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Why doctors prescribe opioids to patients they know are abusing them

Why doctors prescribe opioids to patients they know are abusing them

As an addiction psychiatrist, I was recently asked to consult on whether a patient hospitalized for severe low back pain suffered from opioid addiction. The odd thing about the consult was that it was obvious to even the casual observer that the patient was addicted to opioids: Her personal narrative was marked by the classic downward spiral of a drug-ravaged life, including loss of jobs, friends, family, and a recent near-death narcotic overdose; a “CURES” search, which allows authorized health care providers practicing in California to track prescriptions for controlled substances, revealed that in the past 4-5 weeks alone she had obtained prescriptions for more than 1,200 opioid pills; and two psychiatrists on two prior hospital admissions had already documented “opioid dependence”, the formal “Diagnostic and Statistical Manual of Mental Disorders” term for opioid addiction.

So why the repeat-consult to tell the primary team what they already knew? Because the patient’s treating physicians, albeit fully aware that opioids were destroying her life, were uncomfortable denying her opioids for pain and wanted validation that withholding opioids was an acceptable course of action.

As I describe in a New England Journal of Medicine Perspective piece (subscription required), physicians today experience intense professional pressure to prioritize pain treatment above other competing clinical issues. And the reasons are as much cultural and financial as related to the healing arts:

  • Patients now evaluate their doctors on customer satisfaction surveys which can influence professional advancement and national reputation, and doctors who deny patients’ requests for pain pills are likely not to get very good survey ratings.
  • Today’s cultural ethos of ‘all suffering should be avoided’ encourages patients to believe that any level of subjective pain is unacceptable, and that doctors have a responsibility to remove the pain, lest the patient, in addition to being in pain, is psychologically traumatized by having to experience pain.
  • Writing a prescription for opioids is fast, easy, and readily reimbursed by third-party payers, whereas targeting addiction requires time, is complex, and is seldom financially rewarded.

My article goes on the make some recommendations about how these problems might be addressed. But until there’s a cultural paradigm shift in which addiction is acknowledged by patients, doctors, and third-party payers as a disease that inflicts its own kind of suffering and demands its own treatment, the current national epidemic of prescription opioid abuse will continue.

Anna Lembke, MD, is an assistant professor of psychiatry and behavioral sciences at Stanford.

3 Responses to “ Why doctors prescribe opioids to patients they know are abusing them ”

  1. Karen Fahey, MD Says:

    Even addicts have legitimate chronic pain which can be objectified. Note I said legitimate. I did not say subjective, because subjective pain can be of any cause and derivation, and opiates are not the treatment of choice for subjective pain, especially when we are dealing with addicts.
    The most important thing we as clinicians can do is to listen, then document, and then make a decision that is the best interest of the PATIENT…not the clinician, not the employer, not the drug company

  2. Karl Hurst-Wicker, MD Says:

    Dr Lembke:

    I just wanted to write to thank you for your thoughtful piece to the New England Journal. As a physician specializing in pain medicine, I often run across the same type of referrals and patients that you mention above and in your editorial. I find that, sadly all too often, other physicians find it is easier to NOT have the difficult conversation/confrontation regarding a patient’s pattern of prescription abuse and addiction, than it is for them to give them more pills or a referral to a specialist. Unfortunately, by making such choices many physicians end up violating the first principle of being a physician, that to “do no harm”. Giving these patients more of their drugs of abuse or failing to confront them on their behavior/addiction is harming these patients.

  3. Paul bowman Says:

    Dr. Lembke
    Good advice unless you can see an acute pain issue no narcotics for adicts. Example I had kidney stones and screaming in pain they could see them but because I am in recovery they wouldn’t treat my pain. Also opioid addicts should only get 2 days of medication so we are kept safe. But don’t leave us in pain because you think our MAT will also treat any pain we may have. If this happens we would not have to lie and not tell you we are on methadone: if stigma was not so big we could learn to trust our treatment providers.
    Thank you
    Paul Bowman


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