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Views and experiences of opioid access amongst palliative care providers and public representatives in a low-resource setting: A qualitative interview study

Clark, Joseph; Salins, Naveen; Daniel, Sunitha; Currow, David C.; Jones, Lesley; Pearson, Mark; Bunton, Robin; Mankel, Joseph; Braithwaite, Christopher; Gilchrist, Marianne M.; Johnson, Miriam J.


Naveen Salins

Sunitha Daniel

David C. Currow

Lesley Jones

Robin Bunton

Joseph Mankel

Christopher Braithwaite


Opioids (e.g. morphine) are affordable, effective interventions for cancer-related pain. However, equity of access to this key medication remains a global challenge, particularly in low- and middle-income countries. We aimed to explore views of palliative care providers and public-representatives about opioid analgesia access in two States in India. We conducted a qualitative study using semi-structured interviews. Transcribed audio-recordings were subjected to thematic analysis using a Framework Approach. Palliative care providers and public-representatives were purposively sampled from services reporting consistent opioid availability and prescribing (≥4kg per annum) from Karnataka and Kerala. Twenty participants (doctors (10), nurses (4), pharmacists (2), service managers (2) and public-representatives (2) were interviewed. Three themes were identified: 1) Attitudes and awareness: opioid treatments are perceived as end-of-life (last days/weeks) interventions; fears of addiction and misunderstanding of pain management goals limit access. 2) Expected and unexpected inequities: patients/carers from lower socioeconomic strata accept doctor recommendations if opioids are affordable, more educated patients/families have reservations about opioids, delay access and perceive expensive medicines as better. Non-palliative care specialist doctors have negative entrenched views and require specialist training. 3) Experiential learning–positive experiences can positively alter attitudes (e.g., participants in Kerala report improved attitudes, awareness and understanding influenced by exposure and community awareness, but experience can also reinforce perceptions as end-of-life care. Entrenched negative views are reinforced by poor experiences while positive experiences improve attitudes. To promote access, opioid prescribing must be needs-based rather than prognosis-based. Addressing the lack of training for non-palliative care workforce would help overcome a major barrier.


Clark, J., Salins, N., Daniel, S., Currow, D. C., Jones, L., Pearson, M., …Johnson, M. J. (2023). Views and experiences of opioid access amongst palliative care providers and public representatives in a low-resource setting: A qualitative interview study. PLOS Global Public Health, 3(9), Article e0002401.

Journal Article Type Article
Acceptance Date Aug 24, 2023
Online Publication Date Sep 21, 2023
Publication Date Sep 21, 2023
Deposit Date Sep 29, 2023
Publicly Available Date Sep 29, 2023
Journal PLOS Global Public Health
Publisher Public Library of Science
Peer Reviewed Peer Reviewed
Volume 3
Issue 9
Article Number e0002401
Public URL


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Copyright Statement
Copyright: © 2023 Clark et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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