How Healers Became Dealers

Introduction

How did doctors become complicit in the worst opioid epidemic in US history, and why are they continuing to prescribe copious opioids despite increased national awareness of the dangers associated with these drugs? In other words, how did healers become dealers?

To understand the origins, evolution, and persistence of this massive public health debacle, it is essential to understand that opioids never were the solution to patients' problems. They have been and continue to be the solution to doctors' problems. Doctors' problems arise from four invisible forces shaping modern medical practice: the “Toyota-ization” of medicine, the co-optation of medicine by Big Pharma, the medicalization of poverty, and the demonization of pain.

Finding a solution to the current opioid epidemic, an epidemic which is likely to continue for the foreseeable future, will depend upon elucidating how these invisible forces driving overprescribing impact the doctor–patient relationship. We begin by examining what motivates the compassionate doctor. We then explore what motivates the drug-seeking patient. Finally, we examine the complex dance between the compassionate doctor and the drug-seeking patient, when it comes to writing a prescription for a potentially addictive drug. A deeper understanding of the factors contributing to overprescribing offers potential solutions to the current opioid crisis.

Who is the Compassionate Doctor?

To begin, let's first examine this person we call the “compassionate doctor”. Why? Because this opioid epidemic is not the result of a few prolific prescribers, otherwise known as “pill mill doctors.” The problem of overprescribing is rampant across all medical specialties all over the nation. We have all become pill mill doctors.

Doctors are by and large pleasers. They make it through the complex maze of schooling all the way to medical school by figuring out early on what other people want and providing it. They are temperamentally anxious, obsessional types, preferring structure and certainty to loose boundaries and uncertainty.

Doctors are motivated by a higher calling. When they graduate from college, usually near or at the top of their class, they can choose to go into any number of professions, from business to law to computer science. They choose medicine, however, because they are looking for a chance to make a real difference in the most tangible sense, by saving lives and alleviating suffering.

Once in medical school, doctors are called upon to empathize with patients and imagine their suffering as their own without judgment. They are socialized to believe their patients, without second-guessing the veracity of their stories. The relationship between doctor and patients is founded on an assumption of trust and mutual cooperation.

Once they enter practice, these perennial A-students are intensely invested in being the best doctor they can be. They are, in other words, narcissistically invested in being successful doctors. This is not to say that doctors are narcissists.

Narcissism is not the exclusive domain of pathological self-involvement. The psychoanalytic conception of narcissism leaves room for “healthy narcissism.” Freud described early childhood self-involvement as a normal and healthy part of development. The psychoanalyst Heinz Kohut believed that when the narcissistic demands of early childhood are adequately met by available caregivers, then childhood narcissism evolves into healthy adult self-esteem. Healthy narcissism of adulthood is what allows us to invest our energy and creativity into the things we care about to achieve success, however we define it, whether that activity is bird-watching, parenting, or doctoring.

So how do doctors define success? By mutually affectionate interactions with patients. These mutually affectionate interactions are often characterized by a patient's expression of gratitude. What balm to a doctor's soul when the patient says, “Thank-you, doctor, you have really helped me,” or “Thank-you, doctor, I don't know what I would have done without you.” More objective measures of doctoring-success matter too—a chemotherapy regimen that has eliminated a cancer, or a knee replacement which allows a patient to walk again. But for doctors working day in and day out treating patients, many of whom are chronically ill and will never get better but can only hope not to get worse, the most essential measure of success is a positive, trusting, mutually affectionate interaction.

At its most professionally satisfying, the interaction between doctor and patient can even approach the spiritual, or what philosopher and theologian Martin Buber called an “I and Thou” moment: “Man wishes to be confirmed in his being by man, and wishes to have a presence in the being of the other…. Secretly and bashfully he watches for a YES which allows him to be and which can come to him only from one human person to another.”

When these kinds of moments occur between doctor and patient, and thankfully they occur often enough, all the years of schooling, all the exams, all the nights on-call, all the petty bureaucratic demands (which only seem to get worse with each passing day) are worth it for those moments of deeply shared humanity.

Who is the Drug-Seeking Patient?

Now let's turn our attention to the drug-seeking patient. For the purposes of this discussion, the drug-seeking patient is the patient who attempts to obtain a medication from a doctor for their own, nontherapeutic/addictive use, not the drug-seeking patient who plans to give or sell the medication to others (drug diversion).

The prevailing explanation for drug-seeking is malingering. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), malingering is “feigning illness with the conscious intent of obtaining some tangible good not related to illness recovery.” Malingerers are often seeking a hot meal and shelter (referred to in medical slang as “three hots and a cot”), a disability payment, and/or prescription drugs for nontherapeutic use. Patients who are malingering represent one of the very few instances in medicine in which doctors can refuse care.

But malingering does not fully capture the phenomenon of drug-seeking. Yes drug-seeking patients lie and manipulate their doctors, and they do so knowingly. But if drugs were really all that mattered, they could obtain them with greater ease from a street dealer or an Internet pharmacy in less time and often less money.

The drug-seeking patient is better understood through the lens of addiction. Addiction is an altered brain state in which motivation for basic survival has been “hijacked” by the drive to obtain and use substances.

Patients use many different strategies to manipulate doctors to get the drugs they want. The myriad ways drug-seeking patients effectively manipulate doctors can be codified into distinct categories, or personas, as follows. These labels are not intended to denigrate drug-seeking patients, but to capture complex behavior in memorable ways.

Sycophants: Sycophants are patients who flatter and cajole, assuring their doctor of their competence and compassion, especially as compared to every other doctor they've seen. The patient satisfaction surveys give this technique additional leverage, because the communication goes beyond just the doctor and the patient. It is unveiled for the larger institution to see, and sometimes the whole Internet world, as in the case of Web-based doctor rating platforms who use patient ratings as the only measure.

Senators: Senators are patients who use the filibuster technique, taking most of the allotted time with the doctor to talk about issues unrelated to the prescription, intentionally waiting until the last few minutes of the encounter to bring it up. In doing so, they are relying on the time pressures they know the doctor is under, to tip the doctor over into prescribing because it is the expedient thing to do. Saying yes to a prescription and ordering it takes less than 1 min. Saying no could take 30 min or more, much less time than the doctor has to stay on schedule.

Exhibitionists: Exhibitionists are patients who display intense emotions and dramatic gestures associated with refill requests. Sometimes they writhe in pain. Other times they achieve various stages of undress to reveal colostomy bags, surgical scars, congenital deformities. The heightened theatrics are intended to illustrate a sense of dire need. As one patient said to me regarding my ability to prescribe him the drugs he was requesting, “I'm on fire, and you've got the hose.”

Losers: Losers are patients who exhibit a remarkable tendency to misplace medications. With astonishing regularity, these patients run their medication in the wash cycle, drop them over the side of the fishing boat, flush them down the toilet—water seems to be a common theme. There's also leaving them in a hotel room, being parted from them as a result of lost luggage during a weekend getaway, and yes, I have even heard eaten by the family pet.

Weekenders: Weekenders call for early refills or an increased doses when their regular doctors, the ones who know them best, are least likely to be around. Academic medical centers, where less experienced trainees are most likely to get calls off-hours, are particularly vulnerable to this technique. But large healthcare conglomerates where shift work is the norm also fall prey.

Doctor-Shoppers: Doctor-shoppers are patients who go to multiple doctors simultaneously for the same or similar prescriptions. These patients seek out clinics where drop-in visits are welcome, and where doctors are accustomed to seeing a patient once and possibly never again. Emergency rooms are the ultimate one-stop shopping, because they are staffed by many different doctors. According to one study, doctor-shoppers seeking prescription opioids are more likely to be between 26 and 35 years of age, to pay for prescriptions with cash, and to obtain oxycodone formulations (2.8%), followed by oxymorphone (2.3%), followed by tramadol (2.0%).

Impersonators: Impersonators are patients who assume different identities at different clinics or hospitals—the inverse of doctor shopping. Instead of searching around for different doctors, they become different people.

Dynamic Duos: The Dynamic Duos is patients who present in teams of two, usually the patient and the patient's mother, the most natural codependent. While the patient is writhing in pain, the patient's mother is crying. Together they make a formidable and persuasive team.

Twins: Twins are the patients who are also healthcare providers or occupy a professional and social class that the doctor relates to. These patients know how to create a sense of affiliation with the doctor by talking about the schools they went to, the high-level jobs they've had or have, the people they may know in common. The ones who are healthcare providers use their intimate knowledge of the healthcare system to encourage their doctors to prescribe for them.

Country Mice and City Mice: Country mice and city mice are patients who situate themselves on the opposite ends of the savvy spectrum. The country mouse is the faux-naïve, and the city mouse the slicker. The country mouse pretends to know nothing about prescription medication and gently persuades the doctor to suggest the drugs. The city mouse, by contrast, saunters into the emergency room and announces she is allergic to all pain medications except intravenous Dilaudid push (the “push” meaning the syringe with the opioid medication is emptied into the bloodstream all at once to create an immediate high) with a Benadryl chaser (Benadryl is an antihistamine known to augment the high of opioids). A nurse practitioner I interviewed told me that she once treated a city mouse who was so resistant to transitioning from intravenous Dilaudid push, given to him in the emergency room, to the oral or rectal opioid she offered him once he was admitted to the floor, that he left the hospital without further treatment.

Bullies: Bullies are patients who use emotional or even physical intimidation to coerce doctors to prescribe. Bullying may represent one of the most effective techniques. These patients have a deep understanding of the fears that plague doctors–the fear of a negative review, the fear of litigation. Patients exploit these fears to serve their own agenda.

Internet Copy-Cats: Internet copy-cats use the Internet to obtain information on how to get drugs from doctors. A Google query of “How to trick dr's to give u pain medicine” gives the following result. “The trick–seriously–is to visit a poor doctor in a poor area of town. Get your textbook list of requirements, pay cash for your appointment, and be the perfect patient. Each time, ask for a little bit more painkillers for a little bit more pain. The doctors want to cover their asses legally and not go to jail or get sued, but it's no hair off their back if you're a lifetime pain mgmt candidate.”And “Just look up bullsh_t medical problems like fibromyalgia symptoms and go to the doctor and tell him/her that is how you feel. Fibromyalgia is just a made up medical term for people that want pain killers.”

Little Engines that Could: Little engines are patients who plod along, always communicating enough improvement to convince the doctor they're almost there, almost over the hump, while endorsing enough ongoing distress to continue to receive the desired prescription. These are the same patients who say “I really want to get off these meds,” but never take the necessary steps to make that happen.