Opioid crisis: The difference between sympathy and empathy

Monique Tello, MD, MPH
Monique Tello, MD, MPH, Contributing Editor

Follow me at @Drmoniquetello

I was on call. I looked down at my pager and saw that dreaded message:

Patient running out of pain meds needs immediate refill please call.*

Ugh. More often than not, the phone call that follows this page is full of excuses, explanations, promises, and demands. This one was no exception:

So sorry to bother you, I know you’re only covering. My doctor prescribes me oxycodone for my back pain. It’s horrible pain that I live with. I’m on disability for this.

But my niece was visiting last weekend, and I lifted her up. I shouldn’t have done that, I know! I wrenched my back bad, and I’ve had to double up on my pills, so I’m going to run out a week early.

I’m going to need more pills than usual, since I threw my back out. It REALLY hurts. If I could get twice the normal number that would be great.

I swear I don’t even like to take this stuff unless I really have to! I hate taking pills! My doctor knows I don’t abuse this stuff.

The whole time, my stomach was twisting, my gut instinct practically screaming FRAUD LIES SCAM RUN AWAY, but there I was, on the other end of the phone — and on the hook to deal with this.

In the past few years, laws and guidelines around prescribing opioid pain relievers have changed, and for the better. My own hospital issued requirements and guidelines around opioid prescribing for physicians in January 2014. Since then, for any calls like this one, I now need to check the patient’s record for the signed controlled substance contract on file, and then review their recent drug and toxicology screens. At my hospital, all patients on chronic narcotic drugs are required to have a contract on file, and a minimum of yearly urine drug screening. That urine test had better show only the prescribed drugs, and no illicit ones; any aberrance could result in a cancellation of the prescription, fair and square.

In addition to that, in March 2016, Massachusetts signed into law numerous requirements for doctors, including mandated review of the Prescription Monitoring Program (PMP) database before writing a prescription for any narcotic for any patient. The PMP lists every single narcotic prescription filled by anyone anywhere in the state, when it was filled, and who prescribed it. I can tell at a glance if someone’s been receiving scripts elsewhere, also known as “doctor-shopping.”

So, while this patient pushed hard for her early refill of a double prescription, I checked the data. In this case, the data were on my gut’s side. Yes, there was the signed contract that clearly stated that the patient would not ask for early refills, and would only get refills from their usual provider. And there was recent drug screening that did not show any oxycodone, but did show THC (marijuana). The absence of the opiate reveals that the patient is not taking it regularly, and diversion should be considered.

There it was: the decision on whether or not to prescribe was taken out of my hands.

Still, this is not a pleasant conversation to have. I calmly explained to the patient:

I’m sorry, but your request and your drug testing results are not compatible with our mandated prescribing guidelines. Therefore, I cannot prescribe this for you.

Needless to say, this was not well-received. The patient expressed outrage and defamation. She was going to complain to the hospital administration about me.

She described all the reasons why the testing may be incorrect. And then insisted that all of this had already been cleared with her doctor.

Then came blame, guilt-tripping, drama:

I’m in so much pain. What kind of a doctor are you, that you can leave someone like me totally stranded here, in pain? I’m suffering. You don’t know what it feels like to have this pain. If you had this pain, you would be begging for medication, you know it. 

I stuck to my line, quietly, firmly. It went on and on. I did not budge.

Then, very suddenly, there was a change in the patient’s tone. There was a higher pitch, a desperate crack in her voice:

Okay. You don’t understand. I have two kids, I’m on my own, and I’m having money troubles. I need all the income I can get right now, just to put food on the table, to put lunches in the lunch boxes. I don’t need this from you right now. Okay? Can you just fill my prescription? 

I understood right away that this patient was almost admitting that she was, indeed, selling her pills on the street, for profit. She had likely come to depend on this income. And I was shutting it off.

When I repeated again why I could not fill this prescription, the lady railed at me, called me several choice expletives, and hung up.

While I did not feel sorry or sad or bad about not filling the prescription — it would have been illegal for me to do so, with proof of likely diversion — I did have a glimpse of understanding of where the patient was coming from.

I could picture the squalid apartment, the almost-empty refrigerator, the kids in Goodwill clothes, the landlord demanding the rent. I could hear her frustration with everything: fighting with the ex for alimony, waiting in line at the food pantry, relatives turning their backs. I was touched that she had come that close to a full confession, to revealing a painful and shameful truth.

And that is the difference between sympathy and empathy: sympathy would have been feeling sorry or bad or sad. Empathy is to have a better understanding of where she was coming from, and from that, to feel… a sort of kindness. I was able to come away from the encounter without judgment, and forgive.

There but for the grace of God go I.

It didn’t make what she was doing alright, and it didn’t change my management. I was more than happy to get a few oxycodone pills off the street. Heck, I couldn’t even wait to get off the phone and be done with the whole unpleasant experience.

But I had been given a snapshot explanation of why she was who she was, and what would make someone do what she was doing. With that understanding comes empathy; and when you’re trying to take care of another person, empathy makes all the difference.

Based on an essay originally published Sept. 24, 2015 at www.generallymedicine.com

*All messages from patients in this article represent a composite of cases. Any characteristics that could identify a specific person have been omitted or changed.

Comments:

  1. A Reader

    Though the topic is the “Opioid Crisis”, the doctor detects that the patient’s story is about something else, about economics. In her dedication to relieving pain and suffering, what antidote should a doctor have to counter poverty? What resources does her hospital provide against a patient’s chronic lack of income?

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      Sadly, there is not much we can do to directly treat poverty. We do, however, have access to a team that can help a patient find resources when needed (i.e. meals on wheels, low-income housing, other community resources). The patient has to be open to this and receptive when they call, however.

  2. Cynthia

    My beloved, smart, handsome 23-year-old son died of a heroin overdose three years ago. His addiction started with prescription narcotic pain pills that he bought on the street, before he advanced to heroin use for the last two years of his life. I commend Dr. Tello for making the “tough call,” a composite scenario she used in her article for illustrative purposes. She is showing how policy and doctor’s specific actions can combine to help reduce the available street drugs, while still effectively treating legitimate pain experienced by patients. I would give ANYTHING for those illegal pills not to have been so readily available in our nice, little town in upstate New York.

    • frank harris

      I hate to say this ….however …your son “CHOSE” to use drugs…..no one forced them into his mouth
      America has turned into a country where no one takes thje responsibility or the blame……..
      IT IS THE PARENTS THAT NEED TO TEACH THEIR CHILDREN………

      There is NO OPIOD CRISIS…..this is a contrived , made up story…
      MORE PEOPLE DIE OF REGULAR PRESCRIPTION BP PILLS, and OTHER NON-CONTROLLED MEDS THAN OPIATES BY FAR…..JUST LOOKIN THE INTERNET FOR PRESCRIPTION DRUG LAWSUITS

  3. Misty

    “That urine test had better show only the prescribed drugs, and no illicit ones; any aberrance could result in a cancellation of the prescription, fair and square.”

    Why are we treating patients like criminals? Oppoids have been over prescribed and when the doctor realizes their patient has become an addict, they drop them. No more drugs for you. The doctor should take responsibility for the addiction they facilitated. Their patients are not “bad patients”. They are people who are biologically prone to addiction and the doctor is responsible for treating that MEDICAL problem.

    I am glad that you are bringing awareness to this issue, but I think you should reconsider the way patients are treated when they become addicts. One solution may be to push for education on addiction during medical school (now non-existent).

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      Hello Misty, Thanks so much for reading and for your thoughts. You are correct, and we do offer an opiate taper and addiction treatment when the concern is for addiction or abuse. But in this case that was not the concern, the concern was for diversion, or selling, of the medication.

  4. Robert Morris

    Absent from this article is the discussion is whether OxyContin etc. is even appropriate today. As I understand ibuprofen in combination with acetaminophen can provide similar results.
    The epidemic can be well traced back to big pharma plus physician prescriptions. I refer to my own rotator cuff surgery and 68 tablets of OxyContin prescribed. I took two!
    Anecdotal yes! Factual yes!!
    R Morris DDS MPH

    • Maria

      I absolutely agree. It was shocking to me that my 12 year old son was administered Oxycontin after surgery after we (the parents) explicitly voiced our desire for alternative pain management and making sure that his pain was feasible. He was also discharged with a prescription for the same drug in similar size which we never found necessary to fill.

      My 23 year old nephew was prescribed Oxycontin after a routine dental treatment and I received a prescription for Percocet after a root canal. Neither one of us had asked for these pain prescriptions nor did we fill them. Also a fact.

    • FRANK HARRIS

      NO TYLENOL OR NSAID WILL EVER OR CAN EVER TAKE THE PLACE OF OPIATE MEDICATIONS………THIS IS A FACT>>>>>>
      ANYONE WHO BELIEVES DIFFERENTLY WHEN YOU HAVE SEVERE PAIN TELL YOUR DR YOU JUST WANT TYLENOL….(TYLENOL HAS MANY MANY ADVERSE SIDE EFFECTS BY THE WAY)……….

      THERE IS NO OPIOD CRISIS …THERE IS A “DUMB’ CRISIS !!!!
      AND THERE IS A MEDIA SWAYING THE PUBLIC CRISIS.!!!!

      GOD PUT THE OPIUM PLANT ON THIS EARTH FOR A REASON….AND NO ONE HAS THE RIGHT TO “control” IT !!!!

  5. Blake

    This is a classic case of the American pendulum: always swinging from extreme to extreme without even slowing down to peruse the middle ground. Here are some of the unstated facts the precipitate this situation.
    1. For how long have doctors, in liege with drug companies, OVER PRESCRIBED medications? Indeed, doctors created the addiction by giving people too much medicine, for too long, without any oversight.
    2. Who’s pain needs to be managed? From the outset of the story, one knows that this patient is not wealthy- she’s not calling a personal doctor with whom she has a relationship that guarantees her needs will be addressed. In this story, the doctors fears of poverty motivated drug seeking behavior are confirmed: is that sad or ironic or revelatory? Unfortunately we know that doctors do not treat all patients equally.
    3. We are not even employing the best possible techniques for matching drugs to patients. Instead, docs prescribe ‘popular’ drugs, which just so happen to create astronomical profits… We know that different medications effect people differently, thus a doc could prescribe something that should but does not help a patients pain. In that case, would this poor lady get the benefit of the doubt? Would a doc say, maybe the meds I gave aren’t working or would they say you’re just subsidizing your illicit drug habit? Btw calling marijuana illicit is laughable, it is after all medically prescribed to help people’s pain in many states… perhaps this person used it because it was cheaper than taking the pills but still helped her pain?!?
    Ultimately, we need to reach a middle ground between pill pushers and pain promoters (Doctor as sadist). Do we have a drug problem? Yes!!!! But when I go to the doctor after surgery, for which he gave me 2 days of meds, he should never ask me to justify why does it hurt. I mean, dude, you cut me open!!! After 3 complaints, I was told yea it’ll probably hurt for 4-6 weeks. How is that pain management???? I guess, I’ll just manage having pain

  6. Delise Dickard

    I work in the mental health field and I have many parents coming to see me because their child got addicted to heroin via pain killers. It is very sad! Thank you for the post.

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      You are welcome- I also see many parents who have addicted children or have lost children to overdose among my own patient population.

      • James Marshall

        This needs to be said. However, with the crisis situation as it is today, you are exposing yourself to physical confrontation by revealing your identity and a picture of yourself. Your response to this case is encouraging but opens you up to the phenomenon of “road” rage from the person whom you turned down. Please be careful!

    • frank harris

      THAT THE CHILDREN GOT ADDICTED TO PAIN MEDS …..I ASK YOU

      WHERE WERE THE PARENTS WHEN THEIR KIDS WERE GETTING ADDICTED”

      WHERE WERE THE PARENTS WHEN THE KIDS WERE GROWING UP??

      THE PARENTS HAVE A BIG RESPONSIBILITY ON TEACHING AND GUIDING THERE KIDS ABOUT DRUGS…..STOP BLAMING SOCIETY…..SOCIETY IS NO ONE AND NOT TO BLAME.

  7. F COHEN

    The DEA and the Government have NO RIGHT to monitor peoples’ prescriptions…
    More people DIE FROM NON – CONTROLLED MEDS every year than from OPIODS……. …WHY ARE GOVT AGENTS AFRAID THAT PEOPLE
    “MAY FEEL GOOD”………..
    Many DRs are only concerned about their licenses and prescibe pain meds for months and years then STOP because of an inane idea that they read in a journal stating that “OPIODS” ARE BEING OVER _ PRESCRIBED !!
    It is true more die from RX drugs than C-iii or C-ii meds every year….way more people ,,,however you hear NOTHING about this..

    If the controlled media would stop publicizing “OPIODS” and relating the GREAT HIGH THAT YOU GET …and MORONIC TV SHOWS like INTERVENTION would be banned we would have a safer public…

    JUST LOOK AT HOW MANY “TREATMENT CENTERS ” OPENED in the last few years …all owned by people who fight hard to ban prescription opiods…what will they do when everyone is “CLEAN” …start selling “OPIODS” AGAIN…..
    ALL ADULTS HAVE THE RIGHT TO ANY MEDICATION THE YFIND EFFICACIOUS…… THE DEA HAS STOPPED LEGAL PEOPLE , MYSELF INCLUDED , FROM HAVING THE PHARMACIES FILL RXs for C-IIs..
    and scared the pharmacists from filling them even if you have a legitimate RX.

  8. Kathy

    Someone who is not addicted and acquires drugs to sell to others who are addicted and/or to get them addicted are pretty much bottom feeders and your empathy and then kindness is misplaced.

    Empathize with the non-addicted person made to feel creepy because of the pharmacist looking warily back at them because that prescription you gave them to fill is for an opioid medication.

    Many patients end up pain medication addicted after being handed a prescription.

    None of this makes that phone call easier to deal with but it does show that even physicians are affected by of abuse of opioids.

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      The whole situation is very difficult, and very sad.

    • Lonia

      I agree with Kathy, working in the services field I am able to see all kinds and levels of addiction. The last thing needed is a medical provider who is sympathetic to a person selling drugs that are so highly addictive and may quite possibly result in other criminal acts or death.
      America’s children are dying every day. Many of these young people stated their addictions started with pain pills… A trip to the dentist or the ER.
      We need to Wake Up to the reality that is out there on the streets in every town in our Nation.
      The addiction is also alive and well, thriving in our hospitals where babies are being born addicted, suffering through unimaginable pains of withdrawal. They are born addicts, born from mothers who are so addicted to opiates and other drugs that the life of their unborn baby mattered only second to the addiction.
      Please, consider the many lives attached to your patients that are affected by decisions being made by medical providers every day.

      • frank harris

        i HAVE WORKED IN THE MEDICAL, PSYCHIATIC, SUBSTANCE ABUSE FIELDS FOR OVER 30 YEARS NOW…..

        IT NEVER HAS BEEN THE FAULT OF PAIN MEDS THAT ADDICT CHILDREN BECAUSE CHILDREN DO NOT GET PAIN MEDS FROM DRs…..
        and if they did …..where were the parents?????

        THIS WHOLE CONTRIVED CONSPIRACY AGAINST OPIATES IS ABSOLUTE NONSENSE AND A WAY TO BLAME SOCIETY AGAIN INSTEAD OF THE PARENTS AND THE IMMORAL COUNTRY WE NOW LIVE IN…BLAME THE FACT …BIBLES ARE BANNED AND PRAYER IS BANNED IN SCHOOLS
        BLAME THE FACT WE HAVE MANY MANY 1PARENT HOMES WHERE KIDS DO NOT GET THE GUIDANCE, LOVE AND DISCIPLINE THEY REQUIRE AND NEED TO GROW UP TO BE A RESPONSIBLE TEEN AND ADULT….

        BLAME THE MOVIES THAT SHOW SO MUCH VIOLENCE AND RAW SEX THAT IT IS THESE PEOPLE THAT SHOULD BE SINGLED OUT AND “STOPPED” FROM POISONING OUR CHILDREN….

        SHOWS ABOUT ALL KINDS OF IMMORAL BEHAVIORS ,,,,,I WONT MENTION WHAT OR I WILL BE CHARGED WITH “HATE” CRIMES …
        THIS IS WHAT IS DESTROYING THE FABRIC OF AMERICAN SOCIETY JUST AS FAST AS WE CAN…

        WE KNOW IT…THE POLITICIANS KNOW IT ….AND NO ONE DOES A THING TO STOP IT…………OPIATES ARE NOT TO BLAME…WHAT NONSENSE

  9. Cat

    It saddens me that your very first instinct is to mistrust a patient. Since the new guidelines I live with undertreated pain daily. I have SLE, RA, CKD, lumbar radiculopathy, Chiari Malformation, COPDand FM. Because of my CKD I can no longer take Celebrex. My new pain “management” Doctor reduced my OxyContin from one long acting 20mg twice per day plus Vicodin as needed for break through pain to 10mg 3X per day. I am a 60-year-old woman on SDI. I worked hard on a concrete floor in an unheated warehouse on the coast of the Pacific North West. It is very upsetting to know that I will feel this much pain or worse for the rest of my life just to keep me from becoming an addict. Statistics show doctors are more likely to be addicts than their patients are, yet they are managing our pain medication. In the waiting room of the pain clinic we talk. Four people (2 couples) have told me when the pain gets too bad they will kill themselves. Experts expect heroin use to rise in response to the new restrictions. How will those new types of “epidemics” be handled? Where is the compassion and logic?

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      Cat, your situation sounds incredibly difficult and my heart goes out to you. My suggestion is to form a relationship with your provider. I do have patients on high doses of pain medications for reasons similar to yours, because I know them well and they have followed the pain medicine contract without any issues for years. Of course I would have no problem providing refills for any of those patients. The patient in this story was certainly not following the contract, and had failed drug testing as well… Your comment reminds me, however, that I need to also present the case of patients like you who are deserving of better treatment for pain.