Chronic pain management among people who use drugs: A health policy challenge in the context of the opioid crisis

Background: In Canada, the rise in prescription opioid (PO) overdoses and addiction is a major public health concern. Various health authorities have recently recommended that physicians use caution when prescribing opioids, especially to people with histories of substance use. As a result, fewer therapeutic options are available for people who use drugs (PWUD) and suffer from chronic non-cancer pain (CNCP). This paper examines how PWUD describe their experiences with CNCP management in the context of the opioid crisis. Methods: This qualitative study is based on in-depth interviews with Montreal (Canada) PWUD experiencing CNCP for 3 months or more. Results: Most of the 25 participants (27-61 years; 10 women, 15 men) were polysubstance users (cocaine, opioids, amphetamine, etc.) suffering from CNCP for several years, with multiple additional health and social problems. The majority were unsatisfied with their CNCP management. They felt labelled as "addicts" and stigmatized within the healthcare system. Many participants had been denied PO, even those with severe CNCP and those who were not opioid-dependent. Participants expressed a desire to access non-pharmacological CNCP therapies, but these were often too expensive. Some PWUD were offered methadone to relieve CNCP and found this inappropriate. As a last resort several participants reported self-medicating CNCP with street drugs, increasingly known to be laced with fentanyl. Conclusion: PWUD with CNCP are affected by two opioid crises: the PO crisis and the street-opioid crisis. The lack of a coherent policy that addresses their pain management produces reoccurring problems when seeking CNCP relief. Restrictive prescription measures implemented in response to the PO crisis may have consequences similar to prohibitionist policies: they heighten overdose risks for PWUD by increasing exposure to street drugs laced with fentanyl. Improving access to diverse CNCP management options for PWUD can help reduce harms related to street-opioid use.