The Washington PostDemocracy Dies in Darkness

Some patients are in pain. Some just want drugs. How do I tell them apart?

The opioid epidemic has forced doctors to become lie detectors.

(Maggie Chiang for The Washington Post)

Brittany was a drug-seeker I knew by name, and I was not surprised when she rolled into the ER for the third time that month. As she lay on a wheeled paramedic bed pushed by an ambulance crew through big bay doors, her shrieks resounded down the hall and into the waiting area. She howled and swore through rotten teeth.

Before I uttered a greeting, she demanded that I give her the most powerful intravenous opioids in the hospital, and nothing else would do. This was Brittany’s usual weekly script — every Friday, her mysterious abdominal pain flared up again. During past visits, the simple promise of a prescription miraculously lessened her agony. Despite many extensive workups, tubes of blood wasted on laboratory tests and repeated CT scans pointlessly overexposing her to radiation, no cause of her pain had ever been discovered.

Patients in pain present a daily conundrum for physicians like me. Each one is set against the backdrop of epidemic opioid misuse in our country. Overdose deaths have tripled in the past decade, and addiction has grown into a full-fledged societal calamity fanned by over-indulgent prescription pens. Now doctors are pulled in opposite directions by an individual’s pain and a society’s crisis. Do we prescribe opioids or not?

The mental seesaw has become a familiar part of my job, one made worse by a frequent ER occurrence — patients like Brittany feigning or exaggerating pain to receive painkillers. Some seek a buzz; others want a fix for opioid withdrawal, itself a painful and unpleasant condition. Some are “opioid refugees,” cut off by their primary doctors and migrating from one ER to the next in search of a doctor benevolent or gullible enough to grant a prescription.

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The presence of drug-seekers in virtually every physician’s practice today has tainted our thinking, casting doubt over clinical instincts to relieve suffering and making us suspicious of pain. As an ER doctor tasked with differentiating the life-threatening from the harmless, I waver between the emotional tug of agony before my eyes and a rational view of our public health emergency. Sometimes it feels empathetic to give pain meds; other times empathy demands withholding them. Even when convinced that a patient is lying, I’m startled into doubt by a fellow human being crying in pain. Nurses have called me cruel; other times, they have shaken their heads at how easily a patient fooled me into giving an opioid. Either choice has consequences.

Brittany had the stereotypical signs of a drug-seeker: disheveled; track marks in both arms; smelling of alcohol, old cigarettes and urine. She would arouse a well-honed bias in any physician. Even her timing was suspect — early Friday evenings are when primary-care doctors, who might normally refill a pain prescription, first become unreachable for the weekend.

Brittany also bore significant psychological scars, as I knew from our past conversations and from her medical chart. She had been abused by her father; several family members had committed suicide, and she had attempted it herself in the past. She worked on and off as a prostitute and had once given birth to a son dependent on opioids, his first breaths marked by the high-pitched squeals of infant craving. Each pill or intravenous injection delivered a brief balm for her pain. And I, the physician, was the unlucky holder of the opioid key.

The ER was filling with critically ill patients that night, shrill monitor alarms in the distance demanding my attention, and I had little desire to rehash the same argument with Brittany over pain meds. A prescription, just a few electronic scribbles, was my easiest escape. Every physician practices somewhere on a spectrum of opioid permissiveness. Some flog their patients with powerful painkillers from the first “ouch,” while others virtually never give in. I tend toward the latter and have developed a reputation as an extremely tight-fisted physician. I knew it would enable her addiction, and her next ambulance trip to our ER could be for an overdose.

My first task as a doctor was to rule out the seemingly far-fetched possibility that an actual pathology was causing her pain this time. So I began asking my usual questions, looking for clues as to whether her pain was real.

It’s difficult to prove that pain exists and even more difficult to disprove it. Inherently private, pain is a subjective scream of neurons that no one else can hear. But in medical school, I learned several tricks, part of a universal but unofficial curriculum, and the prescription-fed epidemic had since honed my detective skills.

I first assessed the pattern of Brittany’s pain, its specific location in the abdomen and any accompanying symptoms. The pain was “everywhere,” she said, offering only muddled and contradictory answers to questions about the pain’s timing or associated vomiting, diarrhea, constipation or fever. Brittany is what physicians and nurses call a “terrible historian.” Her only certainty was that this pain was the worst ever, as it had been last week, and only the strongest IV opioids would suffice.

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She writhed as I reviewed her vital signs, her hands gripping the bed’s metal rails. Pain typically raises a patient’s heart rate and blood pressure, rare pieces of objective evidence for internal aches. Brittany’s measurements were near the upper limits of normal — though opioid withdrawal also causes vital-sign elevation, I reminded myself.

I carefully watched her reactions as I examined her abdomen. She flailed and cried in response to the lightest grazing of my hand against her belly, an overreaction that suggested fakery. While listening for bowel churnings, I pressed the stethoscope’s rounded head harder than usual into her abdomen — if she were acting, she might not react, since patients usually expect pain to worsen only when doctors push with their hands, not while using a stethoscope. Still, she grimaced.

In the past, her complaints of pain were easily dismissed. This time, I felt uncertain. I decided to order blood and urine tests, though they felt wasteful. I predicted that her results would come back normal, and then I could feel confident sending her home, though I dreaded the theatrical argument that would ensue. (Most weeks she’d threaten a lawsuit and storm out of the ER, demonstrating no evidence of pain.) I offered Tylenol and an antacid in the meantime and left the room amid a hailstorm of her swearing.

A physician’s decision to administer opioids or not is influenced by the flagrant undertreatment of pain in the 1990s, a widely covered phenomenon that angered the public — what ghastlier sin could a physician commit than having the power to alleviate human suffering and yet withholding it?

By the time I entered medical school in 2005, the approach to pain had changed; aggressive treatment had become the standard of care. I was taught to consider pain as a vital sign, to calibrate it on a subjective 1-to-10 scale and treat the number as I would alterations in heart rate, blood pressure and body temperature. I learned that longer-acting opioid formulations could not be abused; that addiction rarely resulted from treating legitimately painful medical conditions with opioids; that elderly patients had minimal risk of developing dependence. I trained during a brief bubble of ignorance, when the medical profession was convinced that a War on Pain fought with a barrage of prescriptions was risk-free. Yet, even as we learned these lessons in lecture halls, more prescient physicians working on the ground saw the writing on the wall and taught us in our clinical rotations to sniff out drug-seekers.

That curriculum now reads like propaganda, a list of horrifying myths now debunked. Those lessons resulted in a steady of flow of opioids into American communities, compounding despair and accelerating ruin. As I started medical school, the rate and number of opioid prescriptions began climbing, and peaked in 2012 with more than 255 million, at a rate of 81.3 for every 100 people in the United States.

But today, in response to the epidemic, there is a danger of returning to where we were in the ’90s, to the callous undertreatment of pain. Debate rages among physicians, as well as inside each doctor’s head, about when and in what amount opioids are appropriate, but there is little consensus. One study of emergency room physicians and their prescription processes revealed how many factors influence doctors’ decisions to prescribe, including concern about addiction, their personal medical experiences, pressure from state legislators to curb prescriptions and even worries over patient satisfaction scores — some physicians feel administrative pressure to prescribe opioids more freely in order to improve scores. Doctors might see their own addicted relatives or friends in the faces of their patients: a sibling or cousin, perhaps, who stole and spun a web of lies for years, burning bridges and trading a bewildered family for each transient fix.

While waiting for Brittany’s lab results, I perused her electronic medical record. No recent opioid prescriptions from other doctors had run out that day, which might have explained her visit. She had no unusual recent evaluations or test results to suggest a developing medical condition. I saw only diagnoses typical of a drug-seeker: “polysubstance abuse,” “heroin dependence,” “PTSD” — scarlet letters affixed to her chart. I worried about missing a potentially life-threatening disease, but I also didn’t want to be a sucker.

I surreptitiously peeked into Brittany’s room to see if she remained immobilized by pain. If she were sitting comfortably now that no one was watching, I could discount her pain. But she lay there, moaning. I felt disgusted by my paranoid snooping.

I ordered the nurse to administer an IV anti-inflammatory and nausea medication, gradually stepping up the strength of analgesia while hoping to use the minimum needed. The next step was an opioid, which I dreaded giving to her. I impatiently waited for Brittany’s lab results in the physicians’ cubby, still anticipating a quick discharge afterward.

A nurse popped her head into the cubby. “Her white count is 18,” she said. My own abdomen suddenly burned. An elevated white-blood-cell count was extremely concerning, a possible sign of disease hidden in Brittany’s abdomen. And a blood test could not be faked. I returned to her bedside, to the moans I had been trying to ignore. I ordered a dose of IV morphine and a CT scan — the image showed clear signs of a gastric ulcer that had ripped through the wall of her stomach, releasing air into the abdomen. She needed a surgeon, in addition to intensive drug rehab.

Opioids are a mixed blessing: Alongside their destructive potential I regularly witness their unbridled power. Kids with bones bent into question marks receive a quick squirt of aerosolized fentanyl in both nostrils upon entering my ER. Almost immediately, they sit comfortably in their hospital beds, despite broken bones, their pupils shrinking to poppy seeds. Sometimes only opioids will do. At such times, I marvel that molecules from the ovarian ooze of some plant should so precisely match our own pain receptors, alleviating the worst of our physical suffering.

The healing power endowed by the federal Drug Enforcement Administration to physicians brings great responsibility but not much insight into discerning disease from drug-seeking. Opioids are the nuclear power of painkilling, and their misuse similarly brings death and destruction on a national scale. Physicians enabled this epidemic, and now we’re tasked with both saving the overdosed and prescribing rehab. In the prayerful words of addicts everywhere, may we have the serenity, courage and wisdom to help reverse what we’ve wrought.

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