Reflective Practice 401 – Addiction

Background

In 2012, 259 million prescriptions for opioids were filled in the US – enough for every adult in the US to have a bottle of pills. Rates of opioid prescribing have increased by 7.3% from 2007 to 2012, with the most rapid increase occurring in primary care. In 2013, 1.9 million people in the US abused or were dependent on prescription opioids; 6.6% either abused or was dependent on alcohol, and 4.2 million were dependent on or abused marijuana. At the same time, as identified by the Institutes of Medicine, a large number of patients who have pain are underdiagnosed and untreated, something that disproportionately affects racial and ethnic minorities; people with lower levels of income and education; women, children, and older people; military veterans; surgery and cancer patients; and people at the end of life.

Physicians, particularly primary care physicians, enter medicine with the desire to help patients, alleviate suffering, and restore health. Perhaps for this reason, addressing situations in which we have a concern that one of our patients has become addicted to a substance and that patient disagrees and reports the need for pain relief can be quite challenging. Often we feel manipulated by the patient, and impotent to offer them anything meaningful that will help restore their health. One common response is to resent these patients and avoid them. Another is to tell them they are wrong and need to just stop. Both of these responses further ostracize the patient from the care and therapeutic relationship they need.

As we think about this topic, it is critical to recognize that while some perceive addiction to be a consequence of a “weak will”, resulting from poor choices, others identify addiction to be an illness. While it might be reassuring to believe that one’s perspective on the topic is borne out of proven scientific inquiry, the fact that we understand addiction poorly strongly suggests that our perspectives have more to do with our personal contexts (the experiences over the course of our lives) than with science. As such, we potentially enter a physician-patient relationship with long held biases and assumptions that may or may not pertain to the individual patient for whom we are caring at a given point in time.

Assignment: Come to the small group prepared to discuss the following: 

1. Reflect on a patient encounter you had with a patient you were concerned was struggling with addiction. What were the circumstances surrounding this visit?
2. Describe the emotions you experienced – when preparing for, during, and after this encounter.
3. In what ways (if any) was this interaction similar or different from those you have had with other patients who reported similar symptoms?
4. Do you feel you developed a therapeutic alliance with this patient? If so, how did this develop; if not, what did you do/not do that might have impeded this from happening?
5. What do you think you might do in the future if faced with a similar situation?