“…It never was our guise
To slight the poor, or aught humane despise:
For Jove unfold our hospitable door,
‘Tis Jove that sends the stranger and the poor…”
—Homer: The Odyssey, Translation by Alexander Pope
A few weeks ago, Drugmonkey wrote a piece
about perceptions of drug users. Specifically, the study looked at how mental health providers perceive people with substance use disorders depending on whether the patients were referred to being a “substance abuser” vs. having “a substance use disorder.” These data revealed something interesting. Among the mental health professionals:
…those assigned the “substance abuser” term … were significantly more in agreement with the notion that the character was personally culpable for his condition and more likely to agree that punitive measures be taken…
[they were more likely]…to convey internal causal attribution and personal culpability, a moral vs. medical solution, suggesting the character has volitional control and might be viewed as a “perpetrator”who is willfully engaging in the behavior and thus more deserving of punishment.
I would not be surprised if these results were reproducible in primary care physicians. People with substance use disorders can be difficult to care for even before we layer on our own prejudices. Anecdotally speaking, substance abusers can be needy, stubborn, and narcissistic. They can behave inappropriately and show little respect for boundaries. These behaviors set off a whole set of reciprocal behaviors in providers. If a patient demands a narcotic medication, the reaction is often to become angry and say “no” without responding to the underlying pathology (not, that is, the pathology of the back pain, but the narcotic dependence).
This phenomenon has been documented
in various ways over the years but I’ve found little in recent literature examining physicians’ attitudes toward people with substance use disorders. Today, though, I found an interesting article just published in the journal Addictive Behaviors
which looked specifically at doctors’ attitudes toward prescribing opiates in patients with a history of substance abuse. The study’s findings resonated with me, and I suspect they would with many doctors.
One finding was that in persons with a history of substance abuse (PWHSA), doctors often considered them guilty until proven innocent, which in a way makes a certain amount of sense. The patient, having shown themselves to be particularly susceptible to substance use disorders, is, in a sense, already “guilty”. The question here is how will that scarlet letter affect their care.
In this study doctors expressed fears—reasonable ones, I think—of addiction and of diversion. They looked at certain red flags in trying to predict inappropriate narcotic use, including doctor shopping, borrowing others’ opioids, reporting that their prescriptions were lost or stolen, and other traits that often mark a patient as a “danger” to the doctor.
Also prominent was the concept of “genuine pain”, that is—presumably—pain caused by a clear pathological anatomic problem and something more subjective. To me, this is where it gets interesting.
I don’t know if the red flags noted actually correlate with substance abuse. I tend to believe that they do, but of course they could also be behaviors learned in response to not getting adequate pain treatment. These studies bring up some common problems with the way we view substance use disorders: the temptation to blame SA on moral failings, and the splitting of medical problems into those of the mind vs. those of the body (and the implied volitional component of each).
Opioids and other narcotics do not affect only “the mind” or even the brain; they have physiologically and anatomically diverse affects. To call SA a “mind” problem is simply wrong. And since there is no “mind” without “brain”, to speak of mind at all in this context only serves to further confuse the issue.
We know that there are many simple behaviors over which we have variable control: breathing, muscle twitching, tics, yawning. Opioid dependence is associated with many negative behaviors many of which are more complex than twitching, but may be under the same amount of control.
This morning I got up late. My wife and kid weren’t feeling well, so I stayed home and hung out for a while. I made myself a cup of good tea and read a bit. I cuddled the kiddo, and eventually got ready for work. As I pulled into the parking lot at the hospital I realized that I wasn’t feeling so great. My head felt heavy, I felt a little dizzy and nauseated, and I was beginning to get a headache. As the elevator stopped at every floor, I realized that I was also pretty irritable.
As I finished my rounds I realized I need my coffee—NOW.
I walked quickly back toward the elevators thinking about how I would order my coffee, about how quickly I could get downstairs for my coffee, about what my coffee would taste like. I worried that I wouldn’t get my coffee quickly enough to stave off my headache.
Empathy is a critical part of medicine. We can’t (and probably shouldn’t) completely empathize with all of our patients, but we must understand that behaviors and motivations are complex. We may be right to be suspicious of the “dog ate my Vicodin” guy. It may turn out that we have little to offer him. But his behavior looks different when you consider its complexity.
Service is a considerable art of medicine, and while we aren’t obliged to serve everyone in every situation, learning to try is part of the deal.
Kelly, J., & Westerhoff, C. (2009). Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms☆ International Journal of Drug Policy DOI: 10.1016/j.drugpo.2009.10.010
Baldacchino A, Gilchrist G, Fleming R, & Bannister J (2009). Guilty until proven innocent: A qualitative study of the management of chronic non-cancer pain among patients with a history of substance abuse. Addictive behaviors PMID: 19897313