Three themes were developed using TA: Perceptions of dependence, interactions with others and interactions with medical professionals (Table 2).

Table 2 Master table of themesTheme 1: Perceptions of Dependence

Individual perceptions and experiences of dependence to pain medication were frequently discussed amongst all participants. Participants described how they felt the medication itself impacted and often limited their ability to experience life. Below, Karen expressed how pervasive she found her dependence as she felt she was not fully present and instead felt removed from her life,

“You’re not living a life really. You’re doing it through a haze of, ‘I don’t care. I’m off my face,’ sort of thing. I don’t know why anyone would ever recreationally do it to be honest.” (Karen)

Karen describes clearly how she feels her dependence inhibits her from actively engaging in her life due to the side effects of the medication. She feels she is instead a passive bystander who can only witness life obscurely through a “haze.” Similarly, Emma’s comment shows the magnitude of the experience for her. The effects of the medication left her feeling like a completely different person,

“I’m not the same person anymore. I’m a completely changed person.” (Emma)

Below, Annie described the dominating nature of her dependence, where she felt the burden of being tied to a 4-hourly schedule,

“Your whole life is now, you know, based every four hours making sure you remember to take medication.” (Annie)

Despite the negative effect of the medication, participants also spoke of how they needed to take the medication to manage their pain. Some acknowledged that there may be side effects or harm from the medication but their need for the medication to manage the pain outweighed consideration for any negative effects to their physical health, as Karen’s comment below shows,

“I don’t know what… damage they might be doing to my body but…whilst I’m in pain, I have to take them.” (Karen)

Laura likewise noted her reliance on the medication and rationalised it as a need for her to function,

“It might be addiction but it’s also necessary…because I wouldn’t be able to function without it.” (Laura)

The extent of this dependence to the medication was likened to leaving her husband, which clearly shows the importance of the relationship with her medication,

“Once you’ve been on something for so long, you depend on it. It would be like divorcing my husband now… What would I do without it, him?” (Laura)

While participants spoke of the need for the medication, they also wished they could live without it. They viewed their dependence negatively and wished for it to end,

“If somebody could say there’s a magic wand, and I can fix it and no more pills, it’d be fantastic… It’s something I don’t want to be in.” (Cathy)

The participants attempted to make sense of their unwanted dependence by querying the reasoning for being prescribed the medication initially,

“I want to know, why did they start me on this medication? Why did the doctors do this to me?” (Emma)

Participants also frequently mentioned the lack of alternative options for pain management in the National Health Service (NHS), which may have reinforced the necessity of medication,

“If you’re relying on the NHS alone, bar drugs, there’s not a lot of help.” (Annie)

However, Laura suggested that painkillers are the only method suitable for alleviating pain when asked if she had tried non-medicinal alternatives,

“Are you a believer in that? Because I’m not. I’ve tried. I’ve tried the acupuncture, I tried this pacing yourself, I tried everything. It’s real pain.” (Laura)

On the other hand, Cathy observed the implausibility of other options, not due to their perceived limited efficacy, but how they are financially unattainable,

“I know there are alternatives but the alternatives, like the cannabis oil, and everything is so expensive, and I can’t afford it.” (Cathy)

Thus, the limitations posed by medications are overridden by their perceived necessity, which is further facilitated by the lack of viable treatment options for pain. Whilst the participants described their dependence as necessary to maintain physical health, some emphasised that it was solely a physical dependence and showed reluctance in being seen as psychologically dependent. Angela’s quote below is an example of this and alludes to the stigma and stereotypes associated with dependence (to be explored in Theme 2),

“Dependency, in my case, is I have to have them or I’m going to be very very unwell… but I know for a lot of people, dependency means they’re sort of hooked on them.” (Angela)

Theme 2: Interactions with Others

Participants’ experiences of dependence related to their social environment both through others’ appraisal of their dependence and how participants disclosed their dependence to others. Participants felt that dependence on pain medication was associated with the negative stereotypes of those addicted to cocaine and similar illicit drugs. The comment from Annie below shows how she felt that society does not distinguish between different types of addiction,

“I suppose it’s inbuilt into society… If you’re addicted to drugs, you’re a druggie.” (Annie)

Similarly, Karen described those who are addicted to illicit substances as those who ‘wreck’ their lives and engage in stealing,

“When people talk about drug dependency, you think about the addict on the street. You think about the ones that are really wrecking their lives in drugs and robbing… and needing a fix. Whereas we are on that sort of level of medication, but… I don’t see myself as that sort of an addict.” (Karen)

This is further magnified by the view that the participants felt others did not understand how they could be dependent when the drug in question had been prescribed by a medical doctor,

“If I was on speed or cocaine or whatever and say, ‘oh yeah I do that for pain.’ Then they’d think, ‘hmm, yeah, yeah yeah.’ Wouldn’t they? But I think when it’s doctor drugs…people don’t tend to think like that.” (Laura)

In addition, participants were very aware that dependence to substances is not a topic spoken about openly. Laura described it as still a taboo subject,

“[Dependence] is taboo still. Which I don’t think it should be in this day and age. But it’s still a pretty taboo subject.” (Laura)

This perception of lack of understanding from others and an awareness of the stigma associated with being dependent on pain medication influenced who they disclosed their dependence to. Annie describes this below,

“It would only be a select few friends that I would talk to about that…you feel a little bit ashamed to be honest because then you think, ‘well, I know better than a junkie.’” (Annie)

She also described feeling ashamed and criticised herself for being at all similar to a ‘junkie’ as she should have ‘known better.’ Further evidence of internalising the negative stereotypes is shown in Laura’s comment where she described herself as having a weakness,

“It is a weakness… I don’t like admitting I have a weakness.” (Laura)

Theme 3: Interactions with Medical Professionals

All the participants spoke of their interactions with their doctor, with the majority emphasising its negative nature. Some participants attributed the cause of their dependence to their doctor and many felt ignored and misunderstood by the medical profession, as shown by Emma’s comment below,

“He wouldn’t listen to me at all. He wasn’t even trying to understand me. It was alright for him to sit behind a desk…and say things but… he’s not in my shoes.” (Emma)

The negative interactions also included a lack of communication, which in Ellie’s case, she attributed as having serious consequences,

“I mean the only time I got spoken to was after my overdose and, I mean it’s a bit late for that really isn’t it? …the overdose should have been prevented.” (Ellie)

Participants also spoke of a lack of continuity between the doctors, which they listed as a reason for their dependence. Angela detailed how she felt seeing so many different doctors could allow a dependence to be missed,

“if [patients are] seeing a different doctor every time, that questioning might not happen until much much later by which time you know, they’ve become properly dependent physically on them...and psychologically as well.” (Angela)

There were also comments suggesting that the prescribing pattern of some doctors was a contributing factor. In these situations, the prescription was not tailored to the patient, but offered as the standard treatment,

“Some of the other doctors, get a bit fixed in their ways…they know what works for most people. Therefore, that’s what they will immediately prescribe. Whereas my doctors' much more willing to listen to me.” (Angela)

Participants also acknowledged that part of the problem is the tendency to not query the doctor’s advice but to do as they were told,

“I would just you know toddle along, doing as I was told from the doctor.” (Annie),

However, this trust was not held by all participants. Angela shows an awareness for the need to have a more active role in your own health,

“You have to sort of work as a team. You can’t rely on just being looked after like your mum would have looked after you when you were tiny.” (Angela)