Opioids Abuse

Why Doctors Prescribe Opioids to Known Opioid Abusers

Anna Lembke, M.D.
Prescription opioid abuse is an epidemic in the United States. In 2010, there were reportedly as many as 2.4 million opioid abus- ers in this country, and the num- ber of new abusers had increased by 225% between 1992 and 2000.1 Sixty percent of the opioids that are abused are obtained directly or indirectly through a physician’s prescription. In many instances, doctors are fully aware that their patients are abusing these medi- cations or diverting them to others for nonmedical use, but they prescribe them anyway. Why? Recent changes in medicine’s phi- losophy of pain treatment, cultural trends in Americans’ attitudes to- ward suffering, and financial dis- incentives for treating addiction have contributed to this problem.
Throughout the 19th century, doctors spoke out against the use of pain remedies.2 Pain, they ar- gued, was a good thing, a sign of physical vitality and important to the healing process. Over the past 100 years, and especially as the availability of morphine deriva- tives such as oxycodone (Oxycon- tin) increased, a paradigm shift has occurred with regard to pain treatment. Today, treating pain is every doctor’s mandated responsi- bility. In 2001, the Medical Board of California passed a law requir- ing all California-licensed physi- cians (except pathologists and radiologists) to take a full-day course on “pain management.” It was an unprecedented injunction. Earlier this year, Pizzo and Clark urged health care providers as well as “family members, employ- ers, and friends” to “rely on a person’s ability to express his or her subjective experience of pain

and learn to trust that expres- sion,” adding that the “medical system must give these expres- sions credence and endeavor to respond to them honestly and ef- fectively.”3 It seems that the pa- tient’s subjective experience of pain now takes precedence over other, potentially competing, con- siderations. In contemporary med- ical culture, self-reports of pain are above question, and the treat- ment of pain is held up as the holy grail of compassionate med- ical care.
The prioritization of the sub- jective experience of pain has been reinforced by the modern practice of regularly assessing pa- tient satisfaction. Patients fill out surveys about the care they re- ceive, which commonly include questions about how adequately their providers have addressed their pain. Doctors’ clinical skills may also be evaluated on for- profit doctor-grading websites for the world to see. Doctors who re- fuse to prescribe opioids to cer- tain patients out of concern about abuse are likely to get a poor rating from those patients. In some institutions, patient-sur- vey ratings can affect physicians’ reimbursement and job security. When I asked a physician col- league who regularly treats pain how he deals with the problem of using opioids in patients who he knows are abusing them, he said, “Sometimes I just have to do the right thing and refuse to prescribe them, even if I know they’re going to go on Yelp and give me a bad rating.” His “some- times” seems to imply that at other times he knowingly pre- scribes opioids to abusers be-

cause not doing so would ad- versely affect his professional standing. If that’s the case, he is by no means alone.
A cultural change contribut- ing to physicians’ dilemma is the “all suffering is avoidable” ethos that pervades many aspects of modern life. Many Americans to- day believe that any kind of pain, physical or mental, is indicative of pathology and therefore ame- nable to treatment. (The recent campaign to label “grief” a men- tal disorder is just one small ex- ample of this phenomenon.) At least some segments of our soci- ety also believe that pain that’s left untreated can cause a psychic scar, leading to psychopathology in the form of post-traumatic stress; thus, doctors who deny opioids to patients who report feeling pain may be seen not only as withholding relief, but also as inf licting further harm through psychological trauma. Trauma today is seen not just as causing illness, but also as con- ferring a right to be compensat- ed.4 No one understands this be- lief better than addicted patients themselves, who use their aware- ness of cultural narratives of ill- ness and victimhood to get the prescriptions they want. One pa- tient summed it up in this way: “I know I’m addicted to (opioids), and it’s the doctors’ fault because they prescribed them. But I’ll sue them if they leave me in pain.”
Furthermore, for physicians, treating pain pays, whereas treat- ing addiction does not. The main- stays of treatment for addiction are education and effective coun- seling, both of which take time. Time spent with each individual

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PERSPECTIVE

Why Doctors Prescribe Opioids to Known Abusers

patient is medicine’s least valued commodity, from a financial re- imbursement perspective. That’s especially true in emergency de- partment settings, where physi- cians are often evaluated on the numbers of patients seen, rather than the amount of time they spend with each one. Clinicians will not take time to educate and counsel patients about addiction — even if they know how — until they are adequately reimbursed for doing so. Currently, it is faster and pays better to diagnose pain and prescribe an opioid than to diagnose and treat addiction. Busy emergency physicians who would like to refer patients with addic- tion for appropriate treatment have few resources to call on.
To be sure, the recent shift in medicine’s and society’s approach to pain represents a response to long-standing neglect of patients’ subjective experience of pain, as well as an increasing incidence of chronic pain syndromes in an aging population. Although this shift has no doubt benefited many persons with intractable pain that might previously have been undertreated, it has had devastating consequences for pa- tients with addiction and those who may become addicted owing to lax opioid prescribing.
Some short-term changes that can help address this problem in- clude mandating that all physi- cians complete a continuing

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
From the Department of Psychiatry, Stan- ford University, Stanford, CA.
1. Resultsfromthe2010NationalSurveyon Drug Use and Health: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011 (publication no. SMA 11-4658).
2. Meldrum ML. A capsule history of pain management. JAMA 2003;290:2470-5.
3. Pizzo PA, Clark NM. Alleviating suffering 101 — pain relief in the United States. N Engl J Med 2012;366:197-9.
4. Fassin D, Rechtman R. The empire of trauma: an inquiry into the condition of vic- timhood. Princeton, NJ: Princeton University Press, 2009.
DOI: 10.1056/NEJMp1208498
Copyright © 2012 Massachusetts Medical Society.