title: Patient-reported pathways to opioid use disorders and pain-related barriers to treatment engagement.
abstract: Risk factors associated with developing opioid use disorders (OUD) are documented, but less is known about different pathways to initiation of opioids or opioid dependence, or how such pathways affect treatment engagement.
  
  
  
  We recruited 283 adults with electronic medical record (EMR) evidence of opioid dependence diagnoses. Open-ended and structured interview items focused on prior opioid treatment experiences, barriers to and knowledge of treatment options. Interviews were audio-recorded, transcribed, and coded. In exploratory analyses, we used a modified grounded theory approach to organize emergent, patient-reported themes describing participants' perceived pathways to opioid dependence.
  
  
  
  121 participants described one or more pathways to OUD. Qualitative analyses revealed five pathway themes. Three pathways were related to pain control: inadequately controlled chronic pain, exposure to opioids during acute pain episodes, and chronic pain among individuals with prior substance use disorders. A fourth pathway included individuals for whom opioids provided relief from emotional distress; the fifth related to recreational or non-medically supervised opioid use. We identified pain-related barriers to reducing/stopping opioids and treatment engagement barriers among individuals who perceived themselves solely as pain patients.
  
  
  
  Patients' perceptions of inadequately controlled pain, patients' previous substance use disorders, and the relief from emotional distress that some patients feel while using opioids are relevant when making clinical decisions about whether to initiate or sustain opioid therapy, and for how to monitor certain individuals. Among individuals with pain and OUD, treatment barriers include fear of uncontrolled pain, and stigmatization of being treated alongside people with non-medical opioid use.
authors.affiliation: Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Ave, Portland, OR 97227, USA. Electronic address: scott.p.stumbo@kpchr.org.
authors.forename: Scott P
authors.initials: SP
authors.lastname: Stumbo
authors.affiliation: Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Ave, Portland, OR 97227, USA. Electronic address: bobbijo.h.yarborough@kpchr.org.
authors.forename: Bobbi Jo H
authors.initials: BJ
authors.lastname: Yarborough
authors.affiliation: OHSU/PSU School of Public Health, Oregon Health & Science University, 3181 S.W. Sam Jackson Hill Road, CB 669, Portland, OR 97239, USA. Electronic address: mccartyd@ohsu.edu.
authors.forename: Dennis
authors.initials: D
authors.lastname: McCarty
authors.affiliation: Division of Research, Kaiser Permanente Northern California, 2000 Broadway Ave., Oakland, CA 94612, USA; Department of Psychiatry, University of California, San Francisco, 401 Parnassus, Box 0984, San Francisco, 94143, USA. Electronic address: constance.weisner@kp.org.
authors.forename: Constance
authors.initials: C
authors.lastname: Weisner
authors.affiliation: Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Ave, Portland, OR 97227, USA. Electronic address: carla.a.green@kpchr.org.
authors.forename: Carla A
authors.initials: CA
authors.lastname: Green
mesh_terms: D059787:Acute Pain / Q000188:drug therapy*; D000328:Adult; D000342:Affective Symptoms / Q000150:complications*; D059350:Chronic Pain / Q000188:drug therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009293:Opioid-Related Disorders / Q000209:etiology*; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D036301:Qualitative Research; D057545:Social Stigma; D055815:Young Adult
keywords: Emotional distress; Opioid addiction treatment; Opioid use disorder; Qualitative research; Stigma; Treatment barriers