Table 2 Summary of Rhodes’ Risk Environment and patient-centered care themes related to pain management that emerged from 13 focus groups of people who use drugs in British Columbia, Canada, from July to September 2015 (n = 83)

Rhodes’ Risk Environment

Suggests that the health of people who use drugs is not simply defined by individual-level factors, but by the complex interplay between policy, economic, physical, and social environments that may serve as risk factors for—or protective factors against—drug-related harms.

Policy environments

Restrictive policies regarding treatment of pain and opioid agonist treatment

E.g., “And I talked to him [methadone doctor] about my lower back pain and he looked right at me and goes, ‘No, no, I took you on as a patient but I won’t take you on as a pain patient.’”

Economic environments

Economic factors contributing to higher-risk drug use

E.g., “… doctors up here won’t give pain meds … that’s why some people end up going on the street and doing needles because you spend $40 on a pill, you don’t wanna eat it and not get anything out of it.”

Physical environments

Geographic differences in access to socio-physical support systems that facilitate access to pain management

E.g., “So behind the times… for chronic pain issues and I mean… in Vancouver I could’ve went over to [harm reduction program] and they’d send an advocate with me over to that place… down there you do not have to just go ask another doctor.”

Social environments

Stigma from health professionals as barriers to pain management; denial of pain medication reinforcing marginalization and risky self-medication

E.g., “Once you’re flagged, you’re flagged … they have legitimate pain they’re just gonna go to the street and get something”

Patient-centered care

Suggests that quality health care must shift away from paternalistic, one-size-fits-all approaches to clinical care, moving instead toward patient-centered approaches that take into account individual differences and preferences.

Recognition of bio-psychosocial influences on health; acknowledgement of subjective health needs and experiences

Patients as experts in recognizing biopsychosocial differences and subjective health needs and experiences related to pain management

E.g., “…everybody’s pain is different right? Some people’s tolerance to medication is they can handle more medication, not that they’re getting stoned or whatever, it just takes more to get rid of that pain.”

Shared power and decision-making between patients and health care providers; promotion of patient-provider communication and relationships based on mutual trust

Absence of shared power and decision-making in pain treatment plan contributing to distrust of the patient-provider relationship

E.g., “Doctors give you false information … let’s say you’ve been on morphine for 10 years for chronic pain issues and then doctors will try and…some doctors will try and get you to go on methadone when methadone does not work for pain, not for a lot of people.”