Takeaway
When a patient reports pain, their words need to be met with listening, compassion, and a discussion of how best to address the pain.
Lifelong Learning in Clinical Excellence | July 9, 2019 | 5 min read
By Travis Rieder, PhD, Johns Hopkins Berman Institute of Bioethics
Stigma, distrust, and suspicion—these were new to me when I became a pain patient in 2015. Having lived a fairly privileged life, I took for granted having my words taken seriously and my position in most conversations acknowledged. I was therefore not at all ready for what was coming when I was put on opioid therapy.
Despite the traumatic cause of my pain (a motorcycle accident), and the abundant evidence that my pain was “real,” I encountered suspicion from a physician for the first time not even a month after the accident—while still in the hospital recovering from my fifth surgery. And that was not the last time it would happen. My partner, Sadiye, would regularly be regarded with distrust by pharmacists who didn’t want to fill my high (and escalating) doses of opioids.
As most patients and clinicians realize, my experience was not unique. Pain is a stigmatized condition, and opioids are stigmatized drugs. Indeed, these stigmas are deeply intertwined: the distrust of pain patients is often justified by a belief that the patient is “drug-seeking.” New doctors are quickly taught—often implicitly, but sometimes explicitly—that patients of a certain type aren’t to be trusted, because they are just there to feed their habit. This immediate suspicion of patients reporting pain is a toxic response, poisoning the physician-patient relationship. Listening, defaulting to trust and belief, and showing compassion for people reporting pain doesn’t entail writing a prescription.
Respect toward all patients doesn’t undermine opioid stewardship
Opioid stewardship is the idea that prescribers, by virtue of being in charge of what medications go out into the world, can play an important public health role. Analogous to the idea of antibiotic stewardship, opioid stewardship is intended to protect the public from the harms of aggressive overprescribing. This much most everyone agrees on.
In practice, however, the movement toward restricting access to opioids can be stigmatizing. Stewardship feels less like it’s about responsible prescribing and more about reducing raw numbers of pills, regardless of the details of the individual in front of a given clinician. And predictably, if the narrative we tell as a culture is that opioids are addictive and dangerous, and so doctors need to keep them out of the hands of patients, then doctors may start to see patients who want those drugs through a particular lens: they are the problem, the “abusers.”
The result is millions of interactions like the one I witnessed when participating in a working group at a university hospital, where an opioid case study was read, and the residents all rolled their eyes. “This one’s drug-seeking,” a second-year resident immediately offered about the hypothetical patient, and nearly all the trainees were already exasperated. None of the attending physicians jumped in to comment on their attitudes or behaviors.
Responsible prescribing does not require any such attitude, judgment, or body language. Actions and attitudes can come apart, and regardless of what action is clinically called for, the kind of moral judgment implied by language like “drug-seeking” is both unnecessary and problematic. A patient in front of her doctor needs to be helped, not to be shamed.
Treating patients with dignity
Clinicians need to default to belief in their patients and empathy with their pain; this is part of a trusting patient-clinician relationship. All patients deserve respect and to be treated with dignity, and part of dignified treatment is having your words taken as believable. When I first realized that a physician didn’t believe that I needed more pain medication—that I was in excruciating, life-limiting pain—the insult of disrespect was worse than the pain of injury. My testimony wasn’t taken up as something that needed to be responded to (or even acknowledged), and that’s a devastating thing to experience.
Of course, the fact that it was a new experience for me reveals my privilege. Many women and minorities are quite familiar with the experience of not having their words taken seriously in various contexts. There’s even a term for it in the academic literature: epistemic injustice. And unsurprisingly, those from more marginalized populations tend to have their testimony about pain taken seriously much less often than someone who looks like me. Women and black and Hispanic patients are all prescribed opioids less often than white men. So another reason for clinicians to check their judgment at the clinic door is that they—if they are anything like their peers—may well be systematically responding to racial and gender cues in a way that biases their pain care.
Defaulting to trust and compassion not only shows respect, but also decreases the likelihood that clinicians will unconsciously discriminate against marginalized populations by being more suspicious of some than others.
I’m asking clinicians to believe patients who report being in pain, and then to decide what to do about that pain. Not every pain should be medicated, but every pain report should be responded to compassionately.
And what if the patient really is looking for drugs to feed an addiction? Well, guess what: they’re in pain too. At the most surface level, they’re likely in withdrawal (which may be why the clinician suspects addiction in the first place), and withdrawal hurts. It can cause monumental suffering, and the callousness with which society often treats it, just because we associate it with addiction, is chilling. I’ve been in withdrawal, and every moment was the worst of my life.
People take drugs for reasons. Whether the patient started with pills or heroin, she was likely self-medicating—maybe physical pain, maybe emotional pain. Opioids are amazing analgesics (at least at first), and if you spend any time talking with someone who has used heroin, you’ve likely heard them explain why they take it. If life is painful, heroin—like oxycodone—can fix that (again, at least in the short term). That kind of pain calls for compassion, not judgment. When someone is suffering enough to put themselves in front of a clinician, even if that pain is addiction-related, the appropriate reaction is a discussion of how to address it.
That discussion may not lead to the physician writing a prescription. But that doesn’t mean it should be grounded in distrust.
Travis Rieder, PhD, is author of the book “In Pain: A Bioethicist’s Personal Struggle with Opioids.”Listen to his interview with Fresh Air’s Terry Gross here.