**1. Introduction**

Strong opioids have been used for chronic noncancer pain (CNCP) since the 1980s [1]. While opioids show low-to-moderate improvements in pain relief and functionality, the administration of opioids in CNCP can have relevant side effects [2–7], including opioid use disorders [8–10]. Therefore, international and national guidelines have been brought into place [11–13] to help balance the benefits and risks, increase safety and inform prescribers about the evidence-based use of opioids in CNCP.

**Citation:** Schulte, E.; Petzke, F.; Spies, C.; Denke, C.; Schäfer, M.; Donner-Banzhoff, N.; Hertwig, R.; Wegwarth, O. Self-Reported Practices and Emotions in Prescribing Opioids for Chronic Noncancer Pain: A Cross-Sectional Study of German Physicians. *J. Clin. Med.* **2022**, *11*, 2506. https://doi.org/10.3390/ jcm11092506

Academic Editors: Markus W. Hollmann, Casandra I. Montoro Aguilar, Carmen María Galvez Sánchez and Patrice Forget

Received: 3 April 2022 Accepted: 25 April 2022 Published: 29 April 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

However, a current review shows that physicians' adherence to the North American Opioid Guidelines and their compliance with the recommendations has been low: treatment agreements, consented urine drug testing, consultations with drug monitoring programs, assessing the risk of aberrant medication-taking behavior and mental health screening [14]. To the best of our knowledge, we are not aware of any studies that have specifically focused on physicians' guideline adherence with regard to the indications for opioids and the individual opioid formulations. This gave rise to our motivation to investigate the extent to which physicians in Germany prescribe strong opioids for CNCP in line with the indication and the drug formulation.

Despite the lack of evidence for an opioid crisis in Germany comparable to the one in the US [15,16], there remains considerable uncertainty [13] as to when and for how long the types and formulations of opioids should be prescribed for CNCP, leaving ample responsibility with the treating physician. National guidelines have outlined recommendations to support the decision-making process prior to the initiation of opioid treatment that should integrate both the evaluation of risks and the potential benefits of opioids [17]. To date, opioid risk mitigation programs have focused primarily on the individual patient and on preventing addiction, misuse and overuse of opioids [18] and less on physicians' prescriptions habits and the challenges they may face when responding to a patient's desire for pain reduction through opioids and overall limited therapy options to treat chronic pain.

Studies focusing on the physician's decision process show, for example, that they prescribe more opioids to more psychologically stressed patients who express their suffering clearly [19]. In a qualitative study, opioid-prescribing general practitioners expressed substantial frustration and stress in managing chronic pain patients with opioids [20]. However, most studies focused on the patient characteristics (for example, consistent and objective information given by the patient, red flags, patient trustworthiness) that lead the provider to prescribe opioids for CNCP [21–24]. We could not find a single study investigating in depth the "inner conflict" of the opioid prescribing physician in Germany. Therefore, we tried to find phrases that describe this inner conflict and interviewed physicians regularly prescribing opioids for CNCP about whether they can identify themselves with these phrases of "inner conflict".

Taken together, the present analysis examined (I) the adherence of physicians in Germany to the national guideline recommendations for long-term opioid use with regard to indications and formulations of strong opioids in CNCP, (II) physicians' emotional reactions to patients' requests for an increased opioid dose without objective worsening of the underlying condition (presented as a case study vignette) and (III) possible prescriberrelated factors that might be associated with non-guideline-compliant prescriptions.
