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OBJECTIVE Describe patient attitudes toward opioid treatment agreements (OTAs) and characterize perceptions of their impact on patient care, behavior, communication with prescribers, and engagement with the health care system. DESIGN Qualitative descriptive study. SETTING Federally qualified health center with six clinic locations serving a rural population. SUBJECTS Patients were prescribed long-term opioid therapy and were required to sign an OTA through an in-person office visit with a clinical pharmacist. METHODS Patients who signed an OTA were recruited to participate in semistructured, in-person, one-on-one interviews. Data were analyzed using immersion-crystallization methods. RESULTS Among the 20 patients recruited, 50% were men; 70% were insured by the state's Medicaid program; and 85% were using opioids for hip, back, and/or neck pain. Four major themes arose from the interviews. First, individuals who use long-term opioids experience a wide variety of opioid-related fears and stigmas. Second, individuals articulated real or potential benefits from implementing OTAs. Third, opinions differed on whether OTAs affected behavior and reduced opioid misuse and diversion. Finally, individuals provided feedback on the health care system's OTA implementation process. CONCLUSIONS Patients experienced a wide variety of opioid-related fears and stigmas, including how OTA requirements can perpetuate these issues. Despite these feelings, participants articulated real or potential positive outcomes from the use of OTAs, although they were mixed on whether these agreements translated to any behavior changes. If OTAs are to become standard practice, future research is needed to describe the diversity of patient perspectives and experiences with OTAs and to evaluate their effect on patient outcomes.