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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.

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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.

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?

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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.

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  • Thank you for sharing your insights and struggles to a complex conversation few want to work to understand. I have a follow up question: You mention a moral responsibility to alleviate his pain (which I agree with), but I am curious about your other professional, bioethical, humanity expectations?

  • Interestingly the author fails to distinguish opioid-RELATED deaths from opioid-CAUSED deaths. “Related” means that an opioid was present at the time of death. “Caused” means that the opioid caused the death. Why this distinction is important, is that opioids, like handguns, can save lives as well as end lives.

    Consider the role of morphine in cardiovascular tissue. Every human being makes endogenous morphine in our cells, in significant quantities, that’s structurally identical to plant-derived morphine. (Stefano, Kream, et al, Folia Biologica Praha (2012):58; 49-56). This morphine stabilizes highly-corrosive and toxic nitric oxide, the toxin that makes urban smog acutely irritating to the eyes and mucosa, allowing it’s use in the body as a chemical signaling agent. (Stefano, Kream Arch Med Sci 2010; 6,5 pp. 658-662). As a chemical signaling agent, nitric oxide in concert with dopamine and morphine, up-regulates and down-regulates mitochondrial metabolism. (Ibid p 659 ¶3.). Cardiac ischemia, such as results when a coronary artery or arteriole becomes partially blocked by plaque or a blood clot, is partially prevented by the action of morphine, which relaxes the vascular wall, enabling it to enlarge, while also delaying cardiac muscle-cell apoptosis. (Ibid p 659 ¶6 ff). Thus, of the approximately 525,000 Americans who will suffer a first heart attack this year, all of them stand to benefit from a prompt dosage of supplemental morphine, as the medically-administered supplemental morphine not only provides pain relief but also provides known cardioprotective benefits, beyond the cardioprotective benefits of the patient’s endogenous morphine that was already present at the time of the heart attack.

    When doctors administer that supplemental morphine to the patient, but they administer it too late to save the patient’s life, the definition of an “opioid-related” death is sufficiently over-broad, that this failed lifesaving attempt places the doctor at risk of litigation.

    The reason the failed lifesaving attempt can result in litigation, is that ignorant people conflate the cowardly “opioid-related death” language, used by politically-minded folks seeking to create the appearance that pain relief led to an epidemic of poisonings by illegally-manufactured fentanyl, with the concept that the opioids actually caused the deaths.

    The reality of pain care and addiction, is that most people become addicted first to alcohol and then experiment with other drugs, in their teens and early twenties. Most sick people develop chronic intractable pain in their late forties through their early sixties. Few people initially start abusing prescription drugs, without first abusing alcohol. And prohibiting people from obtaining pain relief, encourages those who don’t commit suicide to stop the pain, to seek desperate measures such as taking kratom, ibogaine, or other substances that function like pharmaceuticals but are temporarily classified as “nutritional supplements”, or worse yet, buying illegal drugs. Deaths from stolen prescription opioids have declined every year since 2011, while deaths from illegally-manufactured fentanyl and from heroin that’s often adulterated with cheap fentanyl so that the illegal seller can make higher profits, have been rising. Mixtures of illicit fentanyl and the toxic wastes created from making the illicit fentanyl, have been dumped into bales of low-grade Mexican marijuana and sold as far north as Ohio, posing a danger to cannabis consumers who do not grow their own cannabis and who live in the 24 states where no form of legal cannabis is yet available.
    Only extremists who deny the reality of pain, would suggest that pain ought to go untreated. Unfortunately, those extremists have seized control of the choice of words we use in discussing addiction issues, twisted the methods by which the statistics are interpreted, and created the view that a Mexican organized crime problem of smuggling chemicals and cooking them into fentanyl and methamphetamine, is instead a US medical problem of doctors not being mean enough to people who have pain. These extremists should not be left in charge of setting pain policy.

  • Simple statement. When Doctors abandon the very simple principle that Pain Is Real, & has severe negative effects on a person’s body & mind, and denys treating such pain, Doctors have failed to obey the very oath they took in becoming Physicians, FIRST DO NO HARM. And by denying Pain is REAL AND MUST BE LUSTEBED TO AND TREATED, and never ignored.
    Not every doctor has the education & training needed for proper effective long term Safe Chronic Pain Mgmt. Care.and that’s why Soecialists in Chronic Pain Care exist as a Speciality.

    This new and very serious crisis of denying the existence of Pain, & to Suspect every every Patient complaining of ongoing Pain should not be ignored but addressed and referred to Managed Pain Care.
    Normally that referral would not be a problem, but thanks to the War On Chronic Pain Mgmt. Care and the patients who
    Suffer in pain and the persecution of the Specislists trained to treat Severe Chonic Pain, we have lost many Highly trained Pain Managemebt Doctors, The CDC 2016 Opoid Guidelines, and I empathize the word GUIDELINES, have created a vacuum in the legal Pain Mgmt field.
    So, you can now say there are two wars:
    One:The War
    On Illegal Drugs
    Two: The War on Pain Patients and each one is creating misery and death.

    We have not made a dent in the drugs, namely Manufactured Illegal Fentanyl, made and smuggled into
    The USA from China & other Countries and 100 times stronger than Morphine, and Heroin, also being smuggled into the United Ststes along with fake copycat narcotics, all being sold on the street, extremely dangerous and many times fatal the first time they are used.
    The War on Drugs has been going on for decades and has been a epic failure.
    The CDC 2016 Guidelines, written by a few CDC insiders and contributors, in a vacuume in secret behind closed doors. The facts supporting these guidelines are horribly flawed and The data has been strongly
    Identified as manipulated and fake.
    The 2016 Guidelines have caused Catastrophic Patient abandonment, false accusations, denial of care in urgent care situations, such as emergency rooms, where patients go usually in distress and pain. Now Patients pain in emergency rooms, post operative surgically care, post trauma long term care from car accidents, burns, trauma even The VA has been negatively effected by this perversion of The CDC on the Statistics used to support the theory that Prescriotion Opids, are fueling the Drug Priblem in much higher numbers than are factually correct.
    Since 2012 statistics and data support that the number of OPOID prescriptions has gone steadily down, not the driving drugs fueling the Overdoses we are seeing now in 2015-2017. We know that Fentanyl is the primary source of OD, Folliwed by Heroin and even pot smuggled ( not legal pot grown locally and safe in
    Licensed Dispensaries) that have been tampered with
    And even dipped in Fentanyl.
    Step One: We demand first the CDC 2016 Guidelines be withdrawn, and all policies and laws driven from the ” Guidelines” must be retracted immediately!
    Step 2: The Need for Addiction Services that is safe, effective and affordable is a absolute and separate from any WAR ON DRUGS PLAN!
    Also we all know prison is not the place for those suffering from addiction can always find their drugs on the street, where Compliant Pain Mgmt. Care Patients, who only use legal Rx meds, must go through Drs, then Ins scruitiny, possibly denial of Rx med and now we have The CDC, abranch of the Gov’t issuing Guidelines for how you as a Doctor, should treat your oatient, someone they NEVER MET BUT YOU HAVE. THEY ARE YOUR PATIENTS!!!
    The CDC is telling The you how to treat or I should say NOT TREAT YOUR SICK AND SUFFERING CHRONIC PAIN PATIENT.. it’s WRONG
    AND DOCTORS NEED TO TRLL THE CDC TO STEP OUT OF MY OFFICE!
    Push back, start a petition re: Dr & Patient Rights should be primary. ALWAYS!!!!
    Step 3: Pain exists as much as some Officials at the CDC WOULD like to have it be a imaginary condition.
    Pain in the acute stage is our bodies way of telling us something is wrong.
    When Pain becomes long term and Chronic it still must be treated so that even though someone has a medical
    Condition that causes terrible pain, they will be able to have a quality of life, be mentally stronger and able to be high functioning citizens who go to work, raise their families, and can participate in things that Chronuv Pain would keep them from doing.
    Quality of life is a right that every human being, no matter their financial status, social position or station in life should be a something that is not being used as a Political Football to gain political power or clout.
    Walk a few steps or spend half a day in a chronic Pain Patients life with no medicine to treat, and only then can you as a Doctor sir, are fit to judge the person asking you for pain medications. If you make the assumption that the patient had been in to see you before in pain and is back that they are drug seekers is wrong. Your physical assessment of this patient was telling you something and you could see the impact of poor or no health and dental insurance. Unfortunately, No one wants to be in long term
    Pain and Chronic Pain Patients, did not get high from their pain meds, they get relief if they are accessed and treated properly. Their bodies may be used to the medications, but so are patients who take insulin, and if they were suddenly ripped off their Meds, they could die.
    Pain must be treated like any other long Term disease and the Treatment should NOT BE IN THE HANDS OF GIVERNMENT OR POLITICIANS OR INSURANCE COMPANIES.
    It should be always in the hands of Trained Licensed Medical Professionals. No one should deny care but care should be available through supportive Pain Mgmt Professionals where they can set up a plan to allow the pain suffering to live the best life that can be attained.
    You as a Doctor know this is your job, not to play judge jury and possibly executioner and to treat every person with respect and listen to what they are telling you.
    If the patient you talked about in you
    Piece, had good insurance to cover expensive Dental Care, so they don’t fall through the cracks and end up in pain, distress, and depression and misery.
    That is a profile of a patient at risk for suicide, in pain denied care with no hope of resolution in site.
    Please listen to these facts, diversion and Dr shopping has all but been eliminated with e-scripts, use of one Pharmacy and the Drug Database. Instead of judging the patient, looking for the addict instead of possibly a person in pain either from disease, bad healthcare, neglect and socio-enconomic circumstances, or a tragedy that was not of their making, such as a accident, Fire, shootings, injuries, and genetic and infectious diseases.
    Simply stated, The CDC guidelines are built to make those in pain to loose their caregivers and medications, and that starts the downward spiral into acute depression, and disfunction.
    Treat the whole person including the Pain, look for the cause and support the Patient as they go through the process of getting answers to the causes of pain.
    This is what a great doctor dedicated to patient care, should be doing.
    And push back against the narrative that had been force fed into your head,” if
    I treat his pain I’m hurting him and red flagging yourself. If you feel confident in your abilities, stand strong with them.
    This is what you can do along with all Doctors being threatened by The DEA of overprescribing. All of this mania, began with some morons at the CDC sitting
    In a room at the CDC WRITING GUIDELINES THAT WERE NEVER MEANT TO BE INITIATED AS LAWS, as the CDC HAD ADMITTED ITSELF. Look
    It up. It’s all there!
    “The devil is in the Data”, Google that in ref to the CDC GUIDELINES AND HOW THEY WERE SUPPORTED.
    You sound like a good caring Doctor, step out of your comfort zone and do the research on the Politics behind the CDC 2016 Guidelines and it will open your eyes.
    Then tell the next physical and the next and think about what these acts have done to Pain care in the last 10 months in the United States!!!
    Trust me it’s a really disgusting twisted immoral tale of power and politics.
    None of that fits in medicine, does it Doctor?

    You the Dr., you Decide.
    Thank you
    Caryn

    manipulated to fit the CDC’s Narrative. Articles and Pain Journals are starting to now focus on the second crisis ” fighting the war on pain” has caused.
    When patients who were under managed care and
    On a carefully titrated amount of opid medication, their lives improved, their functionally improved and the quality of their lives and interaction with friends and family also improve.
    And when, for no valid supported narrative, a Government Agency takes it upon itself to insert Guidelines ( backed by data that is lacking in verifiable supportive facts and honest open between the Doctors, like you who we trust on their own, to make smart reasonable assessments of the patient in front of them,

    • You don’t need to overstate the evidence based literature to drive home your moral argument. I was a specialist in pain management, and my mantra was the familiar: “The Patient’s pain is what the patient says it is.” Around 25 years ago, Pain assessment rating scales became part of a standard vital sign assessment. We began to treat chronic pain aggressively, with opioids, using standards that were based on short-term malignant pain studies of cancer patients. We need better research on treating chronic pain syndromes, and our culture needs to open itself to the notion that treating a chronic pain syndrome and restoring/improving function is a lot trickier than getting a terminally ill patient comfortable.

      I deeply resent the comments from the ED doctors in this forum who believe they bear no consequences for the abuse or the misuse of the prescriptions they write. This attitude invites the interference of the CDC. 65, 000 people in the US died from opioid overdoses last year. Im also going to say that clinicians who choose to work in EDs often find the long term patient relationships of ambulatory care practices cause them to lose a lot of sleep. Easier to put in your twelve hours, practice skillfully for your shift, and let the primary care provider worry about the consequences of addiction and follow up care. In this case study, an ED doctor is an active obstacle to the patient getting the correct treatment for his pain: a dentist appt.

      No wonder we have an epidemic of opioid related deaths; and we are all responsible, regardless of our practice setting, of finger pointing and sanctimonious moralizing while a lot of people die.

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