Background In the UK, an aging population of people who use drugs (PWUD) is experiencing vastly reduced life expectancies due to an excess mortality associated with chronic health conditions. Although these anticipated deaths would benefit from palliative care, its provision is fraught with challenges. Identifying these challenges and their underlying drivers is crucial to facilitating the equitable provision of palliative care in this marginalised population.

Methods Primary care-based stakeholders with experience in managing PWUD and palliative care were recruited through purposive sampling methods to undergo semi-structured interviews. These were recorded, transcribed, and analysed thematically. The interview topic guide was informed by the results of a literature review summarising the current evidence base around palliative care provision to PWUD within the primary care sector.

Results Analysis of interviews with eight stakeholders identified two overarching narratives: challenges around identifying palliative need and challenges around the practical delivery of primary care-based palliative care. Underlying drivers included: difficulty distinguishing terminal disease from substance use, the absence of appropriate prognosticating tools for PWUD, poor communication from secondary care specialists, the inflexible and fragmented nature of care services and the complexities of pain management.

Conclusion Many of the identified barriers are unique to PWUD and would benefit from specific interventions to prevent unmet need and the overburdening of acute healthcare services at the end of life These may include the use of peer advocacy services and the embedding of specialist palliative care practitioners within substance use treatment programmes. Accounts present novel ways of working to overcome these barriers and valuable learning opportunities for primary care practitioners where current service fails.