Most doctors would say they went into medicine to help people by making them feel better or live longer. Sometimes helping people means refusing to do what they want. One of the many challenges of opioid addiction is the need to deny patients the painkillers they so desperately crave in the short term to preserve their long-term quality and quantity of life.
One casual Tuesday afternoon during my second year of residency, a young woman in her 20s with sickle cell disease was admitted to my service for a pain attack. Sickle cell disease is terrible and causes numerous bone pain attacks over a lifetime, often requiring hospitalization. This was her fifth time in the hospital that year alone. She was screaming and crying in pain in the hallways before she arrived to her room. I gave her an astronomical amount of injection painkillers that first day she was in the hospital. I truly wanted to make her feel better. Despite my best efforts, her agony continued. She could barely speak between her sobs.
Over the coming days, my suspicion that I was feeding into her addiction to opioids in addition to treating her pain was confirmed. I noticed that many times throughout the day, she would be comfortably watching TV or texting friends, but the moment I would enter her room to check on her, she would start writhing in pain and demand more opioids. Within minutes of me leaving her room, she would return to calmly watching TV. I had seen this pattern many times before.
I remember this patient so vividly because she had no sharps container in her room, and for good reason. During a previous hospitalization, this patient broke open her sharps container to look for any vials of opioids that may have a few drops left for her to self-inject. It would be like digging for gold in a mine field.
She had brought her own needles to inject herself too.
While this story still shocks me years later, it would be too easy to vilify this young woman and others suffering from opioid addiction. Most people with opioid addiction got started on prescription painkillers, whether they were directly prescribed to them or obtained illegally. That means that I as a prescribing physician have a role to play in the opioid epidemic.
There are many external forces pushing physicians to prescribe more opioids despite everything we’ve learned about their deadly consequences.
Patient satisfaction surveys are one factor. Increasingly, physicians are paid and/or promoted based on their patient satisfaction ratings. In one survey of emergency room and primary care doctors, 60% reported their compensation was linked to patient satisfaction scores and 20% said their job had been threatened based on their patient satisfaction scores. Negative reviews on Yelp or Healthgrades can be damaging to a physician or practice. One doctor in Indiana was murdered because he refused to prescribe opioids.
Patients who don’t get the opioids they want will be less satisfied, even if opioids were not the right treatment for them. Saying no to an opioid request often leads to a time-consuming negotiation or argument. This can indirectly prevent a doctor from being able to see other patients and give them the attention they deserve too. These financial pressures encourage doctors to prescribe opioids to improve patient satisfaction scores and to get through their days faster. Studies so far have not proven a link between patient satisfaction surveys and opioid prescribing, but the evidence overall is weak.
To some extent, human nature drives physicians to prescribe more opioids to make patients happy. I hope that I can help every patient I see in some way. On a deeper, perhaps more selfish level, I hope patients and their families notice that I am trying to help them and are grateful to have me in their lives.
That is not to say patients should feel indebted or feel so lucky that I am their doctor, but a small amount of gratitude goes a long way. Three years ago, I received a thank-you note written on an index card and a pint of Graeter’s ice cream from a patient’s wife and parents. Lunch is sometimes a luxury in medicine, so the Graeter’s didn’t last long, but I still have the index card in my night stand today. Patients in severe pain are so grateful when someone hears their concerns and controls their pain. It is plausible that positive feedback from patients who got the opioid they wanted reinforces physicians to keep prescribing them.
Human nature can also drive physicians to prescribe opioids to avoid conflict. We are all capable of doing the right thing for someone else even when it means making them unhappy. Parents do this regularly when they discipline their children. Doctors do this regularly too when they say no to patients inappropriately seeking strong painkillers. While we can mentally reinforce ourselves that we are doing the right thing, it is depressing to leave a room with the patient yelling and cursing at you. The repeated conflicts and negotiations over opioids become mentally and emotionally draining over time. These negotiations are also extremely time-consuming and can completely wreck a busy work day.
I have to believe that at some point in residency, I gave a patient opioids to avoid the emotional toll of the conflict and to move on more quickly to my other patients. I suspect I am not alone.
The opioid epidemic is a complex interplay of the chemistry of the human brain, patient needs for good pain control, physician motivations, and systems-level pressures. It will require a complex, yet cohesive solution. The lives of thousands of Americans depend on it.