What’s behind the pain? Exploring physicians’ views on prescribing practices and structural factors that contribute to opioid use among Indigenous patients

Indigenous populations in Canada face an unequal burden of opioid-related issues, including significantly higher rates of opioid prescriptions, emergency room visits, hospital admissions, and opioid toxicity fatalities. Previous studies have identified factors that elevate the risk of opioid use disorder, such as overprescribing, trauma from ongoing colonization, systemic racism, socioeconomic disadvantage, and obstacles to accessing culturally safe health services. While there has been a growing emphasis on enhancing access to care and addressing structural inequities, the role of healthcare providers and the systems in which they operate has received comparatively less focus. Therefore, the purpose of this study is to investigate physicians’ perspectives on opioid prescribing and the structural elements that shape care for Indigenous peoples facing opioid use disorder. This study used qualitative methods to investigate physicians’ perspectives on opioid prescribing practices, the contexts of their practice, their attitudes towards opioid misuse, the challenges or successes they encounter in delivering care, and their suggestions for enhancing medical education curricula. In-person, open-ended, semi-structured interviews were conducted with a convenience sample of 13 physicians working in diverse urban, rural, and on-reserve environments. An inductive thematic analysis method was implemented, with transcripts independently examined and coded by two research associates using an iterative coding process to identify overarching themes and associated sub-themes. Four predominant themes emerged: the importance of maintaining relationships with patients; the need for increased attention to pain management strategies; the challenges and goals inherent in a de-prescribing approach; and structural and social contexts shaping OUD care. Participants described variation in experience, knowledge, and comfort in working with Indigenous patients, as well as constraints related to clinical schedules, resource availability, and access to services. Providers highlighted the influence of colonization, intergenerational trauma, poverty, and systemic inequities on patient outcomes, while also expressing challenges in addressing these factors within clinical practice. These findings highlight the necessity for fundamental changes in the conceptualization and delivery of care for Indigenous peoples with opioid use disorder. Physicians function within a disjointed system influenced by persistent colonial dynamics, unequal resources, and inconsistent training. Progress will rely on approaches that engage social realities, strengthen clinical relationships, and address structural factors that shape health outcomes.