Sonny 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.

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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.

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In her book, “The Body in Pain,” author and professor Elaine Scarry said it best: “To have pain is to have certainty; to hear about pain is to have doubt.”

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.

  • Winter Texans and residents on the border go to Mexico for affordable dental care. I’ve talked to a number of people who do this and were very happy as it was a fraction of the cost with acceptable outcomes. Check out border towns like Reynosa, Progresso, or Matamoros.

  • The opioid crisis has highlighted not only addiction but a healthcare system that is woefully inadequate in addressing pain. Much more research needs to be done in addressing chronic pain. Let us be reminded that the foundation of healthcare is entirely rooted in comfort care. If we can’t provide relief from pain we aren’t meeting this mandate.

  • The approach to the opioid crisis that we currently have is failing both addicts and people whose pain is real. I have no idea if your patient was scamming or not, but I appreciate the effort you put in to try to treat his pain. There isn’t enough room here to elaborate on the ways in which this has personally effected me. I have had migraines for 50 years. I am currently taking 4 preventives. 4!! and Midrin, which is better than Excedrin PM and not as good as codeine or Vicodin. Somehow, I would rather take a few less preventives and be given an opioid when I need it than pushing all this crap in my body every day. I work in HealthCare, have sensitive and helpful practitioners, but their reluctance to prescribe is drastically effecting my quality and enjoyment of life. For what its worth, all the chronic pain people I know NEVER say their pain is 10 or more, that is a red flag. We try to answer in a reasonable way and low ball it, so we will get treatment. I stopped going to the ER about 15 years ago for this reason. I would rather be in pain and vomit for 14 hours [which happens, btw] than face a smirking ER doc or nurse.

  • I don’t know much about opioid addiction but I do know about untreated injuries and chronic pain. Chronic pain and the untreated injury caused me extreme unrelenting insomnia. I couldn’t get adequate sleep for months, kept waking up repeatedly every time I moved. It also caused social isolation, I couldn’t walk or drive for months. It caused me to quit school because I couldn’t get there and even if I could I could not concentrate. It caused me to lose my job because I couldn’t stand and I worked in a restaurant. It caused severe financial difficulties, including homelessness. It, and the associated problems, caused my psychosis. I often wonder what may have happened if the pain had been treated…but I have to remind myself that the cause of the pain was not treated either. Having had chronic pain, as diagnosed by my doctor, I will always be angry that it was not treated. It was my version of hell. I think restricting opioids out of fear would be a mistake. Many people cannot function while in severe pain. And in case you are curious, I have had opioids for other conditions and I usually don’t finish the prescription. I guess it’s really a Devils choice. either prescribing or not prescribing has its drawbacks but I really wish my chronic pain had been treated.

  • ACH
    Not sure how your suggestion helps
    ASSUMING that the patient is legitimately an in pain patient (and that is a BIG assumption because as the article suggests there is virtually NO way to separate drug shoppers from real pain patients) but by refusing to allow him into in the ED doesn’t get him a mouth full of extractions! The PCP is TOTALLY inept to handle this mess as a medical issue he can at best feed more drugs but that won’t solve the issue the guy needs Dental care and has no money. If we expand medical coverage to include Dental care expect insurance to double in one year. Dental is the most expensive coverage available since once it is open people tend to use all they can each year. It is basically pre-paid care since even those who don’t need it now get free check-ups so they increase the usage
    NO winner here
    The issue is two-fold one part is separating out pain from gamers and then how to provide care to those who are in need and not waste either money or expertise OR feed the opioid abuser system. I can see it now if we in ANY way modify the system to allow freer access to narcotics!!!! The 50K dead per year will be more like per month
    What ideally should happen is non-opioid drugs to be discovered and approved so that we can end pain without getting high then we are done. then only drug addicts will have narcotics and real pain patients will get drug X and will accept it
    Dr Dave

  • After fighting this exact issue for now almost 4 decades I can easily understand Jay’s dilemma. If he withholds the patient who might legitimately be drug seeking is sent packing. If however, the patient is legitimately in pain then he has lost the central focus of what we do. Our job is to help sick people in need. JUST because there is an opioid crisis doesn’t mitigate our core principle and make us any less a servant of disease. YES, we might be scammed by the drug abuser who has honed his spiel well enough to get past our BS radar but so what.
    Yes I get it that 50K people died last year with opioid addiction BUT to suggest that there is a finite link between prescribed drugs and illegal addiction is a statistical stretch at best
    My “previous life” was built partly as a Federal Drug Interdiction Task Force Director on the east coast. I can tell you that although yes there are some people who never intended to or even wanted to get hooked on or even tried opioids the majority did so for the feel and fun of the drugs not because they misused a prescription for an abscessed wisdom tooth
    Sure we can numerically track the DOA thru their life to some event where a professional wrote a script for Vicodin but in reality, the majority of people who are given opioids never finish the bottle and or even consider using the remainder for anything other than future accidents or emergencies
    We need to weigh the issue of how to solve the problem when like this article there is NO way to eliminate the pain source unless we are now going to add Dental to our existing over abused medical insurance process. This patient needs some Dental work to finally resolve the matter but how (same for chronic back and nerve pain etc..)? The cost of Dental care is disproportionate to ANY other medical service short of Oncology. This man could easily spend $5K or 10K to resolve his dental pain and get his mouth under control. If he had the money he wouldn’t be spending $1K (of our money) on an ED visit.
    That is assuming that he is really in pain and not drug seeking. We will never know
    The only solution is to see if he ends up either in a Dental clinic or a morgue over the next few years.
    The healthcare industry can’t solve all problems and shouldn’t be held responsible for every issue in society. YES some will OD on narcotics but if we lose control over prescribing them like we have in some states already expect the societal costs to go up exponentially since what could have been resolved with an office visit at 1 PM and a script for Vicodin will end up being an ED visit at 1AM and a $1K bill charged to society thru either private or public 3rd party payers. Either way, we all pay for it
    Dr Dave

    • I agree with all of your points. People should save EDs for true emergencies, and EDs should stop feeling like they have to treat anyone or anything that presents in their waiting room. What the patient needs is a dentist. I imagine a time when our publicly funded insurance will refuse to reimburse a hospital for these sorts of inappropriate, revolving door ED visits. Then watch the hospitals expedite appropriate care, that is, turfing them to the right clinician, and watch them say no to treating these sorts of cases. Ultimately, if Mass health, Medicare, etc stopped paying for ED visits for non emergency usage, the admission criteria will prevent him from being seen in the ED. The patient would be turfed back to his primary provider, which is where he ought to be getting seen and that staff should be getting him a referral to a free dental clinic. As it is, he will stay on this hamster wheel for a bit longer, with deteriorating health.

  • To give this person a Vicodin prescription could lead to the end of professional activity as a doctor. Each doctor has a DEA number exactly for this reason, so they can monitor each doctor’s prescribing practices and in the case of what the DEA believes is unreasonable, either cancel the number or bring legal charges against the doctor prescribing the medicine.
    If the police find the prescription bottle with the doctors name on it at the site of a drug overdose or a clandestine sale, the police ordinarily call the doctor and will make note of it. You are vulnerable if you prescribe to anyone you don’t know, or even someone you do know.
    Being a professional, a doctor is expected to place professional behavior over emotional context.
    At the very least, always get drug screens in places such as an emergency room.
    Certainly for things like broken arms or severe injuries, a limited narcotic prescription might be reasonable. For a chronic problem like dental problems, not so much.
    Personally, I would prefer they just eliminate the DEA and leave everything up to doctors judgment, just like other prescriptions for things like antibiotics, heart or blood pressure medicine or even chemotherapy, but that’s not the way it is.
    The message has to be never prescribe narcotics for these chronic problems, especially in an emergency dept.
    If they need to be prescribed, maybe one pill when you can actually see the person take the pill in front of you.

  • He may indeed be an addict, but he is also in pain due to serious dental problems. Half of his problem could be cured if adequate dental care was available. How many people become addicted to painkillers because they have real medical problems with no easy fix? Simply denying a patient access to painkillers does not improve their health and solves nothing.

  • Thanks for bringing this daily dilemma to the light. The pendulum of opiate prescribing has swung so quickly and absolutely without taking into account the individual circumstances of many patients. Thanks.

  • This situation is not unlike our response to a beggar working an intersection with a sign and a cup. We feel real compassion, but we know that giving them a dollar, or even twenty dollars, just keeps them coming back with a sign and a cup, when what they need is a home and a job. Repeated ER visits which result in a prescription only feed a cycle of revisits. Hard to say no, and hard to find an alternative, but this man, who is raising your red flags, and mine, should have a case manger assigned to help him find a free dental clinic. And then, no more Rxs.

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