citation37,Citation50,Citation52,Citation55,Citation58	Most providers felt that guidelines were difficult to enact and felt like they were “flying by the seat of their pants.” For example, some felt like these guidelines were not straightforward or did not pertain to complex patients. Some providers expressed gratitude for prescribing guidelines, indicating that they enabled helpful decision-making processes and aided in setting effective boundaries	Moderate confidence	Moderate concerns about methodological limitations, coherence, and adequacy

See Table 1 for abbreviations.

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