The use of prescription opioids for the management of chronic pain is controversial. Patients can be harmed by opioid overuse—through opioid-related adverse effects including respiratory depression or the development of opioid use disorder (OUD)—and underuse—through unwarranted withholding of opioids. Despite the effectiveness of opioids for the treatment of acute pain (e.g., post-surgery), their analgesic benefits in chronic non-cancer pain are less clear.1,2 Yet, opioid prescriptions increased dramatically in the 1990s and early 2000s, with a substantial portion prescribed for chronic pain management.3 Given these trends and associated increases in opioid-related overdose deaths,4,5 the US Centers for Disease Control and Prevention (CDC) released opioid prescribing guidelines in 2016 targeted towards primary care clinicians and other clinicians providing chronic pain care.6 The release of these guidelines was followed by large reductions in opioid prescribing,7 including in people with cancer.8,9 These reductions raised concerns that the guidelines were misapplied and may have contributed to increased suffering among patients in pain.10 Undoubtedly, the issue of opioid prescribing is complex. Clinicians are faced with regulatory pressures and fear of licensure repercussions with any perceived missteps in opioid prescribing.11 Patients are increasingly asked to jump through regulatory hoops (e.g., pill counts, urine drug tests, signed agreements), creating the perception that they are doing something wrong or even criminal in their pain care.12 Hence, efforts to curb opioid prescribing, although rooted in patient safety, have had the unintended consequence of creating an adverserial and transactional relationship between clinician and patient.

In response to these concerns, the CDC updated their clinical guidelines for prescribing opioids in 2022.13 CDC recommends that patients and clinicians engage in shared decision-making (SDM) to arrive at individualized opioid prescribing for chronic pain. Some experts, however, argued that SDM plays, at best, a limited role in the care of patients facing complex situations such as long-term opioid prescribing.14,15 We argue that to best understand the role of SDM in opioid prescribing, it is helpful to reframe SDM as a method of care.16

When patients and clinicians collaborate to determine the best next steps in care, they participate in SDM.17,18 This participatory approach stands in contrast to unilateral approaches by which clinicians ask patients to decide alone or clinicians make recommendations or treatment decisions. The updated CDC guidelines, following the pattern of most guidelines, particularly emphasizes SDM when there is no clear best treatment option, invoking a traditional SDM approach that encourages patient involvement in deliberating about the relative merits and disadvantages of available options in light of their preferences, personal views, and priorities.19 In practice, traditional SDM occurs infrequently and may even be seen as optional, a nice-to-have “add-on” to usual care,20 or as largely inappropriate when patients have limited capacity to make decisions.21 Employing observer-based assessment of patient-clinician interactions across 33 studies in various clinical settings, the mean (standard deviation) score of patient involvement in clinical decision making was 23 (14) out of 100, with higher scores indicative of greater involvement.22 Barriers that impede broader SDM utilization may be clinician-related (e.g., time constraints, lack of training, biases), patient-related (e.g., fear, distrust, lack of readiness to participate), or systemic (e.g., lack of organizational support, gaps in care coordination, policies, and regulations which promote transactional care).

Experts challenging CDC recommendations to use SDM to individualize opioid prescribing argue that long-term opioid prescribing affects not just the patient but society (through, for example, opioid diversion), is an ineffective treatment for chronic pain, and impairs patient decision-making capacity.14,15 They call for “supplements” to SDM such as involving family members in deliberations; using decision aids presenting non-opioid alternatives while drawing attention to the risks of opioid use in light of comorbidities, co-prescriptions, and age; and focusing on daily functioning rather than pain relief as the primary goal of treatment. These experts correctly highlight that decision-making regarding the use of opioids for chronic pain extends beyond a simple discussion of pros, cons, and preferences. However, this does not mean that SDM is inappropriate. Rather, it may indicate that the traditional form of SDM may not adequately address the real and deeply personal problems that accompany life with chronic pain and suggest that other forms of SDM may be required.

Distinct from traditional descriptions of SDM in which patients select their preferred treatment approach after being presented with a menu of available options, the Purposeful SDM model23,24,25 centers on patients and their clinicians working together to understand and change the patient’s problematic situation. Development of the purposeful SDM model was driven by the recognition that weighing pros, cons, and preferences (i.e., traditional SDM) is not the only way in which collaborative decisions are made by patients and clinicians.23 Rather, purposeful SDM recognizes that there are a range of methods that may be employed to collaboratively address the patient’s problematic situation, not as “add-ons” to care but as central components of care. The use of purposeful SDM has been described in diverse medical settings, including diabetes care and vascularized composite allotransplantation.23,25,26 Regarding chronic pain care, purposeful SDM begins with working out what kind of problem pain is and what might be possible ways to address it. Purposeful SDM is a method of care because it pays attention to the problem, uses a collaborative way of figuring out how to tackle that problem, and answers the question, “What is the solution or response for which this pain is the problem?”.

What pain is and how it manifests as a problem varies. Some patients describe the painful situation and how it should be changed in terms of pain severity, and yet others do so in terms of function, relationships, or well-being.27 Although some experts have asserted that patients consistently prioritize improvement in pain intensity,15 there is considerably more nuance. Reducing the intensity of pain may not treat other ways that pain diminishes life; for instance, avoiding activities as an adaptive mechanism may diminish pain intensity but worsen social participation, daily functioning, and overall quality of life.

Under Purposeful SDM, the method of SDM depends on what problem is being addressed. Weighing beneficial and harmful effects of medicines against patient preferences may make sense when the problem is pain intensity, but when the problem lies in pain interference and disruption to day-to-day life, problem-solving ways to adapt that are minimally disruptive may be more useful at arriving at a plan of care. Alternatively, at the end of life, the problem may be existential yet sedative effects of medications may impose a new existential disconnect. The method of SDM appropriate for each of these situations (weighing, problem-solving, developing existential insight) is different for each one, but this difference is not in steps, roles, policy mandates, best practices, add-ons, or supplements to care. The difference is in the kind of problem, which serves to determine the kind of SDM to use.

In Table 1, we summarize several types of problematic situations which demand care but may complicate decision-making, along with a method of Purposeful SDM that may help. In Table 2, we bring these situations to life in clinical scenarios that represent some, but certainly not all, of the nuances and complexities of opioid prescribing decisions and chronic pain management. We contrast current approaches with those employed under Purposeful SDM. Importantly, SDM may be undermined when clinicians make unwarranted assumptions regarding the reason for seeking consultation or treatment—e.g., to achieve immediate pain control or to obtain more opioid medications. These assumptions, unexplored, weaken the ability of clinicians to respond to the patient situation, develop mutual trust, and engage productively in co-creating care with the patient.

Table 1 Problematic Situations and Methods of Purposeful SDM to Address Them
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Table 2 Example Scenarios of How Purpose SDM may Improve Collaborative Care for Those with Chronic Pain
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Pain is not purely a biological sensory phenomenon; rather, the pain experience represents an interaction between biology and biography. It is an individualized unpleasant and emotional experience, shaped by previous life experiences and emotions.28 In many cases, therapies are trialed for both diagnostic and therapeutic purposes, recognizing the highly individualized experience of pain and subsequent treatment response. Oftentimes, there is limited evidence of superiority of one treatment modality over another. Thus, there cannot be an a priori approach to pain treatment expected to be useful, usable, and desirable for most patients.29 Although healthcare systems are often organized to identify and recommend such optimal treatments for “patients like this,” Purposeful SDM, by seeking a shared understanding of each patient’s problematic situation and by uncovering together some ways to change it, seeks to form care plans “for this patient in this situation.”

And yet, some contextual factors limit the possibility that clinicians and patients engage in collaborative deliberation. The opioid epidemic and high-profile state and federal lawsuits over the last decade have sought to curb opioid prescribing. Institutional pressures, medicolegal concerns, and perceptions that opioid use may lead to dependence, misuse, or diversion strongly dissuade clinicians from prescribing opioids.30 Not all patients will benefit from opioid therapy, and some may be harmed. Harm can result from opioids’ high-risk physiological effects (e.g., respiratory depression) or from the development of opioid use disorder. Seeking to “first, do no harm,” many clinicians prefer to avoid opioid prescribing altogether. Often conflated with these safety concerns, opioid use also contributes to the tendency of communities and health professionals to stigmatize patients presenting with pain, including questioning the decision-making capacity, suffering, or worth of patients with chronic pain prescribed long-term opioids.

There are also broad recommendations that seem antithetical to SDM. State guidelines recommend that patients and clinicians enter a formal, written, and signed patient-clinician agreement outlining responsibilities of both persons with regard to opioid prescribing and describing potential consequences of noncompliance for patients. While arriving together at a treatment plan is consistent with SDM, these signed agreements often signal distrust and include punitive contingency plans. There is limited evidence to suggest that signed agreements prevent opioid misuse or strengthen the patient-clinician therapeutic alliance.31

Urine drug screening to monitor for opioid misuse or diversion may also inhibit SDM. These expensive (US$8 billion per year) programs32 may undermine patient privacy, produce results of varying accuracy and disconnected from productive next steps, and enshrine a hierarchal and punitive healthcare model that erodes collaborative patient-centered care.33,34 There is minimal evidence to suggest that urine drug screening improves patient safety beyond standard clinical evaluations.

Most states mandate the use of prescription drug monitoring programs that require prescriber registration and review of its database before opioid prescribing. These programs, however, were not designed for patient care or safety, but rather as surveillance tools for the US Drug Enforcement Administration, a law enforcement agency.35,36 While busy clinicians may find it useful to consult a program database to quickly identify multiple prescriptions or prescribers, these programs may also place excessive pressure on clinicians to minimize opioid prescribing at all costs,37,38 including through the broad application of analytical tools which are largely untested and lack clinical outcome correlates.39 Evidence to suggest that these programs successfully reduce opioid misuse or improve opioid-related outcomes remains limited.40,41

Collectively, punitive written agreements, urine drug screening, and prescription drug monitoring programs may not enhance the safety and appropriateness of opioid prescribing or, when they do, do so at the expense of restricting access to care, undermining trust and the patient-clinician relationship. Beyond this, these mechanisms risk masking the nature of the situation that requires care either by diverting clinician attention towards issues not central to the patient’s suffering, or by constraining patients’ abilities to safely voice relevant concerns. How patients use opioids may contribute positively or negatively to their situation. Either way, use is a response to something that should be the focus of care. SDM is thwarted when it is not applied to the real problematic situation, as the cases in Table 2 demonstrate.

Yet, hope remains for patients with chronic pain and their clinician partners. There is considerable nuance in chronic pain management and opioid-prescribing decisions. The Purposeful SDM framework is based on and contributes to a collaborative, non-punitive relationship between patient and clinician to tackle problems, make care fit, and avoid unintended harm from unilateral treatment decisions. SDM is not a retail transaction between a demanding patient and an obsequious prescriber, but a generative collaboration toward effective person-centered care. It may seem an implausible form of care in a healthcare system in which access, efficiency, and cost constraints call for the hurried processing of patients. And yet, patients who are suffering from pain are among those who most need a healthcare system capable of relational continuity, trust, and unhurried conversations.

Due to the multidimensional nature of how chronic pain can impact biological, psychological, social, and spiritual aspects of daily life, Purposeful SDM should not be thought of as a one-time, laborious, and extensive conversation. Rather, this form of care may be best deployed as a longitudinal process, spanning across encounters, and thus functioning well within the time and resource constraints of our healthcare system. As demonstrated in the cases, through Purposeful SDM, potentially simple solutions can be identified to improve quality of life without necessarily involving modalities that may not be available, accessible, or affordable. This framework may even be employed for patients with co-existent chronic pain and opioid use disorder, helping clinicians and patients to work together through the patient’s problematic situation and “try-on” starting buprenorphine, making a referral to a comprehensive addiction center, or leaving room for further conversations prior to agreeing on a course of action.

We propose that SDM, as a method of care, grounded in the problematic situation of each patient and centered on an ongoing patient-clinician partnership, is an adequate framework for establishing trust, mobilizing compassion, negotiating conflict, and co-creating situationally appropriate pain care that fits each person.