Trust and Distrust in Opioid Decision-Making: A Qualitative Assessment of Patient-Doctor Relationship

Published:December 13, 2021DOI:


      Surgeons often prescribe opioid analgesics for pain management after surgery. However, we understand little about how patients perceive opioid prescribing and make decisions to use opioids for postoperative pain management. In this study, we aimed to gain an understanding of patients’ decision-making process on postoperative opioid use.


      We conducted semi-structured interviews with 30 adult patients undergoing elective surgery at our institution. The interviews were content-coded for thematic analysis. We used trust in the medical setting as a conceptual framework to interpret and find the inherent theory in the data.


      We found that participants based their opioid decisions on their trust or distrust toward various elements of their postoperative pain management. Participants believed that the surgeons “know,” thereby, reinforcing their trust in surgeons’ postoperative opioid prescribing to be in the participants’ best interest. Moreover, the positive reputation of the institution strengthened the participants’ trust. However, participants conveyed nuanced trust because of their distrust toward the opioid medications themselves, which were viewed as “suspicious,” and the pharmaceutical companies, that were “despised.” Despite this distrust, participants had confidence in their inherent ability to protect themselves from opioid use disorders.


      Understanding how patients perceive and form decisions on postoperative opioid use based on their trust and distrust toward various factors involved in their care highlights the importance of the patient-doctor relationship and building trust to effectively address postoperative pain and reduce opioid-related harms.

      Clinical relevance

      Through a strengthened therapeutic alliance between patients and surgeons, we can improve our strategies to overcome the ongoing opioid epidemic through patient-centered approaches.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bicket M.C.
        • Long J.J.
        • Pronovost P.J.
        • Alexander G.C.
        • Wu C.L.
        Prescription opioid analgesics commonly unused after surgery: a systematic review.
        JAMA Surg. 2017; 152: 1066-1071
        • Kim N.
        • Matzon J.L.
        • Abboudi J.
        • et al.
        A prospective evaluation of opioid utilization after upper-extremity surgical procedures: identifying consumption patterns and determining prescribing guidelines.
        J Bone Joint Surg Am. 2016; 98: e89
        • Chapman T.
        • Kim N.
        • Maltenfort M.
        • Ilyas A.M.
        Prospective evaluation of opioid consumption following carpal tunnel release surgery.
        Hand (N Y). 2017; 12: 39-42
        • Waljee J.F.
        • Zhong L.
        • Hou H.
        • Sears E.
        • Brummett C.
        • Chung K.C.
        The use of opioid analgesics following common upper extremity surgical procedures: a national, population-based study.
        Plast Reconstr Surg. 2016; 137: 355e-364e
        • Rodgers J.
        • Cunningham K.
        • Fitzgerald K.
        • Finnerty E.
        Opioid consumption following outpatient upper extremity surgery.
        J Hand Surg Am. 2012; 37: 645-650
        • Chua K.P.
        • Brummett C.M.
        • Waljee J.F.
        Opioid prescribing limits for acute pain: potential problems with design and implementation.
        JAMA. 2019; 321: 643-644
        • Chua K.P.
        • Kimmel L.
        • Brummett C.M.
        Disappointing early results from opioid prescribing limits for acute pain.
        JAMA Surg. 2020; 155: 375-376
        • Blanco C.
        • Volkow N.D.
        Management of opioid use disorder in the USA: present status and future directions.
        Lancet. 2019; 393: 1760-1772
        • Miller A.
        • Kim N.
        • Zmistowski B.
        • Ilyas A.M.
        • Matzon J.L.
        Postoperative pain management following carpal tunnel release: a prospective cohort evaluation.
        Hand (N Y). 2017; 12: 541-545
        • Matthias M.S.
        • Krebs E.E.
        • Collins L.A.
        • Bergman A.A.
        • Coffing J.
        • Bair M.J.
        I’m not abusing or anything”: patient-physician communication about opioid treatment in chronic pain.
        Patient Educ Couns. 2013; 93: 197-202
        • Craig B.M.
        • Strassels S.A.
        Out-of-pocket prices of opioid analgesics in the United States, 1999-2004.
        Pain Med. 2010; 11: 240-247
        • Smith R.J.
        • Rhodes K.
        • Paciotti B.
        • Kelly S.
        • Perrone J.
        • Meisel Z.F.
        Patient perspectives of acute pain management in the era of the opioid epidemic.
        Ann Emerg Med. 2015; 66: 246-252.e1
        • Dardas A.Z.
        • Stockburger C.
        • Boone S.
        • An T.
        • Calfee R.P.
        Preferences for shared decision making in older adult patients with orthopedic hand conditions.
        J Hand Surg Am. 2016; 41: 978-987
        • Doring A.C.
        • Hageman M.G.
        • Mulder F.J.
        • et al.
        Trigger finger: assessment of surgeon and patient preferences and priorities for decision making.
        J Hand Surg Am. 2014; 39: 2208-22013.e2
        • Gaspar M.P.
        • Pflug E.M.
        • Adams A.J.
        • et al.
        Self-reported postoperative opioid-prescribing practices following commonly performed orthopaedic hand and wrist surgical procedures: a nationwide survey comparing attending surgeons and trainees.
        J Bone Joint Surg Am. 2018; 100: e127
        • Cabo J.
        • Hsi R.S.
        • Scarpato K.R.
        Postoperative opiate use in urological patients: a quality improvement study aimed at improving opiate disposal practices.
        J Urol. 2019; 201: 371-376
        • Saldaña J.
        The Coding Manual for Qualitative Researchers.
        3rd ed. SAGE, 2016
        • Creswell J.W.
        Research Design - Qualitative, Quantitative, and Mixed Methods Approaches.
        4th ed. SAGE Publications, 2013
        • Forman J.
        • Creswell J.W.
        • Damschroder L.
        • Kowalski C.P.
        • Krein S.L.
        Qualitative research methods: key features and insights gained from use in infection prevention research.
        Am J Infect Control. 2008; 36: 764-771
        • Tolley E.E.
        • Ulin P.R.
        • Mack N.
        • Robinson E.T.
        • Succop S.M.
        Qualitative Methods in Public Health: A Field Guide for Applied Research.
        John Wiley & Sons, Incorporated, Hoboken2016
        • O’Brien B.C.
        • Harris I.B.
        • Beckman T.J.
        • Reed D.A.
        • Cook D.A.
        Standards for reporting qualitative research: a synthesis of recommendations.
        Acad Med. 2014; 89: 1245-1251
        • Hall M.A.
        • Dugan E.
        • Zheng B.
        • Mishra A.K.
        Trust in physicians and medical institutions: what is it, can it be measured, and does it matter?.
        Milbank Q. 2001; 79: 613-639
        • Robbins B.G.
        What is trust? a multidisciplinary review, critique, and synthesis.
        Sociol Compass. 2016; 10: 972-986
        • Beauchamp T.L.
        • Childress J.F.
        Principles of Biomedical Ethics.
        Oxford University Press, 1989
        • Gillon R.
        Medical ethics: four principles plus attention to scope.
        BMJ. 1994; 309: 184-188
        • Gupta S.
        • Brenner A.T.
        • Ratanawongsa N.
        • Inadomi J.M.
        Patient trust in physician influences colorectal cancer screening in low-income patients.
        Am J Prev Med. 2014; 47: 417-423
        • Epstein E.G.
        • Wolfe K.
        A preliminary evaluation of trust and shared decision making among intensive care patients’ family members.
        Appl Nurs Res. 2016; 32: 286-288
        • Haywood Jr., C.
        • Lanzkron S.
        • Bediako S.
        • et al.
        Perceived discrimination, patient trust, and adherence to medical recommendations among persons with sickle cell disease.
        J Gen Intern Med. 2014; 29: 1657-1662
        • Haywood Jr., C.
        • Lanzkron S.
        • Ratanawongsa N.
        • et al.
        The association of provider communication with trust among adults with sickle cell disease.
        J Gen Intern Med. 2010; 25: 543-548
        • Thom D.H.
        • Hall M.A.
        • Pawlson L.G.
        Measuring patients’ trust in physicians when assessing quality of care.
        Health Aff (Millwood). 2004; 23: 124-132
        • Lynch T.J.
        • Wolfson D.B.
        • Baron R.J.
        A trust initiative in health care: why and why now?.
        Acad Med. 2019; 94: 463-465
        • Mou E.
        • Schapira L.
        • Kunz P.
        The power of trust.
        JAMA Oncol. 2018; 4: 1173-1174
        • Arora N.K.
        • Gustafson D.H.
        Perceived helpfulness of physicians’ communication behavior and breast cancer patients’ level of trust over time.
        J Gen Intern Med. 2009; 24: 252-255
        • Armstrong K.
        If you can’t beat it, join it: uncertainty and trust in medicine.
        Ann Intern Med. 2018; 168: 818-819
        • Sherman K.J.
        • Walker R.L.
        • Saunders K.
        • et al.
        Doctor–patient trust among chronic pain patients on chronic opioid therapy after opioid risk reduction initiatives: a survey.
        J Am Board Fam Med. 2018; 31: 578-587
        • Samuel G.
        • Dheensa S.
        Perspectives on achieving institutional trust in personalized medicine.
        Am J Bioeth. 2018; 18: 39-41
        • Lee S.S.-J.
        • Fullerton S.M.
        • Saperstein A.
        • Shim J.K.
        Ethics of inclusion: cultivate trust in precision medicine.
        Science. 2019; 364: 941-942
        • Hjelmaas A.J.
        • Vercler C.J.
        How should a physician respond to a patient’s pain when new opioid prescribing laws limit shared decision making?.
        AMA J Ethics. 2019; 21: E838-E843
        • Matthias M.S.
        • Johnson N.L.
        • Shields C.G.
        • et al.
        I’m not gonna pull the rug out from under you”: patient-provider communication about opioid tapering.
        J Pain. 2017; 18: 1365-1373
        • Matthias M.S.
        • Krebs E.E.
        • Bergman A.A.
        • Coffing J.M.
        • Bair M.J.
        Communicating about opioids for chronic pain: a qualitative study of patient attributions and the influence of the patient-physician relationship.
        Eur J Pain. 2014; 18: 835-843
        • Alter T.H.
        • Ilyas A.M.
        A prospective randomized study analyzing preoperative opioid counseling in pain management after carpal tunnel release surgery.
        J Hand Surg Am. 2017; 42: 810-815
        • Vincent S.
        • Paskey T.
        • Critchlow E.
        • et al.
        Prospective randomized study examining preoperative opioid counseling on postoperative opioid consumption after upper extremity surgery.
        Hand (N Y). 2020; 1558944720919936
        • University of Michigan Hospitals - Michigan medicine
        US News and World Report.
        (Accessed April 5, 2020)