Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The opioid crisis: Does empathy make physicians more vulnerable?

Jay Baruch, MD
Physician
June 4, 2016
Share
Tweet
Share

It was Saturday evening, and Audrey G lay awkwardly on an emergency department stretcher in search of a comfortable position. She suffered from chronic hip pain, the unfortunate and unexpected effect of pelvic surgery. But her real chief complaint involved her drug-abusing husband, who that morning stole her recently filled bottle of oxycodone, an opioid pain medicine. Her story included the surgeon who doubted her pain and a year of failed therapies. Now only oxycodone touched the pain, or so she said, fighting back tears. The on-call physician didn’t know her and said to go to the ER.

Any decision that involves prescribing an opioid asks that I pivot in a space mined with judgment and peril. Studies show that four of five new heroin abusers began their habit by abusing painkillers, and opioid painkillers and heroin have a heavy hand in the 47,000 lives lost prematurely in a single year from drug overdoses.

To be an emergency physician requires, first and foremost, being a skilled story listener. Before I can fashion a response or formulate a plan, I must first understand the patient’s story. This isn’t earth-shattering news. Humans, a group that includes both physicians and patients, have been using stories for thousands of years to communicate, connect and forge relationships.

However, when the Centers for Disease Control and Prevention recently published opioid prescribing guidelines to stave off the tragic march of addiction, overdose and death, they didn’t address the critical forces at play in my clinical practice — the power and seduction of stories and their capacity to influence behavior. Their well-reasoned recommendations ignored opioid prescribing as a narrative problem.

When pain is a subjective experience best appreciated and understood through the patient’s story, my emotional connection to the story is often a factor in my response.

The physicians and nurses involved in the care of Audrey G were emotionally moved by her story. How could we not? Audrey G wasn’t simply a patient in pain, she was a petite woman who endured powerful antagonists with quiet dignity. Substance-abusing husband, hints of domestic violence, chronic pain the result of a mysterious surgical event. She didn’t blame the surgeon. All she asked for was recognition that the pain wasn’t in her head, and at this moment, to be spared of pain.

What to make of the stolen pills?

Every emergency physician has been duped by a patient claiming stolen pills or the lost script. Red flags that raise the suspicion for “doctor shopping” include allergies to non-narcotics, a requesting a narcotic by name, a history of multiple visits for the same complaint or documented substance abuse problems, and a weekend presentation to the ED.

Over years of clinical practice, these red flags aren’t intellectualized, they’re felt in my bones. Even so, when Audrey G asked for Dilaudid, a strong narcotic, especially when given intravenously, concern for addiction or abuse didn’t register like it often does with other patients.

I wasn’t in a position to judge her because I was too busy participating in her story. A good story has a way of dodging or beguiling analytical thought.

In her book The Confidence Game,  Anna Konnikova delves into the sneaky ways story can work its charms. This occurs without our knowledge, and sometimes against our better judgment. Once invested emotionally in a story, the listener becomes drawn in, and whether the story is believable matters less. In fact, the more extreme the story, the greater is its capacity to enthrall the listener or reader.

Audrey G’s story was extreme for sure, but in emergency medicine, every time you pull back the curtain, introduce yourself and ask “how can I help you, today,” there’s a fair chance the response will be a story throbbing with life.

Unfortunately, data and scientific evidence, even those as devastating as the opioid statistics mentioned earlier, serve as a poor antidote to story. Data must earn its validity, methods must pass scrutiny. Even then it might not feel true.

ADVERTISEMENT

False or inconsistent notes matter less when folded into an emotionally engaging story. Scientific research lifts the curtain on this narrative-neural wizardry. Research using brain fMRI reveal how a coupling develops between the teller of a story and its listeners, whose brains respond to a story as if experiencing it firsthand. A dramatic story may also influence behavior by stimulating the release of the neurochemical oxytocin, which has ties to mother-infant bonding, generosity, and trustworthiness. The very empathy that physicians are often accused of lacking may serve as a point of vulnerability for the stories patients tell us.

Which may explain the deep hurt that cut through us when Audrey G’s old records revealed a distant history of drug abuse. It didn’t matter that combing through state prescription monitoring program failed to uncover past red flag behaviors. Once doubt entered, we were thinking about her story and no longer participating in her story.

Pain is the most common complaint that drives people to the emergency department. Objective, expert guidelines are an important step towards responsible opioid prescribing habits, but to apply them appropriately we cannot forget that the road to understanding pain and our responses to it are paved with stories. Story-education belongs alongside other formal steps as the opioid crisis forces physicians, patients and families onto unstable ground.

Strangely, oxycodone wasn’t my focus when caring for Audrey G. Her pain severity — whether it was 5 out of 10 or 10 out of 10 — bore little influence, either. It was the context of her pain, the story in which her pain was embedded. A story of hardship, where people dismissed her suffering, or put their own selfish needs first.

Was I duped? Was Audrey G an addict? Was she in cahoots with her husband? I cannot say. I only know that her story possessed enough truth, at that moment, to move me emotionally to relieve her pain — a prescription for ten pills, enough to hold her through the weekend. It moved me to shape a different story, hopefully, a better one. But I don’t know.

Jay Baruch is an emergency physician and the author of What’s Left Out and Fourteen Stories: Doctors, Patients and Other Strangers. He can be reached on Twitter @JBaruchMD. This article originally appeared in Littoral Medicine.

Image credit: Shutterstock.com

Prev

It's time for academic medicine to embrace direct primary care

June 4, 2016 Kevin 22
…
Next

Why young physicians should consider locum tenens

June 5, 2016 Kevin 2
…

Tagged as: Pain Management

Post navigation

< Previous Post
It's time for academic medicine to embrace direct primary care
Next Post >
Why young physicians should consider locum tenens

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by Jay Baruch, MD

  • The appendix: an ancient organ for the modern age

    Jay Baruch, MD
  • The toughest task in emergency medicine

    Jay Baruch, MD
  • The critical medical and moral stakes for all patients in pain

    Jay Baruch, MD

Related Posts

  • The miscalculated fear of an opioid crisis in Haiti

    Kenny Moise, MD
  • How do we manage pain in the era of the opioid crisis?

    Rita Agarwal, MD
  • Seeing the effects of the opioid crisis play out live

    Praveen Suthrum
  • The opioid crisis: Doctors cannot lose hope

    Linda Girgis, MD
  • Fight the opioid crisis with physician assistants

    James Cannon, PA-C
  • Are patients using social media to attack physicians?

    David R. Stukus, MD

More in Physician

  • Why U.S. health care pricing is so confusing—and how to fix it

    Ashish Mandavia, MD
  • From survival to sovereignty: What 35 years in the ER taught me about identity, mortality, and redemption

    Kenneth Ro, MD
  • When doctors forget how to examine: the danger of lost clinical skills

    Mike Stillman, MD
  • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

    Anonymous
  • The man in seat 11A survived, but why don’t our patients?

    Dr. Vivek Podder
  • When did we start treating our lives like trauma?

    Maureen Gibbons, MD
  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • What if medicine had an exit interview?

      Lynn McComas, DNP, ANP-C | Conditions
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • What if medicine had an exit interview?

      Lynn McComas, DNP, ANP-C | Conditions
    • Why U.S. health care pricing is so confusing—and how to fix it

      Ashish Mandavia, MD | Physician
    • From survival to sovereignty: What 35 years in the ER taught me about identity, mortality, and redemption

      Kenneth Ro, MD | Physician
    • When doctors forget how to examine: the danger of lost clinical skills

      Mike Stillman, MD | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 2 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • What if medicine had an exit interview?

      Lynn McComas, DNP, ANP-C | Conditions
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • What if medicine had an exit interview?

      Lynn McComas, DNP, ANP-C | Conditions
    • Why U.S. health care pricing is so confusing—and how to fix it

      Ashish Mandavia, MD | Physician
    • From survival to sovereignty: What 35 years in the ER taught me about identity, mortality, and redemption

      Kenneth Ro, MD | Physician
    • When doctors forget how to examine: the danger of lost clinical skills

      Mike Stillman, MD | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

The opioid crisis: Does empathy make physicians more vulnerable?
2 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...