Introduction

The opioid epidemic, also called the opioid crisis, has been marked by explosive and continuous growth in inappropriate use and overdose of opioid analgesics (OAs), both for medical indications and recreational use. This epidemic has led to a sharp increase in addiction, deaths from overdose, and an increased burden on the health and social care systems.¹ In Poland, the opioid crisis is not a new phenomenon, but it is not a significant public health issue (medical and social).² Still, opiophobia is clearly prevalent among the general population.³ It is defined as concern, anxiety, irrational fear, or excessive caution before using opioids for medical reasons. Opiophobia manifests itself in various ways. Doctors often avoid prescribing opioids even in justified cases, and patients refuse to take them out of fear of addiction. Additionally, the law often limits the possibility of obtaining proper pain treatment.^3,4

Already in 2012, the European Society for Medical Oncology and the National Institute for Health and Care Excellence guidelines for cancer pain treatment emphasized the need to assess the risk of opiophobia in patients.⁵ However, there is insufficient knowledge about reliable assessment of opiophobia and specific interventions that may be effective in preventing and addressing it. While the opioid crisis in Poland, in comparison with the scale of the phenomenon in North America (United States [US] and Canada) or in some European countries, is still not a major public health threat, the ongoing discussion in the media may partly contribute to increased concerns about opioid use and intensification of opiophobia. This mainly concerns fentanyl, which, together with other synthetic opioids, was responsible for over 70% of all opioid‑related deaths in the US between 2001 and 2021.⁶

In Poland, severe cases of overdosing, especially fatal ones, are relatively rare, but they do occur. In 2024, the Polish Chief Sanitary Inspectorate recorded 48 cases of fentanyl overdosing in the country.⁷ Furthermore, it is essential to distinguish between the 2 main groups of opioid users: patients taking OAs for medical indications and individuals taking them for nonmedical purposes. Some patients, for various reasons and individual predispositions, begin taking opioids in an inappropriate and uncontrolled manner. In Poland, by law, opioids are classified as medicines and narcotics.

Methods

The study participants were practicing physicians (n = 227) who had obtained their license, allowing them to prescribe strong OAs. They were doctors of various specialties (or in the course of specialist training) who agreed to anonymously complete a questionnaire consisting of 5 closed and open questions. A total of 300 questionnaires were distributed, of which 230 were returned correctly completed—all closed questions were answered. Three questionnaires were rejected because the respondents were not part of the study group (pharmacists). The survey was conducted during workshops on symptomatic treatment, targeting doctors from various specialties, at 2 university hospitals in Bydgoszcz, Poland, between June 2024 and June 2025. It examined several areas regarding the use of opioids in everyday practice, such as concerns associated with the use of drugs among the participating doctors, factors influencing their perception of opioids, as well as their attitudes toward cannabinoids, especially tetrahydrocannabinol (THC), and their application in the treatment of chronic pain, particularly as an alternative to opioids. The questionnaire is presented in Supplementary material. The study was approved by the Bioethics Committee at the Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland (KB 690/2011).

Results

The respondents included 227 doctors of various specialties or undergoing specialist training at an average age of 46 years (range, 25–84 y). Among the respondents, there were 155 women (68.6%), 68 men (29.7%), and 4 individuals (1.8%) who did not specify their sex. The study group was dominated by internal medicine specialists (n = 58; 25.5%), followed by palliative medicine ones (n = 51; 22.5%), and family physicians (n = 45; 20%). Next, in descending order, were specialists in anesthesiology and intensive care (n = 30; 13.2%), urology (n = 26; 11.5%), neurology (n = 21; 9.3%), physical medicine and rehabilitation (n = 9; 4%), geriatrics (n = 7; 3%), psychiatry (n = 7; 3%), medical oncology (n = 6; 2.6%), and other specialists in smaller percentages (6 different medical specialties). The doctors often indicated more than 1 specialty.

Approximately 11% of the respondents (n = 25) never prescribed opioids, and 22% (n = 48) rarely prescribed them in their daily medical practice. In contrast, over 34% (n = 77) of the study participants reported prescribing opioids regularly, and 18% (n = 41) frequently. The remaining 15% (n = 33) prescribed them with average frequency. Before initiating chronic pain treatment with strong OAs (eg, morphine, oxycodone, buprenorphine, or fentanyl), nearly 39% of the respondents (n = 85) had concerns or doubts about the use of this type of medication. Furthermore, of almost 200 physicians who prescribed opioids in their practice, 77 (39%) still had concerns about their use. Table 1 summarizes the most common concerns of the respondents regarding prescribing opioids, and presents their statements regarding the impact of the global opioid crisis on their perception of these substances.

The attitude of the respondents (n = 224) toward the use of cannabinoids, including THC, was positive in 68% of the respondents (n = 153), whereas 30% (n = 67) were neutral, and only 2% (n = 67) had negative attitude toward them. Significantly, over 80% of the surveyed physicians (n = 213) believed that the opioid crisis did not affect their perception of cannabinoids—approximately 16% (n = 34) perceived them negatively, and only 2.4% (n = 5) perceived them positively. Among the surveyed physicians who prescribed opioids (n = 199), the majority of the respondents (n = 135) saw the potential of cannabinoids in the treatment of chronic pain. According to 29 respondents (13%), the opioid crisis affected physicians’ perception of opioids and cannabinoids.

Discussion

Pain management remains a complex issue both in Poland and worldwide. On the one hand, there is a risk of opioid abuse, premature use, or use outside of medical indications. On the other hand, there is the phenomenon of opiophobia, or excessive fear of opioid use for medical reasons. In practice, the use of drugs from this group is delayed due to fear of addiction, adverse effects, or anxiety about “what if the opioids stop working.” Therefore, opiophobia can become a key barrier in effective pain management with OAs. However, our findings are optimistic, as most doctors who prescribe opioids are not afraid of administering them to their patients. It is also reflected in the growing number of generated prescription codes for synthetic opioids for medical purposes in Poland. Doctors issued more prescriptions for oxycodone (reimbursed and nonreimbursed) and fentanyl (reimbursed) in 2023 (258 126 and 11 389, respectively) than 2019 (oxycodone, 173 242 prescriptions and fentanyl, 5901 prescriptions).^2,8 The physicians who were apprehensive about using OAs when they started professional careers now recognize their positive aspects and clinical benefits in patients who require pain management. The most common concerns, which have remained unchanged over the years, relate to the development of addiction (n = 29) and respiratory depression (n = 10). Medical professionals may unconsciously transfer their own fears and anxieties to patients and contribute to spreading fears about the use of this group of drugs.

The media may distort their perception of opioids among both physicians and patients, and foster the feeling of anxiety about their use.² It can lead to inappropriate dosing and, consequently, patient suffering. Health care professionals should base their knowledge and therapeutic decisions on scientific reports, and not transfer their own fears to patients. According to some of the physicians participating in the study, media reports on the opioid crisis may directly or indirectly influence perceptions of opioids, changing the image of this class of drugs and affecting decisions regarding chronic pain treatment. Such situations may exacerbate opiophobia, resulting in suboptimal use of drugs—introducing opioids too late, choosing other preparations, or using too low doses. This, in turn, gives rise to incorrect treatment of chronic pain and, in extreme cases, to its complete absence. False beliefs or negative attitudes about opioid pain treatment are indicated in some studies as common among patients, carers, and physicians.^3,9

It is essential to understand the nature of pain and for specialists, patients, and their families—to collaborate in this area. The most appropriate approach is to individualize the treatment of chronic pain, focusing on details to best adjust pharmacotherapy to the current stage of disease or symptomatic management. An equally important factor is a rational approach to the selection of therapy and pharmacotherapy for pain, especially when using potent opioids. The term “opioid‑sparing” refers to a treatment strategy that involves reducing the need for opioid drugs by using other methods and medications. This strategy aims to ensure adequate pain relief while minimizing the risks associated with opioid abuse and addiction. In short, opioid‑sparing encompasses all approaches aimed at reducing the use of opioids in the treatment of chronic pain.^4,10 It requires cooperation between many groups (medical and nonmedical) and education of medical staff (all health care professionals, especially family doctors and primary health care nurses), patients, and their family members. Working with a psychologist, physiotherapist, or occupational therapist can also be a source of support for patients. It is essential to approach pain as a complex problem in a comprehensive, personalized, and coordinated manner, choosing innovative methods derived from evidence‑based medicine. Multimodal analgesia is a key strategy for effective pain management, with the added benefit of minimizing adverse effects caused by opioids.¹¹

The opioid crisis in the US, where opioid drugs are increasingly prescribed and used for nonmedical purposes, caused concern that this would also occur in Poland. Despite the increase in the number of prescriptions in Poland, the available data do not show any significant abuse of fentanyl and opioids, similarly as in previous years.⁸

However, as a preventive measure, legal regulations have been amended to restrict access to prescriptions for certain strong OAs and medical cannabis.¹² In accordance with pain management recommendations, including the World Health Organization analgesic ladder¹³, in addition to OAs, nonopioid therapies should also be considered in treating chronic pain. These include nonopioid analgesics (eg, nonsteroidal anti‑inflammatory drugs), coanalgesics (duloxetine, gabapentinoids), and cannabinoids (cannabidiol [CBD], THC), as well as nonpharmacological techniques (eg, physiotherapy, massage, acupuncture, behavioral therapy, meditation, and other relaxation techniques that can help manage pain and teach patients how to cope with it). Currently, multimodal approaches to pain management, are becoming increasingly common. Although opioids play an important role in the treatment of severe pain, especially in palliative care and oncology, the global opioid crisis is prompting doctors to be more cautious in prescribing opioids and seek safer options, as was also acknowledged by the participants of the study.

As part of the survey, the physicians were asked about their attitude toward medical cannabis, which, in most cases, turned out to be positive or neutral, which may translate into willingness to prescribe CBD and THC preparations. Cannabinoids are gaining increased recognition among scientists, doctors, and patients, and the range of their application, including pain management, is expanding. There is no substitute for opioids in the modern model of pain management, and there is an unmet need and demand for nonopioid therapies.^11,14 Cannabinoids are increasingly seen as a source of hope. However, there are still key areas where high‑quality clinical research on cannabinoids is needed, as well as recommendations for improving patient safety and reducing social harm in the context of pain management.¹⁵

This study provides a timely, specialty‑diverse snapshot of physicians’ attitudes toward strong opioids and cannabinoid‑based pain management strategies in Poland, collected using a unified instrument that allows for the side‑by‑side interpretation of both domains, which is uncommon and clinically informative. Nevertheless, the fact that participation in the study was voluntary and not based on a random selection of participants, and that the responses were derived from self‑reports, makes it difficult to generalize the results to the entire population. Additionally, they may be subject to bias resulting from the respondents’ memory lapses or desire to present themselves in a more favorable light. The questionnaire was developed for specific purposes of this study for this study and has not undergone formal psychometric validation. We also lacked information on the  years of practice / seniority and structured pain management training of the respondents. The analyses were primarily descriptive in nature and were not conducted according to a predefined multivariate analytical framework. Additionally, the partial lack of responses resulted in varying denominators across individual items. These constraints should guide cautious interpretation and motivate larger, probability‑based studies using validated scales and multivariable modeling, ideally with linkage to prescribing and clinical outcomes.

The clinical use of medical cannabis is attracting increasing interest from scientists, therapists, and patients. This is prompting pain research theorists, clinical practitioners, and key scientific societies in this field to develop a consensus on the use of cannabinoids in the treatment of various types of chronic pain.^16-20 Furthermore, the convincing nature of the available data and the relatively good safety profile of cannabis justify further research into its use as a complementary or alternative treatment for opioid use disorder.^10,16,21