In medical school I learned all about the various effects that drugs and alcohol can have on the body, how to detect and diagnose these problems, and how to treat them. We spent a lot of time learning about the effects of drugs and alcohol, but very little time learning about alcoholism and addiction. I went to medical school in the 90s and it's gotten somewhat better by now, but I have worked as a medical educator at two medical schools and I still see a lot of deficiencies.
Some doctors are not very street-wise.
Without painting everyone with one brush, it is fair to say that to become a doctor is largely the domain of the socio-economically privileged. These people often have little or no exposure to some of the realities of the low underbellies of the world, especially the homelessness, destruction, despair, and crime that are part of addiction. At best, very few have had any kind of exposure to these realities. My experience in medical school and later as faculty at medical schools has been that the students and new doctors are utterly naive about the harsh social realities around us. Any knowledge they have of it tends to be statistics and generalities extracted from the pages of a book.
These naive doctors can be easy prey to the addict who will do anything to get that prescription for oxycodone. Addicts are the very best of liars and manipulators, myself included during my time as an addict and alcoholic. These naive well-meaning doctors are the gate-keepers of the opiate narcotics prescription pads, a disaster waiting to happen. I know that this was true of me as a newly minted doctor. In fact, until I went through addiction myself I really had little idea about how people from that world lived and behaved.
Docs don't understand addicts and their behaviors
My medical training left me with a well fostered "us versus them" attitude toward addicts. I saw my own attitudes reflected in other doctors and in medical students, so I will presume to use the pronoun "we" here. We saw addicts as bad people who make bad choices every day. We resented their endeavours to manipulate us for drug prescriptions. They were seen as an enemy to be wary of, and we received constant reminders to be wary of them and their machinations. Since we viewed their drug use and their drug-seeking behaviors as a choice, we saw them as bad people. We came to resent them deeply and saw them as a thorn in our side. We didn't see their problem, we saw the problems they caused us.
Most people (including docs) don't understand the weird and illegal behaviors that addiction will drive good people to do in order to support their addiction.
As the medical regulatory bodies started cracking down on physician prescribing, these resentments towards addicts deepened. Doctors were now suffering censure at the hands of the medical regulators, the media, or even the law when they were "conned" into prescribing narcotics inappropriately. For example, there was a case not far from where I live where a doctor got sued for prescribing narcotics to a man who had an addiction. The man professed to have severe low back pain, one of the many medical complaints where doctors have no way of proving or disproving. He played on his doctor's empathy, begging for prescriptions to relieve his suffering. He denied any inappropriate drug use. He was a frequent visitor to the clinic, always pushing for more pills, higher doses, stronger medications. He phoned the receptionist daily, pushing for more prescriptions for his pain. In the end, the man went to drug rehab and after coming out he sued the doctor for prescribing him narcotics, even though he lied to the doctor, harassed him, and manipulated him and his staff by playing on their empathy. He won the lawsuit and received a large payout.
When these kinds of things happen doctors' resentments toward addicts deepen. A lot.
Going through addiction and then recovery was a tremendous eye-opener for me. All of a sudden I was one of those "bad people making bad decisions," abusing the medical system to obtain prescriptions. But I didn't feel like a bad person making bad decisions, I felt like someone who wanted to get better but couldn't I felt trapped. When I ended up in a men's detox facility I was surrounded by other addicts, the very people I used to look down upon. I soon saw that each one of them was a real person who was very sick. They were all really good guys, and I made a lot of good friends, many of whom I remain in contact with today. What an eye-opener.
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Since my own experience with addiction I no longer see enemies; I see unfortunate people with a deadly disease who are driven by their addiction to do things they ordinarily would never do. The desperation of getting that next high and avoiding withdrawal is massive and over-powering. I see victims of a lethal affliction that takes over a mind no less completely than does Alzheimers disease.
I definitely do not see a moral failure, or bad choices when I see an addict. Data published by the U.S. NIH tells us that by by age 26, 87% of us have used alcohol and more than 50% have used drugs. Yet fewer than 15% become addicted. Some of us have the correct mix of genetics, life situation, and opportunity and become addicted and some don't. Drinking or using is -- at the beginning -- a choice, but is no longer a choice once the addiction begins. Even distasteful behavior - crime, lying, cheating, stealing - undertaken to get that next drug no longer becomes a choice. These things are a symptom of a disease, not bad people making bad choices.
The Catch-22 of prescribing addictive drugs
As a doc, when someone comes to you with a painful condition that would substantiate narcotics it puts you in an awkward position. Maybe the person is faking and has no pain (there is no test to prove or disprove pain). Maybe you are the third doc they've visited that morning to get narcotic pain-killers. So you've got a decision to make with little or no proof to back up the decision. My policy always was that I gave people a reasonable benefit of the doubt until they gave me reason not to. Statistically, I know that I gave people an Rx that did nothing more than feed their addiction, but I didn't want ppl who really needed pain meds to suffer by cutting off all prescribing.
Even in legit cases of pain requiring strong pain meds, you know there is a good chance the patient will become addicted or dependent. But there is no way to know who or when. And you can't just leave them to suffer in pain, just in case they might become dependent. When does the stay-at-home mom with the kidney stone cross the line from using a prescribed narcotic for pain relief and using it for its euphoric effect? And how can the doctor know when that is? Perhaps she will enjoy the euphoric effects but only take it as prescribed and never touch it again after the pain is gone. Or perhaps not. There is no way to know. You can't just allow her to pass the stone without anything to ease her suffering (women compare the pain of kidney stones to the pain of childbirth).
There is a desire amongst most doctors to never prescribe narcotics again, and to be done with the conflict and controversy around them. But, as an ER doc how can I be face to face with someone who is truly suffering and not do what I can to ease their pain?? You can do them great harm by handing over a prescription for narcotics, and you can do them great harm by not treating their pain. Either way you can come off looking like the bad guy.
For doctors, the benefit versus harm battle with pain medications is a huge source of frustration.
And then there is the temptation. What if the doctor is one of those 15% of people who are predisposed to addiction? People return unused narcotics to the clinic (although they shouldn't). People offer you money for prescriptions. Or other things. Having all the things that come together to make us an addict and having your own prescription pad is a dangerous combination. It's a messy business. Sometimes I think it's unfair to put doctors in a position where they have such power over prescribing addictive drugs, because if they become addicted they suffer grave consequences.
Doctors hate prescribing narcotics
These days there is tremendous pressure on docs to reduce their prescribing of narcotics and other addictive medications. Yet, there is tremendous pressure from many patients to prescribe them. People get quite irate if you won't prescribe them or won't prescribe what they see as enough.
There is often a lot of pressure from allied health workers on docs as well. For example, I had one patient who was in a minor motor vehicle accident. It was so minor it was more of an incident than an accident. However, she complained of debilitating neck pain afterwards. Usually that kind of a neck injury - which used to be called a "whiplash" injury, but is now referred to as a "soft tissue injury of the neck" - gets worse after the car accident, peaks at 72 hours, and then progressively improves afterwards. Most are all better within two weeks. Not her. Her pain continued and worsened, so that her two weeks off work stretched out to 18 months.
She was a mother of two young boys, and worked as a teacher. Her pain was such that she said she needed pain medications just to participate in caring for her kids. Every time she came in my office she cried about her pain and how it affected her life. And she went to see specialists and even had injections in her neck, something that most people who are faking pain won't do. Her neck pain certainly exceeded what would be expected from her minor injury, and even the specialists she saw were surprised by it. Her X-rays and MRI were fine, but they often are in soft tissue injuries.
So, the doctor has to give the patient the benefit of the doubt. If she really has pain and needs the meds to be able to look after her kids, it would be terrible to cut her off. In fact, she could sue the doctor for cutting her off. On the other hand, if she is using the drugs inappropriately for an addiction then the doctor is fuelling that addiction by continuing to prescribe, and could get sued for doing so. This is the dilemma that doctors face with nearly everyone who gets narcotic prescriptions.
Even when we suspect someone is seeking narcotics prescription without a legitimate reason, to refuse them the doctor will be subjected to a tirade of begging and anger. Some even make threats. Either way, it's unnecessary and unwanted conflict in the middle of an already hectic day. And it's insulting to the doctor. This isn't what we went to school for, to fight it out with drug seekers, right? And it happen s A LOT. Most docs would rather just not prescribing any pain killers whatsoever. But many people would suffer dearly if we did that.
The "Other" Narcotics Crisis
There is a new opioid crisis going on, as a direct consequence of the addiction crisis. There is so much pressure on docs to reduce or stop prescribing narcotics and there is so much risk involved in prescribing narcotics that many docs have simply stopped prescribing them at all. As a consequence, many people with legitimate pain, including people with terminal cancer, have been having their pain medications drastically cut regardless of their medical situation. Or, they can't get access to pain medications at all.
Recently created guidelines for prescribing opioid pain medications have reduced the maximum dosing limit by 75%. Many patients who have been prescribed opioids for many years are having their dose lowered, whether they like it or not, to the point that they cannot function. Their doctor tells them the doctors' regulatory body (College of Physicians) requires them to do so or lose their license to practice. Some patients have gone from being active, to doing almost nothing due to their pain. Some have even become suicidal.
New guidelines tell physicians to lower their patient’s dose of opioid. However, the guidelines also say that if a patient tries but cannot lower their dose because their pain levels jump and their function deteriorates the patient should not be forced to lower their dose. Yet many doctors still force their patients to reduce or stop, not out of concern for the patient but for fear of getting in trouble themselves. Doctors are sworn to never pursue any form of personal advantage at the expense of a patient. Yet, when docs forces a patient to lower their opioid dose no matter what, they do so to cower from the threats of their regulatory body with no regard for what's best for the patient.
Personally, I fear for the eventuality that someone I care about will be struck by a very painful condition - such as pancreatic cancer, or breast cancer that spreads to the bones - because I am sure that the doctors will not be there to relieve their pain. This is the "other" opioid crisis.
Bottom Line
In the end, prescribing any medication -- including opiates -- has always been about balancing the potential harm with the benefits of that medication. Nowhere has achieving that balance been more elusive and challenging than in the case of addictive drugs. Well-meaning doctors relieve a lot of suffering with judicious use of opioid medications, but they also do a lot of harm with equally judicious care. Efforts to curb the opioid crisis have led to a small decrease in the problem, but also a great increase in the amount of suffering that opioids are able to relieve. In any case, the doctors are in a tight spot.
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