Background: Many patients with cancer pain are appropriately managed on long-term opioid therapy (LTOT), but are at similar risk of overdose and addiction as are patients with non-cancer pain. Whether to commence opioids for cancer pain is often a shared decision between patient and provider. Little is known about this process.

Methods: Semi-structured interviews with 20 cancer patients on LTOT and 20 interdisciplinary providers who prescribe LTOT from two VA medical centers. Transcripts were coded and analyzed using constant comparison to find common themes.

Results: Providers and patients largely weighed the risks and benefits of LTOT similarly, except in the case of cancer patients with past/present substance use disorder (SUD). In those cases, providers felt the risks outweighed the benefits, while patients felt the benefits outweighed the risks. Generally, patients considered pain relief their overarching concern. Other factors that impacted their risk/benefit calculus included: personal/family experience with opioids and the opinions of trusted providers. Only rarely did patients defer decision making to providers. Factors that impacted the risk/benefit calculus of providers included: disease status, patient goals, patient characteristics, and providers' past experiences/biases. Of note, patients with past opioid exposure generally viewed their experience with opioids as positive, and usually anchored their risk assessment for opioids relative to those of chemotherapy. Patients also expressed that they would prefer to spend less physician time discussing LTOT and more time discussing cancer treatment instead.

Conclusions: Patients and providers often agree on when it is appropriate to use LTOT for cancer pain. In cases where they disagree, providers are well advised to explore and address patients’ fears about the adequacy of pain management without opioids, as well as their lived experience with opioids. Patients are comfortable having such discussions with physician extenders in order to reserve face-to-face physician time to discuss cancer treatment instead.