"A lot of bureaucracy": Structural barriers to prescription opioids in cancer pain management.

Well-intentioned policies to reduce opioid prescribing can conflict with efforts to manage advanced cancer pain, resulting in structural barriers to opioid pain management that complicate the delivery of guideline-concordant care. This study examined how patients with advanced cancer and their support people perceive barriers to opioid access, how those barriers affect their cancer pain management, and the extent to which they recognize and attribute them to policy guidance. Results from an analysis of in-depth qualitative interviews with 20 patients with advanced cancer and 11 support people, applying a rigorous inductive, qualitative approach to characterize findings, are presented. Patients and their support people reported barriers in multiple phases of opioid access for pain management, including 1) obtaining opioid prescriptions, 2) obtaining insurance authorization, and 3) obtaining the prescription at a pharmacy. These barriers were perceived as contributors to increased, avoidable hardships in pain management. Participants also expressed concerns about the negative impact of opioid prescribing policies on effective cancer pain management, highlighting the perception that patients had few avenues to influence legislation they may view as arbitrary or unfeeling. The complexity of cancer pain management necessitates that policymakers ensure that prescribing guidelines are clear and implemented as intended, while also inviting patients with advanced cancer and their support people into the policymaking process. Future research with more diverse samples can expand on these findings to explore how to best structure state-level opioid policies to ensure safe and equitable opioid access for patients with advanced cancer. PERSPECTIVE: Using qualitative interviews with patients with advanced cancer and their support people, this study shows how opioid policies create and exacerbate multistage barriers to opioid access for pain management. These structural barriers undermine guideline-concordant pain care, emphasizing the need for clearer policy implementation and patient inclusion in opioid policymaking.