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Pain as a risk factor for substance use: a qualitative study of people who use drugs in British Columbia,… Voon, Pauline; Greer, Alissa M; Amlani, Ashraf; Newman, Cheri; Burmeister, Charlene; Buxton, Jane A Jul 5, 2018

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RESEARCH Open AccessPain as a risk factor for substance use: aqualitative study of people who use drugsin British Columbia, CanadaPauline Voon1,2, Alissa M. Greer2,3, Ashraf Amlani3, Cheri Newman3, Charlene Burmeister3 and Jane A. Buxton2,3*AbstractBackground: People who use drugs have a significantly higher prevalence of chronic non-cancer pain compared tothe general population, yet little is known about how various policy, economic, physical, and social environments mayserve as risk or protective factors in the context of concurrent pain and substance use. Therefore, this study sought toexplore perspectives, risks, and harms associated with pain among people who use drugs.Methods: Thirteen focus group interviews were held across British Columbia, Canada, from July to September 2015. Intotal, 83 people who had lived experience with substance use participated in the study. Using an interpretivedescription approach, themes were conceptualized according to the Rhodes’ Risk Environment and patient-centeredcare frameworks.Results: Participants described how their experiences with inadequately managed pain in various policy, economic,physical, and social environments reinforced marginalization, such as restrictive policies, economic vulnerability, lack ofaccess to socio-physical support systems, stigma from health professionals, and denial of pain medication leading torisky self-medication. Principles of patient-centered care were often not upheld, from a lack of recognition of patientsas experts in understanding their unique pain needs and experiences, to an absence of shared power and decision-making, which often resulted in distrust of the patient-provider relationship.Conclusions: Various risk environments and non-patient-centered interactions may contribute to an array of healthand social harms in the context of inadequately managed pain among people who use drugs.Keywords: Pain, Self-management, Harm reduction, Patient-centered care, Risk environment, MethadoneBackgroundPain presents a significant public health concern that isestimated to cost at least $560–635 billion USD annuallydue to lost productivity and health care costs [1]. Theprevalence of chronic non-cancer pain appears to be sig-nificantly higher among people who use drugs (PWUD)(48–60%) compared to the general population (11–19%)[2], which may be attributed to inadequate pain manage-ment from clinicians who may be hesitant to prescribepain medications due to potential risks for dependence,misuse, diversion, morbidity, or mortality [3–5]. Theescalating crisis of opioid-related overdose across NorthAmerica has highlighted the extent to which such risksmay be manifested. Given the current opioid crisis andthe potential role of past prescribing practices on con-tributing to iatrogenic opioid use disorder [6], recentguidelines have recommended that tighter restrictionsbe placed on opioid prescribing [7].Little is known about the experiences of PWUD whoseek pain management, and how various policy, eco-nomic, physical, and social environments may serve asrisk or protective factors in the context of concurrentpain and substance use. A small body of qualitative stud-ies has been published in this area, which have primarilyfocused on the patient-provider relationship and issuesrelated to stigma, distrust, suspicion, or inexperience inthe context of concurrent pain and substance use, which* Correspondence: jane.buxton@bccdc.ca2School of Population and Public Health, Faculty of Medicine, University ofBritish Columbia, 2206 East Mall, Vancouver, BC V6Z 1Z3, Canada3British Columbia Centre for Disease Control, 655 West 12th Avenue,Vancouver, BC V5Z 4R4, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Voon et al. Harm Reduction Journal  (2018) 15:35 https://doi.org/10.1186/s12954-018-0241-ythese studies suggest may contribute to compromisedtherapeutic relationships between PWUD and health careproviders [4, 8, 9]. However, the experiences of painamong PWUD have not yet been described in the contextof patient-centered care, which has been identified as animportant model of care that is associated with improvedhealth outcomes, quality, and safety [10], as well asRhodes’ Risk Environment, which suggests that the healthof PWUD is not simply defined by individual-level factors,but by the complex interplay between policy, economic,physical, and social environments that may serve as riskfactors for—or protective factors against—drug-relatedharms [11, 12]. Therefore, this study sought to exploreperspectives on pain management among PWUD in sev-eral urban and rural settings across British Columbia,Canada, using the patient-centered care and Rhodes’ RiskEnvironment frameworks.MethodsFocus group data were derived from the Peer Engagementand Evaluation Project (PEEP), a participatory qualitativeevaluation of harm reduction services (including opioidagonist and substitution treatment) in British Columbia,Canada. This study has previously been described else-where [13–15]. In brief, from July to September 2015, 13focus groups were held at harm reduction sites across 12urban and rural locations throughout each of the five re-gional health authorities in British Columbia. Throughlocal PWUD and service providers, snowball samplingwas employed to recruit a total of 83 PWUD. Partici-pants were eligible for inclusion in the study if theyself-identified as a person who uses drugs (i.e., at leastonce in the past week), were 19 years of age or older,had been living in British Columbia in the past6 months, able to provide informed consent, and ablespeak and understand English.Each focus group was facilitated by trained “peer” re-search assistants (PRAs). Peers were defined as PWUDwho draw on their lived experience of substance use to in-form their professional work [16, 17]. A PRA-informedquestion guide sought to elucidate perspectives on barriersand enablers to accessing harm reduction services. Allfocus group participants provided informed consent andreceived food, transportation, and a $20 stipend. Thisstudy received ethical approval by the University of BritishColumbia Research Ethics Board (H15-00126).Following the completion of each focus group, thePRAs and non-peer researchers debriefed to discussemerging themes and questions that could be chan-ged or added to explore newly identified perspectivesin future focus groups. Audio recordings from thefocus groups were transcribed verbatim, and datawere organized using NVivo 11 software. After thetranscripts were cleaned, the researchers and PRAscoded the transcripts using preliminary themes thatwere conceptualized through debriefing and discus-sions with the research team. The coded data wasthen validated during a member checking session withthe PRAs. The resulting four major themes from theproject included (1) access to harm reduction, (2)readiness for engagement, (3) peer community andnetworks, and (4) stigma and trust.The present study describes participants’ experi-ences of concurrent pain and addiction, whichemerged as a recurring topic within the theme of“stigma and trust.” We used the qualitative approachof interpretive description, a non-categorical method-ology that seeks to describe themes related to clinicalphenomena in order to inform clinical understandingfor applied health disciplines [18, 19]. The conceptualframeworks informing this analysis include Rhodes’Risk Environment and patient-centered care. TheRhodes’ Risk Environment framework suggests that thehealth of PWUD is not simply defined by individual-levelfactors, but by the complex interplay between policy, eco-nomic, physical, and social environments that may serveas risk factors for—or protective factors against—drug-re-lated harms [11, 12]. The patient-centered care modelposits that quality health care must shift away from pater-nalistic, one-size-fits-all approaches to clinical care, mov-ing instead toward patient-centered approaches that takeinto account individual differences and preferences relatedto biopsychosocial factors, subjective health needs and ex-periences, shared power and decision-making, and com-munication and relationships built upon mutual trust [11].ResultsA summary of the participants’ socio-demographic anddrug use characteristics is shown in Table 1. As summa-rized below and in Table 2, several themes related toRhodes’ Risk Environment and patient-centered careemerged in the focus group discussions on pain manage-ment. The following excerpts are labeled according tofocus group number, gender (e.g., female (F) or male(M)), and participant number.Restrictive policies regarding treatment of pain andmethadone maintenance treatmentIn the study setting, many methadone maintenancetreatment (MMT) clinics have strict policies againsttreating patients for concerns ‘unrelated’ to their metha-done treatment, despite the often comorbid nature ofpain and opioid use disorder. Several participants wereenrolled in MMT and recounted how such restrictivepolicies served as barriers to effective pain managementin their interactions with physicians:Voon et al. Harm Reduction Journal  (2018) 15:35 Page 2 of 91-M3: And I talked to him [methadone doctor] aboutmy lower back pain and he looked right at me andgoes, “No, no, I took you on as a patient but I won’ttake you on as a pain patient.”Other participants described their experiences withsimilar barriers in acute care settings:2-M6: If you use methadone and go on a methadoneprogram, then, then you injure yourself and you needpainkillers and go to a hospital, and they find outyou’re on a methadone program, you don’t getanything more than an aspirin.Economic factors contributing to higher-risk drug useParticipants expressed how their inability to obtain paintreatment from physicians led them to obtain divertedor illicitly manufactured pain medication fromstreet-based drug markets, and how economic factors in-fluenced their decisions to use such pain medications viahigh-risk injection practices (e.g., in order to achieve amore potent or rapid effect, as opposed to consumingpain medications via oral administration):Table 1 Socio-demographic and drug use characteristics ofparticipants in the Peer Engagement and Evaluation Project(PEEP) (n = 70a)CharacteristicAge Mean (years) Range (years)All clients 44 18–64Female 41 18–60Male 45 20–64Gender n %Female 30 42.9Male 38 54.3Transgender 1 1.4Other 1 1.4Ethnicity n %Aboriginal 25 35.7Non-Aboriginal 45 64.3Income sourceb n %Full-time employment 0 0Part-time employment 6 8.6Self-employed 7 10.0Disability assistance 42 60.0Social assistance 20 28.6Other 13 18.6Housing status n %Owned unit 3 4.3Rental unit 38 54.3Shelter 10 14.3No fixed address 16 22.9Other 3 4.3Drugs used in the last weekb n %Heroin 30 42.9Methadone 19 27.1Morphine 28 40.0Dilaudid 15 21.4Oxycodone 12 17.1Fentanyl 15 21.4Benzodiazepine 15 21.4Cocaine 27 38.6Crack 37 52.9Crystal Meth 36 51.4Stimulant 12 17.1Marijuana 10 14.3GHB 2 2.9Suboxone 3 4.3Acid (LSD) 3 4.3Ecstacy 1 1.4Tylenol #3 1 1.4Table 1 Socio-demographic and drug use characteristics ofparticipants in the Peer Engagement and Evaluation Project(PEEP) (n = 70a) (Continued)CharacteristicNumber of drugs used in the last week n %0 2 2.91 8 11.42 7 10.03 18 25.74 15 21.45 7 10.06 2 2.97 6 8.68 1 1.49 3 4.310 1 1.4Method of drug use in the last weekb n %Smoke 69 98.6Snort 61 87.1Inject 44 62.9Swallow 54 77.1Other 8 11.4aMissing responses due to incomplete demographic forms in onerural regionb Individuals were able to provide more than one answerVoon et al. Harm Reduction Journal  (2018) 15:35 Page 3 of 91-F1: I mean doctors up here won’t give pain meds.1-F2: They won’t give you anything.1-F1: Like so I mean that’s why some people end upgoing on the street and doing needles because youspend $40 on a pill, you don’t wanna eat it and notget anything out of it.In light of the economically vulnerable position of manyPWUD, participants described the protective potential ofapplying harm reduction principles in the context of painmanagement among people who actively use drugs:1-F1: Harm reduction would be the doctorsprescribing [to] people who are in pain.1-F2: Yeah. Yeah. If I had my own prescription, Iwouldn’t be selling it, I’d be using it and I wouldn’t bespending all my money on pain killers.Participants also expressed how the financial strain ofobtaining diverted or illicitly manufactured pain medica-tions subjected them to economic vulnerability heightenedby competing familial demands:3-M3: You know I’m paying $30 a pill for my painmeds for actual, you know, for true chronic painlike…[gets cut off].3-F1: [Inaudible]…and we have two teenageddaughters, how the fuck are we supposed to [pay] 30bucks a pill?Table 2 Summary of Rhodes’ Risk Environment and patient-centered care themes related to pain management that emerged from13 focus groups of people who use drugs in British Columbia, Canada, from July to September 2015 (n = 83)Framework Element ExampleRhodes’ Risk EnvironmentSuggests that the health of people who usedrugs is not simply defined by individual-levelfactors, but by the complex interplay betweenpolicy, economic, physical, and socialenvironments that may serve as risk factorsfor—or protective factorsagainst—drug-related harms.Policy environments Restrictive policies regarding treatmentof pain and opioid agonist treatmentE.g., “And I talked to him [methadone doctor] aboutmy lower back pain and he looked right at me and goes,‘No, no, I took you on as a patient but I won’t take youon as a pain patient.’”Economic environments Economic factors contributing to higher-risk drug useE.g., “… doctors up here won’t give pain meds … that’swhy some people end up going on the street and doingneedles because you spend $40 on a pill, you don’twanna eat it and not get anything out of it.”Physical environments Geographic differences in access to socio-physicalsupport systems that facilitate access to pain managementE.g., “So behind the times… for chronic pain issues and Imean… in Vancouver I could’ve went over to [harm reductionprogram] and they’d send an advocate with me over to thatplace… down there you do not have to just go ask another doctor.”Social environments Stigma from health professionals as barriers to painmanagement; denial of pain medication reinforcingmarginalization and risky self-medicationE.g., “Once you’re flagged, you’re flagged …they have legitimate pain they’re just gonna goto the street and get something”Patient-centered careSuggests that quality health care mustshift away from paternalistic, one-size-fits-allapproaches to clinical care, moving insteadtoward patient-centered approaches thattake into account individual differencesand preferences.Recognition of bio-psychosocialinfluences on health;acknowledgement of subjectivehealth needs and experiencesPatients as experts in recognizing biopsychosocialdifferences and subjective health needs and experiencesrelated to pain managementE.g., “…everybody’s pain is different right?Some people’s tolerance to medication is they can handlemore medication, not that they’re getting stoned or whatever,it just takes more to get rid of that pain.”Shared power and decision-makingbetween patients and health careproviders; promotion ofpatient-provider communicationand relationships basedon mutual trustAbsence of shared power and decision-making in paintreatment plan contributing to distrust of thepatient-provider relationshipE.g., “Doctors give you false information … let’s say you’ve beenon morphine for 10 years for chronic pain issues and thendoctors will try and…some doctors will try and get you to goon methadone when methadone does not work for pain,not for a lot of people.”Voon et al. Harm Reduction Journal  (2018) 15:35 Page 4 of 9Geographic differences in access to socio-physical supportsystems that facilitate access to pain managementParticipants expressed how the culture of practice amongphysicians varied by geographic location. Resoundingly,participants in rural regions described their fear of being“outed” as a PWUD in their community as their access topain management would be compromised. In rural towns,participants often had access to only one physician. Oneparticipant in a rural location stated, “doctors up herewon’t give pain meds,” while others expressed:4-F2: [Man who was shot] was an addict so theywouldn’t give him anything.4-M2: That’s something else altogether.4-F2: Is that not cruel and unusual?4-F4: Yes it is and it doesn’t happen at all thehospitals because [Name], when he OD’d, he went to[rural town] and he was looked after really well asfar…so I mean, I think this particular hospital and theattitude of all these [expletive omitted] doctors suck.4-M1: We’re all labeled…we’re all labeled.However, even in urban centers, barriers to accessingmedical care for pain management were expressed, such asdifficulties walking to public transportation while in pain.Geographic differences were also observed in relation to ac-cessibility to socio-physical support systems for PWUD. Forinstance, a specialized addiction clinic with staff who couldhelp advocate for PWUD was accessible in an urban city,compared to a smaller rural setting without such supports:3-M3: So behind the times… for chronic pain issuesand I mean… in Vancouver I could’ve went over to[harm reduction program] and they’d send anadvocate with me over to that place… down there youdo not have to just go ask another doctor.Similarly, a larger urban setting provided access to ap-proachable staff and a culture of care that may have beenfostered in part by a well-established peer advocacy group:4-F2: […] I got stuck in Vancouver once when I lived inAbbotsford and I have back issues and so I had somesevere sciatic pain and called them at [harm reductionprogram] because I’d been there and talked to peoplethere and they told me how to get on the bus and get to[hospital]. I walked in the door… front door of [hospital]where they have their initial triage, they sent me down toFast Track and from the minute I walked in the door tothe minute the doctor saw me, it was 24 min.4-F4: That’s an awesome hospital it is.4-F2: Right, and he […] immediately gave mesomething for pain and prescribed Percocets for me,which is what I can take because I am allergic toother things and was no problem. Now I know that[peer-based organization] has worked countless hoursand years with [hospital] but perhaps we should getsome hints from them…those two groups to see abouttraining the hospital staff.Stigma from health professionals as barriers to painmanagementParticipants commonly expressed their experiences ofaddiction-related stigma from health professionals,which served as a barrier to accessing pain management:5-F3: Like if you go…me having HIV, I go up to thehospital, some of the nurses up there are really nicebut a lot of them are kinda like…just look at you…likeyou just feel disgusting the way they look at you and ifthey know you’re an addict, they’ll push…if…if you goto the emergency room and you’re there first, you’llbe the last one seen. They think you’re just theretrying to get drugs or…or whatever, it doesn’t matterif you’ve got a broken arm and it’s hang out to yourfrikken’ elbow, you’re elbow’s popped out, you’regonna be the last one seen, like it’s that bad up here.5-M2: And you won’t get any pain killers.5-F3: No, they’ll maybe give you a couple Advil andsend you home.Other participants expressed how inadequate paintreatment may stem from a perception that such treat-ments may be “enabling”:4-F2: So it’s not like you’re abusing it, you know, butthey’ve got this idea in your head, their heads that ifyou’re an addict then you don’t deserve anything for….4-F4: Treatment, that’s right.4-F2: You don’t deserve anything for pain and they’renot gonna enable.Denial of pain medication reinforcing marginalization andrisky self-medicationMany participants expressed their experiences with be-ing unable to obtain pain medication from clinicians,which led them to subsequently self-manage their painVoon et al. Harm Reduction Journal  (2018) 15:35 Page 5 of 9by obtaining diverted or illicitly manufactured painmedications, thereby reinforcing marginalization andentrenchment in street-based drug markets. Examplesinclude “And I said, you know, ‘You don’t give me thepain meds I gotta go get ‘em, I’m in chronic pain’”[1-M3], “I wouldn’t be…have much to do with thestreet scene if the doctor gave me the pain killers”[1-F2], “It wouldn’t be such a black market if the doc-tors didn’t punish us for past self-medicating” [1-F2],“Once you’re flagged, you’re flagged and I mean thatjust…if you…they have legitimate pain they’re justgonna go to the street and get something” [4-F4], and“I didn’t have a doctor and I self-medicated myself be-cause of the pain right? And, uh, lo and behold here Iam trying to get an operation. I’ve been like this for ayear and a half” [6-M4]. One participant even reflectedon the unethical nature of individuals having to resortto managing their pain on their own, stating “That’swhat I mean, by the doctors turning people away likethat, look what happens … Self-medicating…yeah.That’s inhumane” [4-F4]. For some, the inability to ac-cess pain medication contributed to high-risk injectionpractices:1-F2: The doctors won’t prescribe him painmedication because he used needles….1-M3: And I was only using needles because he cutme off and I told that to my doctor and he said, youknow, he’s like, “Oh, so you been using needles thewhole time,” and I’m like, “No, a year…I started upabout a year ago ‘cause you cut me off first.”Patients as experts in recognizing biopsychosocialdifferences and subjective health needs and experiencesrelated to pain managementAs experts with insight into their own health needs, par-ticipants expressed an understanding of pain treatmentconcepts such as tolerance, and the person-specific na-ture of pain treatment:1-M2: I would like to know where they draw, uh,everybody’s pain is different right? Some people’stolerance to medication is they can handle moremedication, not that they’re getting stoned orwhatever, it just takes more to get rid of that pain.[…] Well what I’d like to say is that we come outwith a scale or… “Okay, this pain regulates thatmuch more pain, or this much Oxycontin or…”whatever right? And, you know, put somebody onthat amount but my doctor once said he hadsomebody 300 lbs doing the same amount as me,couldn’t get off the couch.1-F2: Well he’s got a lower tolerance.1-M2: And that…that’s my point like I had to go andbuy more … Because he can’t prescribe any more.Absence of shared power and decision-making in paintreatment plan contributing to distrust of the patient-provider relationshipThe patient-centered care principles of shared powerand decision-making, communication, and relationshipsbuilt upon mutual trust emerged as particularly frac-tured in participants’ experiences in the context of painmanagement. Specifically, methadone was seen as atreatment option that lacked shared power anddecision-making:1-F1: They’re trying to put everybody in pain onMethadone and Methadone does not work foreverybody but they don’t care […] It’s Methadoneor nothing.1-F2: Yeah, I’ve got back issues but because I’ve self-medicated in the past, I don’t…I’m not allowed to getany prescriptions for back pain or anxiety.Distrust was also evident in participants’ perceptionsof methadone, exemplified by statements such as “Nowthey’re lying about methadone, ‘Oh, it’s one of the purest,most excellent pain medicines in the world and youwon’t get anything better.’ It’s all a lie. It’s a completelie” [1-M3], and “Doctors give you false information …let’s say you’ve been on morphine for 10 years forchronic pain issues and then doctors will try and…somedoctors will try and get you to go on methadone whenmethadone does not work for pain, not for a lot ofpeople” [3-M3].Another common theme that appeared to strainpatient-provider relationships was being suddenly “cutoff” pain prescriptions with little communication orshared decision-making:2-M1: I don’t know why but everybody’s beengetting cut down or cut off on opiates andeverybody, chronic pain, like I got a broken neckand I’ve got chronic pain, I’m sure multiple peoplehave the same situation, it’s just chronic, always inpain. Now for a doctor to turn around and say likemy doctor said to me, people are selling ‘em on thestreet, blah, blah, blah, blah, blah, therefore I’mcutting you down to half a dose and then we’regoing to wean you off within a 2 week period. Well,does that give me a new neck? No, it didn’t doabsolutely nothing.Voon et al. Harm Reduction Journal  (2018) 15:35 Page 6 of 9DiscussionCollectively, these findings highlight the ways in whichvarious levels of Rhodes’ Risk Environment mayreinforce marginalization in the context of inadequatelymanaged pain among PWUD, such as program-levelMMT policies, economic vulnerability, lack of access tosocio-physical support systems, stigma from health pro-fessionals, and denial of pain medication leading to riskyself-medication. Furthermore, these findings highlighthow the principles of patient-centered care are often notupheld in the context of pain management amongPWUD, from a lack of recognition of patients as expertsin understanding their unique pain needs, to an absenceof shared power and decision-making, which often re-sults in distrust of the patient-provider relationship.Complexities surrounding the intersection betweenpain management and MMT emerged as a recurringtheme throughout the present study. Despite the highprevalence of chronic pain among individuals on MMT(estimated to be between 55 to 61%) [20, 21], many cli-nicians are reluctant to prescribe pain medication toMMT patients; may view MMT as a treatment for eitherpain or addiction separately; or may prescribe MMT as aone-size-fits-all approach to managing concurrent painand opioid dependence, without taking into accountpatient-centered care principles such as biopsychosocialdifferences and individual preferences [22]. For instance,literature has found that significantly higher doses ofMMT may be required for individuals with concurrentchronic pain [23]; metabolism of methadone varies con-siderably between individuals [24]; and that a range painmanagement options exist for individuals on MMT, suchthat clinicians should not have to simply deny painmedication altogether [25].Furthermore, as illustrated in the present findings,stigma and inadequately managed pain appear to be com-mon among MMT patients, with 78% reportingMMT-related stigma in one study [26], and several studiesreporting undertreated pain among individuals on MMT[21, 27–29]. As such, it is perhaps not surprising that manyPWUD with pain are distrustful of the “methadone ornothing” approach, and often self-manage their pain in-stead of, or in addition to, methadone treatment [26].Thus, clinicians may wish to explore alternative ap-proaches for treating pain, particularly in the context ofopioid use disorder, such as buprenorphine/naloxoneand specialist-led approaches, which have recently be-come more widely implemented in the study settingsince the time of this study’s data collection [30]. Spe-cifically, buprenorphine/naloxone has become the rec-ommended first-line option for pharmacologicaltreatment for opioid use disorder, due to its superiorsafety profile compared to methadone [30]. Addition-ally, specialist-led approaches for treating opioid usedisorder such as maintenance treatment with slow re-lease oral morphine or injectable opioid agonists (e.g.,hydromorphone, diacetylmorphine) have also been im-plemented in the study setting [30]. Given that little isknown about the effect of these non-methadonealternatives on pain management, patient preference, en-gagement and retention in treatment, and other factorssuch as perceived stigma among PWUD, these are import-ant areas that warrant exploration in future research.Self-managing pain among PWUD evidently poseshigh risk for morbidity and mortality such asinjection-related harms (e.g., infection, HIV/HCV trans-mission) or overdose, especially given recent concernsrelated to fentanyl contamination in the illicit drug mar-ket [31, 32]. In the present study, PWUD described theirexperiences with self-medicating after being unable toobtain pain medication from health providers. Thisphenomenon has previously been described in other lit-erature. One study found that 97% of people who injectdrugs reported self-managing pain via injecting heroin(52%) or obtaining diverted or illicitly manufactured painmedication from street-based drug markets (65%) [33].Additionally, 66% of people who inject drugs reportedthey had been denied pain medication, often for reasonssuch as perceived drug-seeking (44%), clinic policiesrestricting narcotic prescribing (26%), or being told thatmethadone is sufficient for pain (18%), as echoed in thepresent findings [34]. Furthermore, denial of pain medica-tion significantly predicted in-hospital illicit drug use [35].These findings also demonstrate a range of psycho-social harms related to inadequately managed painamong PWUD, from economic vulnerability due to thefinancial strain of buying street-based pain medication,to perceptions of “inhumane” and “cruel and unusual”treatment from health care providers. Such factors mayperpetuate and reinforce the marginalization of PWUD,such as economic vulnerability leading to high-riskinjection drug use, and perceived stigma leading toavoidance of health care and subsequent riskyself-medication. Indeed, other research has found thatfactors related to economic vulnerability (e.g., drugprices, perceived cost-effectiveness) may determine riskydrug use practices, including initiation into injectiondrug use [36], and that stigma from health professionalsin the context of pain among PWUD may lead to furtherharms (e.g., withdrawal) and compromised therapeuticrelationships [8]. To mitigate these harms, strategies areneeded to improve pain management for PWUD, suchas improving access to peer advocacy groups that maysupport PWUD and facilitate education, as was endorsedby participants in the present study.This study has limitations that should be noted. First,it is often difficult to disentangle the complex interplaybetween physical and emotional pain. Second, whileVoon et al. Harm Reduction Journal  (2018) 15:35 Page 7 of 9focus groups can have the advantage of encouraging par-ticipation and active discussion [37], this methodologyalso poses inherent areas for potential bias, such as ten-dencies toward normative discourse [38]. Third, the ex-cerpts presented represent individuals who were identifiedby the transcriptionist as gender-binary (i.e., male or fe-male voice) due to the inability to connect participants’self-reported demographics to those speaking within thefocus groups, in order to maintain confidentiality. Whiletwo participants in the study identified as non gender bin-ary (i.e., transgender or other; see Table 1), the lack ofnon-binary gender diversity represented in the focusgroup quotations is a limitation of this study. In general,representation of non-binary gender perspectives in thefield of pain and addiction research is limited; thus, thispresents an important area for future exploration.ConclusionsAs the opioid crisis continues to devastate communitiesof PWUD across North America, these findings shedlight on lesser-described phenomena of self-managed inthe context of various risk environments, which couldbe contributing to high-risk opioid use. Recent guide-lines on prescribing opioids for chronic pain proposescaling back on opioid prescribing [7]; however, withoutproviding effective analgesic alternatives for individualswho use opioids for pain, these findings (notably gatheredbefore the release of these recent guidelines) illustratehow denial of pain medication may paradoxically put indi-viduals at risk for self-harm, while potentially also dam-aging trust in the patient-provider relationship anddiminishing individuals’ willingness to seek maintenancetreatments for opioid use disorder. Therefore, more re-search is needed to investigate trends in self-managementof pain in light of developing policy discussions. For in-stance, prescription drug monitoring programs (PDMPs)are being widely implemented in many settings; however,the effectiveness of these systems, particularly from theperspective of PWUD with pain, has not been well estab-lished [39]. In fact, one recent systematic review found in-sufficient evidence of effectiveness of PDMPs, and evenhighlighted three studies that found an increase in heroinoverdoses after PDMP implementation [40]. Other majorpolicy discussions in the study setting relate to cannabislegislation, which emerging research suggests may play arole in mitigating the opioid crisis through reduced opioidprescribing [41, 42]. Added to this, the potential role ofcannabis in pain management among PWUD will be animportant area for future research.Certainly, the potential for fatal overdose and other se-vere harms that may be associated with opioid analgesicsis not to be understated, yet equally important is the“need to engage patients in an honest and open way ra-ther than quickly writing or refusing to write opioidprescriptions” [43] or consider other pain managementapproaches (e.g., non-opioid pharmacological, interven-tional, psychological, physical rehabilitation, or comple-mentary and alternative approaches) in ways that takeinto account individuals’ complex risk environments andpatient-centered care principles.AbbreviationsMMT: Methadone maintenance treatment; PDMP: Prescription drugmonitoring program; PEEP: Peer Engagement and Evaluation Project;PRA: Peer research assistant; PWUD: People who use drugsAcknowledgementsWe wish to thank the members of the PEEP team: Heather Burgess, ErinGibson, Katie Lacroix., Hugh Lampkin, Brian Leblanc, Emily Ogborne-Hill,Bernadette Pauly, Alex Scott, James Tigchelaar, and Jeff Walsh; the BC HarmReduction Strategies and Services committee; the focus group participants;the Vancouver Area Network of Drug Users (VANDU); SOLID; and the RuralEmpowered Drug Users Network (REDUN).FundingThis study was made possible with awards from the Peter Wall Institute forAdvanced Studies Solutions at the University of British Columbia and theBritish Columbia Centre for Disease Control (BCCDC) Foundation. PaulineVoon (PV) and Alissa Greer are supported through Vanier Canada GraduateScholarships from the Canadian Institutes of Health Research and PV alsoholds a Trudeau Doctoral Scholarship from The Pierre Elliott TrudeauFoundation. The funders had no role in the conduct of this study.Availability of data and materialsThe datasets generated and/or analyzed during the current study are notpublicly available.Authors’ contributionsPV, AG, and JB conceived of the study. As members of the Peer Engagementand Evaluation Project (PEEP), AG, AA, CB, CN, and JB collected, analyzed,and validated the data. PV further analyzed the data and drafted thismanuscript. All authors were given opportunities for feedback and revision;all authors approved the final manuscript.Ethics approval and consent to participateAll focus group participants provided informed consent and received food,transportation, and a $20 stipend. This study received ethical approval by theUniversity of British Columbia Research Ethics Board (H15-00126).Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1British Columbia Centre on Substance Use, 400 - 1045 Howe Street,Vancouver, BC V6Z 2A9, Canada. 2School of Population and Public Health,Faculty of Medicine, University of British Columbia, 2206 East Mall,Vancouver, BC V6Z 1Z3, Canada. 3British Columbia Centre for DiseaseControl, 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada.Received: 5 March 2018 Accepted: 27 June 2018References1. Institute of Medicine Report from the Committee on Advancing PainResearch, Care, and Education. Relieving pain in America, a blueprint forVoon et al. 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