These docs are rewriting the script when talking to patients about opioid addiction

Dr. John Kare introduced himself to his patient, a middle-aged African American woman from Compton, California, and her husband as he sat down to start a sensitive conversation.

The woman was visiting the emergency department in search of relief from her chronic migraines –– migraines that didn’t seem to be lessening, despite the fact that she had become heavily dependent on the opioids used to treat her pain. Kare already knew about her prescription history from reviewing her chart, but as an emergency medicine physician with over 20 years of practice under his belt, he knew better than to insinuate she was simply there seeking drugs.

Instead Kare listened to her symptoms, then took the couple on a journey down to the cellular level to teach them about the source of her dependency. He explained that the problem lay in the pills and their inherently addictive nature. Kare painted a picture of the way opioids can remodel the architecture of the brain’s reward pathways with chronic use. Opioids could in fact worsen the perception of pain over time, a phenomenon known as opioid-induced hyperalgesia. The main takeaway: Her dependency was a result of an explainable biological process, not simply a moral weakness on her part. 

The effect was profound: The patient and her husband thanked Dr. Kare profusely, telling him that over the years she had consistently felt shamed by other doctors she had seen. He was the first to explain the medical basis of her condition and make her feel understood rather than judged for something she felt was out of her control. 

Many opioid-dependent patients routinely experience discrimination in medical settings that makes them less willing to discuss their drug use with providers. It’s a problem that compounds the toll of the country’s ongoing prescription opioid crisis, which has claimed more than 200,000 lives over the past two decades and resulted in an estimated $1 trillion in medical costs and lost productivity since 2001. Addiction experts say there is a growing need for health care professionals to reexamine the way they discuss opioid addiction with patients and rethink how the medical establishment as a whole educates providers on treating addiction. And several training programs are working to do just that.

“Many patients tell me they can’t really bring up their opioid use disorder to their families because they're ashamed, or to their provider, because they feel like they've let not just themselves down, they feel like they've let the provider down,” said Dr. Kevin Sevarino, a Yale-trained psychiatrist and clinical expert with the Providers Clinical Support System (PCSS), a program that trains primary care physicians to better treat and prevent opioid use disorders. “Guilt and shame really play a big part in keeping somebody's substance use disorder sort of under the rock, and if it’s there, nobody can treat it.”

In a news story recently published by Nature, infectious-disease physician Judith Feinberg likened the stigma surrounding today’s opioid crisis to the 1980s HIV epidemic. “People don’t feel they deserve to live. They hear people say it’s a lifestyle choice,” she explained.

The stigma surrounding drug addiction goes beyond making patients hesitant to bring up the issue with doctors; it can actually change the way physicians interact with those patients. Sevarino points to a 2009 study that surveyed over 500 clinicians about their attitudes toward patients, described as either “substance abusers” or individuals with a “substance use disorder.” While the effect was small, when clinicians perceived a patient as a “substance abuser,” they were more likely to believe the patient was to blame for their disorder, made reckless decisions and deserved punishments such as jail time. The findings suggest that the language used to describe opioid-dependent patients can influence how doctors interact with those patients and approach their care. 

“The reason why it’s important to frame a lot of addiction as a chronic brain disease is to medicalize it for physicians and other providers, in a sense, so that they don't take this pejorative moral view of it,” Sevarino said. “I think when physicians think about something as a disease, they're less likely to view that person negatively.”

Kare, the emergency medicine physician, adds that doctors must recognize their own role in the opioid crisis. “People come in with pain, we want to relieve their pain, we give them medications, and then they become dependent on them, and then become addicted to them, and then eventually start abusing them.”

The problem is exacerbated by the fact that most doctors don’t get adequate medical training to prevent or manage addiction.

“I'm surprised at how many prescribers nowadays actually have a hard time figuring out whether the benefit (of an opioid) outweighs the risk and when it doesn’t, how to talk to their patients in a humane way and how to convince them that they need to come off this, and then how to taper them off it — as opposed to just saying, ‘I'm not going to give them the opioid anymore,’" Sevarino said. 

He explains that medical schools offer little if any formal training in addiction treatment, and psychiatry residents are only required to have four weeks out of four years of schooling dedicated to addiction. Sevarino argues for more training for all health care providers, not just doctors, on how to treat addiction.

Joseph Skrajewski, executive director of medical and professional education at the Hazelden Betty Ford Foundation, has dedicated his career to this goal. He has a unique perspective as both an expert in addiction treatment and a former patient. Skrajewski was a financial advisor at Morgan Stanley in New York City’s World Trade Center, and following 9/11 he struggled with alcohol and substance addiction before going through recovery, returning to school and earning his license as a marriage and family therapist. 

“The reason why it’s important to frame a lot of addiction as a chronic brain disease is to medicalize it for physicians and other providers, in a sense, so that they don't take this pejorative moral view of it. I think when physicians think about something as a disease, they're less likely to view that person negatively.” — Dr. Kevin Sevarino, Providers Clinical Support System 

Skrajewski points to a 2012 report showing that medical schools generally only provide a handful of hours of education on addiction throughout a four-year curriculum –– a statistic that he finds alarming given that addiction affects anywhere from 10% to 16% of the population. The report also explained that this training deficit is compounded by inconsistent approaches to treatment among health care providers. 

Skrajewski says many medical students enter the clinical setting with perceptions of addiction based on dramatized cases they’ve seen in movies or on television. He adds that most people struggling with addiction also hold jobs, raise families and lead lives not mirrored by the extreme situations portrayed in the media. Yet providers sometimes use pejorative terms to describe such patients.

“A lot of times people will use terms like drug seeker, which I hate, and then I’ll redirect them and tell them, well why not use terminology like relief seeker? I mean, isn’t that a much more positive, bright type of language? That really could change the conversation,” Skrajewski said.

He offers some additional suggestions for how doctors can handle conversations with patients they sense are dealing with opioid addiction.  

Doctors might start a conversation by asking what opioids help the patient accomplish, followed by asking what the opioids prevent the patient from doing. After asking those questions, Skrajewski says he often follows up with a key statement: “Tell me why you really came here.” This prompts patients to open up and elaborate on their current needs. He continues by asking patients to describe their first times using opioids and their most recent times, the juxtaposition of which can give a sense of the scope of their dependencies. 

To help medical students better conceptualize the realities of dealing with addiction, Hazelden Betty Ford offers a summer program that trains 195 medical students from 115 medical schools who visit either the foundation’s California or Minnesota locations for a five-day course. The foundation offers additional educational opportunities for doctors in medical residency or mid-career physicians who never received in-depth education on addiction treatment during their training. The goal is to teach doctors to view addiction as a disease rather than a choice, Skrajewski said.

Doctors routinely face difficult situations when treating cases of opioid addiction, from drug-dependent patients becoming angry or abusive when doctors refuse to prescribe additional narcotics, to the lack of time in their busy schedules to devote to such cases. Kare believes the best approach is to view the encounter as an opportunity to help a struggling patient, and to treat potential addiction cases with the same consideration as any other disease. 

“I think just having the mindset that every patient that comes to see you has a problem that you want to help them resolve, and really approaching every patient with a love and desire to help them without judgment — I think that’s important,” Kare says.