Read the article
To the OFP Editor:
This letter will hopefully encourage colleagues to consider becoming more empathetic towards patients suffering from opioid addiction. After 24 years in private medical practice, I admittedly had developed a general disdain and cynicism for patients with addictive behavior and issues based upon my own experiences. Over the years, I had been duped, taken advantage of and robbed by patients suffering from addictions. But all that changed after I closed my practice to accept a teaching position in my specialty of neuromusculoskeletal and osteopathic manipulative medicine.
Due to a state and community-wide need for doctors in addiction medicine, the department I joined suddenly expanded to include chronic pain of all kinds and, as a teacher of musculoskeletal medicine, I was recruited as well. Though deeply skeptical, I moved forward with the department training and obtained my X-Waiver certification. Our practice makes every effort to keep patients despite contractual violations and has resources like intensive outpatient programs (IOPs), inpatient, ER and other options readily available. We started partnering with regional law enforcement to serve and care for our community and region, including the neediest and indigent. Additionally, we worked with federal grants to assist when available. Since joining the practice, my assumptions and prejudgments about our patients have all but disappeared.
The impact of a particular patient encounter helped reshape my thinking about the opioid crisis both personally and professionally. Earlier this year, my office was approaching closing time when a staff member informed me of a colleague’s 42 year old female patient who was on the phone frantically begging to come in to refill her Suboxone® prescription. Attempting to comply with our strict office policy and standard opioid contract, the patient was already racing to our office for the mandated in-person visit. When you take a patient’s history to learn what led someone to get to this point in their life, it is intellectually compelling as well as incredibly humbling. Each new patient I see with an addictive or pharmacologically compulsive past reveals a truly thought-provoking history regarding how they arrived at this particular time and place. I am required to ask a detailed query regarding patients’ prior drug-of-choice; how they initially received the opioid; if it came with an official prescription (most of the time) or illegally; how much money they spent at the peak of their usage and how they obtained the drugs. Overwhelmingly and most unfortunately, the patient’s story begins with an iatrogenic cause, but then indeed, a physician suggested an opioid initially before anything medically progressed. Subsequently, the patient begins spiraling downward.
My patient begins telling her story. She was only 16 years old when a gymnastic injury landed her in the family physician’s office. This doctor referred her to the local orthopedic surgeon concerned she fractured her pelvis and handed her mother a script for 'pain meds' — Oxycodone. Over the next few years, other doctors continued prescribing her more and more opioids. At the height of her addiction, the patient took approximately 30 tablets a day of either 10/325 Oxycodone/Acetaminophen or Oxycodone HCL 10 mg and sold the excess to help pay for her habit. She stole money from her household and nearly destroyed her marital relationship, until her family’s intervention sent her to an inpatient rehabilitation program. Over the next seven-plus years, they enlisted a new family physician, social workers and clergy who all helped guide her from the inpatient program to intensive outpatient programs and eventually to our outpatient detoxification program.
Our state-run detox program offers Suboxone® in a carefully regulated medication-assisted treatment center, along with a comprehensive adjuvant non-interventional pharmacologics, psychological and psychiatric staff, referrals to aqua/land physical therapy, unique adjuvant options such as osteopathic manipulative treatment (OMT) and diagnostic workups including imaging, EMG/NCVs. We also have supportive staff comprised of experienced recovery experts to help guide and positively reinforce patients as they traverse through outpatient rehabilitation.
Because of our program’s training and support, I could accept this patient before me without judgment. She expressed through her tears how grateful she was to have someone take the time to get to know her. This experience left an indelible impression on me and helped redefine my preconceived notions. My primary care training taught initial rapport-building interview skills with various open-ended techniques. Moreover, my private practice experience and OMT's unique hands-on skills helped build compatibility and trust with these patients.
More than ever, during this opioid crisis, physicians should be making an effort to understand the mindset of a new generation of the pharmacologically dependent patient population with an addictive mentality. As physicians, an empathetic approach ensures we are truly providing comprehensive treatment for our patients.
David Abend, DO
Assistant Professor, Department of Osteopathic Manipulative Medicine, Rowan University School of Osteopathic Medicine, Stratford, NJ Board Certified, Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine
Board Certified, Family Practice and Osteopathic Manipulative Treatment