onny D is cupping his jaw with both hands, writhing on the gurney, and pleading with me to give him “something for the pain.” His teeth, those that remain, are a ragtag crew of decay. He’s been popping ibuprofen like candy. Antibiotics no longer help. He needs a dentist, but he lacks insurance and the private dentists he contacted won’t see him without cash upfront. “I’m trying, doc,” he says, as if reading what I’m thinking. “You think I want to be here?”
I don’t know what to think. Looking into his mouth makes my own jaw throb. But I do know that 4 of 5 new heroin users kickstarted their habits by abusing painkillers. Opioid painkillers and heroin were responsible for nearly 50,000 lives lost in 2016 from drug overdoses. In my emergency medicine practice, these statistics have faces, and sometimes these faces have rotted teeth.
Sonny (not his real name) wants what he says worked the last few times he came to the emergency department for dental pain. He’s asking for Vicodin, a combination of the opioid hydrocodone and acetaminophen. It’s in the top five most commonly prescribed drugs in the United States. Opioids — whether it’s Vicodin or oxycodone or many others — have transformed dental and other pain into a moral and clinical cage fight. This struggle is lost in the headlines that blame physicians for the opioid crisis. It ignores the on-the-ground experiences of many of us who strive to do the right thing when the “right thing” is the very thing in question.
Will the opioid pills Sonny is asking for treat his pain, feed an addiction, or both? Will prescribing it fulfill my moral responsibility to alleviate his distress, contribute to the supply chain in the illicit pill economy, or both? Prescribing guidelines from the Centers for Disease Control and Prevention and recommendations from medical specialties and local hospitals are well-intentioned and necessary. But they do little to address the central anxiety that makes this decision a source of distress for physicians like me. It’s hard to evaluate pain without making some judgment about the patient and the patient’s story.
Sonny tells me his pain is an 11, off the charts on the standard 1 to 10 pain scale. But what really drives my understanding of Sonny’s pain, and my response to it, is the degree to which I believe his story and my emotional connection to it.
I have doubts. And I doubt my doubts. Sonny’s medical record reveals multiple visits to the emergency department in the past few months, always in the heart of the night, for the same throbbing ache. Past treatment has included antibiotics, ibuprofen, naproxen, and opioids, though for never more than a few days.
He shakes off my suggestion of a local nerve block, the preferred remedy to numb dental pain. “They tried that the last time,” he says. “The pain finds a way in.”
Sonny needs a dentist, not opioids. I suggest phone numbers to local dental clinics.
“Called them,” he says. “I leave messages. They don’t call back. The clinics that answer the phone are booked for months.”
I sympathize with Sonny. I sympathize with the overworked dental clinics. That said, every emergency physician has been duped by patients who use the ruse of pain to feed an addiction and divert drugs onto the streets. Decades of experience has created an internal radar for red-flag behaviors that raise the suspicion of doctor shopping — seeing multiple providers in hopes of finding one with a lower threshold for prescribing opioids. But I’ve discovered that my gut instinct is prone to error, again and again.
A good story shortcuts analytical thinking. It can work its charms without our knowledge and sometimes against our better judgment. Once an emotional connection is made and the listener becomes invested in the story, the believability of the story matters less. In fact, the more extreme the story, the greater its capacity to enthrall the listener or reader.
Stories can elicit empathy and influence behavior in part by stimulating the release of the neurotransmitter oxytocin, which has ties to generosity, trustworthiness, and mother-infant bonding. I’m intrigued by the possibility that clinicians’ vulnerability to deceit is often grounded in the empathy they are reported to be lacking.
Sonny’s story isn’t life and death, but it is extreme. His dental plan involves letting his teeth decay and then having them pulled.
“Look at this mouth,” says Sonny. “Is this the mouth of a faker? I used to be a good-looking guy.”
I believe that. He inhabits a T-shirt, an open flannel shirt, jeans, and steel-tipped work boots with the remains of swagger.
The opioid statistics cast a dark and devastating truth, but what good are data against a man with dental pain telling a compelling story?
I review the statewide prescription monitoring database. Sonny’s name pops up with the same thing that is in his medical record: prescriptions for a few days of opioids here and there. But they are written by multiple health care providers, not one. Such a pattern echoes the activity of someone hunting opioids for illicit purposes. I explain to Sonny that in an opioid epidemic, perception alone can harden into permanent suspicion.
“What about your medical doctor?” I ask. Sonny shrugs. His medical clinic has a strict policy against prescribing opioids, another reason why he’s in the emergency department.
“I’m stuck,” he says. “I know you probably don’t believe me.”
I’m stuck, too.
In emergency medicine, we care for anyone with any problem at any time, and that includes people with secondary motives. Sonny’s story knocks against other stories I heard during that night’s shift. The woman with a migraine and a long history of substance abuse who yelled at us because we wouldn’t prescribe opioids for her migraine. The man claiming low back pain and an inability to walk who jumped off the stretcher and stormed out when we wouldn’t prescribe Dilaudid, a powerful opioid painkiller.
When I consider pain through the lens of story, I recognize that patients may go on the defensive, fueled by previous experiences with medical personnel, and never get the chance to tell their stories. In one report, a sickle cell patient described how encountering the opinions and feelings of medical staff were worse than the pain. In a profession built on the moral precept of “do no harm,” physicians’ biases and judgments can devalue patients and push away people already isolated by their pain.
My relationship to Sonny’s pain deepens as I learn how he supports his young family by juggling two jobs. He works at a warehouse until 2 a.m. four nights a week. His wife came and waited with him in the emergency department for a few hours tonight.
I ask Sonny how he could have been sleeping in the waiting room, his jean jacket pulled over his eyes, and then a few minutes later in the examination area be rocking in pain. Before his wife left to get their kids off to school and head to work, he says she gave him some ibuprofen that took the edge off his pain for a bit.
I’m curious how he endured the pain yesterday and the day before. And what about tomorrow? He lowers his head, assumes a posture of confession. Sometimes he buys Vicodin and other opioids on the street when the pain becomes unbearable.
Finding clarity is hard when deaths from opioid overdoses exceed those from gun violence and motor vehicle crashes combined. Physicians, especially emergency physicians, have been called out as culprits in the opioid crisis. Practice patterns vary, but reports show that my colleagues and I prescribe opioids in a responsible fashion — short-acting formulations at the lowest possible dose, and only for a few days.
Sure, alternatives to opioids are ideal. Examples include regional nerve blocks, disease-specific therapies, and an integrative approach to pain. They aren’t risk free, but medical decision-making is always a wrestling match between risks and benefits. With Sonny, however, I can’t dodge the opioid question.
I feel uneasy. Overdoses and substance abuse are a devastating part of my practice. But without a dental appointment in sight, Sonny will be back, incurring the financial burden of another emergency department visit. Or he’ll find what he needs on the street.
If Sonny comes to the emergency department in pain and goes home in pain, what does that say about me? I’ve perpetrated a grave moral harm. Not only because I provided substandard care, but because I didn’t believe his story and I didn’t fully trust him.
I finally decide to prescribe a few doses of Vicodin for Sonny. My reasoning isn’t easy to grasp. I’m responding to his pain directly, but also to the story of his struggles, of which the pain is a part. I realize that what I am doing might tag me with a red flag. But indifference isn’t a virtue, and writing prescriptions for medications that haven’t been effective doesn’t feel right either.
Relieving pain is a basic human gesture. Yet in an opioid crisis, a simple case of dental pain becomes a source of frustration and mental exhaustion. I can’t say my choice was right. Uncertainty rules when stories are subjective and open-ended. But uncertainty also suggests possibility. Story is the ground where clinicians and patients meet, where they can become more accountable and recognizable to one another. Responsible and compassionate pain management requires fluency in both science and story.
Jay Baruch, M.D., is associate professor of emergency medicine and director of the Medical Humanities and Bioethics Scholarly Concentration at the Warren Alpert Medical School of Brown University in Providence, R.I.