Some patients are in pain, some just want drugs. How do doctors tell them apart?

By Elliot Bullman

The opioid epidemic has forced doctors to become lie detectors.

Patients in pain present a daily conundrum for physicians. Each one is set against the backdrop of epidemic opioid misuse in the United States.

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Overdose deaths have tripled in the past decade, and addiction has grown into a full-fledged societal calamity fanned by over-indulgent prescription pens. Now doctors are pulled in opposite directions by an individual’s pain and a society’s crisis.

Should doctor’s prescribe opioids or not?

The mental seesaw has become a familiar part of the medical profession, one made worse by patients feigning or exaggerating pain to receive painkillers. Some seek a buzz; others want a fix for opioid withdrawal, itself a painful and unpleasant condition. Some are “opioid refugees,” cut off by their primary doctors and migrating from one ER to the next in search of a doctor benevolent or gullible enough to grant a prescription.

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The presence of drug-seekers in virtually every physician’s practice today has tainted medical professionals thinking, casting doubt over clinical instincts to relieve suffering and making doctors suspicious of pain.

ER doctors are tasked with differentiating the life-threatening from the harmless. They waver between the emotional tug of agony before their eyes and a rational view of public health emergency. Sometimes it feels empathetic to give pain meds; other times empathy demands withholding them. Even when convinced that a patient is lying.

Every physician practices somewhere on a spectrum of opioid permissiveness. Some flog their patients with powerful painkillers from the first “ouch,” while others virtually never give in.

It’s difficult to prove that pain exists and even more difficult to disprove it. Inherently private, pain is a subjective scream of neurons that no one else can hear.

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By 2005, the approach to pain had changed; aggressive treatment had become the standard of care. The rate and number of opioid prescriptions began climbing, and peaked in 2012 with more than 255 million, at a rate of 81.3 for every 100 people in the United States.

But today, in response to the epidemic, there is a danger of returning to where we were in the ’90s, to the callous undertreatment of pain. Debate rages among physicians, as well as inside each doctor’s head, about when and in what amount opioids are appropriate, but there is little consensus.

One study of emergency room physicians and their prescription processes revealed how many factors influence doctors’ decisions to prescribe, including concern about addiction, their personal medical experiences, pressure from state legislators to curb prescriptions and even worries over patient satisfaction scores — some physicians feel administrative pressure to prescribe opioids more freely in order to improve scores.

The healing power endowed by the federal Drug Enforcement Administration to physicians brings great responsibility but not much insight into discerning disease from drug-seeking. Opioids are the nuclear power of painkilling, and their misuse similarly brings death and destruction on a national scale.

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