Story seduction and the opioid crisis

May 11, 2016

It was Saturday evening and Audrey G lay awkwardly on an emergency department stretcher in search of a comfortable position. She suffered from chronic hip pain, the unfortunate and unexpected effect of pelvic surgery. But her real chief complaint involved her drug-abusing husband, who that morning stole her recently filled bottle of oxycodone, an opioid pain medicine. Her story included the surgeon who doubted her pain and a year of failed therapies. Now only oxycodone touched the pain, or so she said, fighting back tears. The on-call physician didn’t know her and said to go to the ER.

Any decision that involves prescribing an opioid asks that I pivot in a space mined with judgment and peril. Studies show that four of five new heroin abusers began their habit by abusing painkillers, and opioid painkillers and heroin have a heavy hand in the 47,000 lives lost prematurely in a single year from drug overdoses.

To be an emergency physician requires, first and foremost, being a skilled story listener. Before I can fashion a response or formulate a plan, I must first understand the patient’s story. This isn’t earth-shattering news. Humans, a group that includes both physicians and patients, have been using stories for thousands of years to communicate, connect and forge relationships.

However, when the Centers for Disease Control and Prevention recently published opioid prescribing guidelines to stave off the tragic march of addiction, overdose and death, they didn’t address the critical forces at play in my clinical practice — the power and seduction of stories and their capacity to influence behavior. Their well-reasoned recommendations ignored opioid prescribing as a narrative problem.

When pain is a subjective experience best appreciated and understood through the patient’s story, my emotional connection to the story is often a factor in my response.

The physicians and nurses involved in the care of Audrey G were emotionally moved by her story. How could we not? Audrey G wasn’t simply a patient in pain, she was a petite woman who endured powerful antagonists with quiet dignity. Substance-abusing husband, hints of domestic violence, chronic pain the result of a mysterious surgical event. She didn’t blame the surgeon. All she asked for was recognition that the pain wasn’t in her head, and at this moment, to be spared of pain.

What to make of the stolen pills?

Every emergency physician has been duped by a patient claiming stolen pills or the lost script. Red flags that raise the suspicion for “doctor-shopping” include allergies to non-narcotics, a requesting a narcotic by name, a history of multiple visits for the same complaint or documented substance abuse problems, and a weekend presentation to the ED.

Over years of clinical practice, these red flags aren’t intellectualized, they’re felt in my bones. Even so, when Audrey G asked for Dilaudid, a strong narcotic, especially when given intravenously, concern for addiction or abuse didn’t register like it often does with other patients.

I wasn’t in a position to judge her because I was too busy participating in her story. A good story has a way of dodging or beguiling analytical thought.

In her book The Confidence Game,  Anna Konnikova delves into the sneaky ways story can work its charms. This occurs without our knowledge, and sometimes against our better judgement. Once invested emotionally in a story, the listener becomes drawn in, and whether the story is believable matters less. In fact, the more extreme the story, the greater is its capacity to enthrall the listener or reader.

Audrey G’s story was extreme for sure, but in emergency medicine, every time you pull back the curtain, introduce yourself and ask ‘how can I help you, today,’ there’s a fair chance the response will be a story throbbing with life.

Unfortunately, data and scientific evidence, even those as devastating as the opioid statistics mentioned earlier, serve as a poor antidote to story. Data must earn its validity, methods must pass scrutiny. Even then it might not feel true.

False or inconsistent notes matter less when folded into an emotionally engaging story. Scientific research lifts the curtain on this narrative-neural wizardry. Research using brain fMRI reveal how a coupling develops between the teller of a story and its listeners, whose brains respond to a story as if experiencing it firsthand. A dramatic story may also influence behavior by stimulating the release of the neurochemical oxytocin, which has ties to mother-infant bonding, generosity, and trustworthiness. The very empathy that physicians are often accused of lacking may serve as a point of vulnerability for the stories patients tell us.

Which may explain the deep hurt that cut through us when Audrey G’s old records revealed a distant history of drug abuse. It didn’t matter that combing through state prescription monitoring program failed to uncover past red flag behaviors. Once doubt entered, we were thinking about her story and no longer participating in her story.

Pain is the most common complaint that drives people to the emergency department. Objective, expert guidelines are an important step towards responsible opioid prescribing habits, but to apply them appropriately we cannot forget that the the road to understanding pain and our responses to it are paved with stories. Story-education belongs alongside other formal steps as the opioid crisis forces physicians, patients and families onto unstable ground.

Strangely, oxycodone wasn’t my focus when caring for Audrey G. Her pain severity–whether it was 5 out of 10 or 10 out of 10–bore little influence, either. It was the context of her pain, the story in which her pain was embedded. A story of hardship, where people dismissed her suffering, or put their own selfish needs first.  

Was I duped? Was Audrey G an addict? Was she in cahoots with her husband? I cannot say. I only know that her story possessed enough truth, at that moment, to move me emotionally to relieve her pain–a prescription for ten pills, enough to hold her through the weekend. It moved me to shape a different story, hopefully a better one. But I don’t know.

 

 

Jay Baruch (@JBaruchMD) is Associate Professor, Department of Emergency Medicine at Alpert Medical School of Brown University, as well as a writer, baffled participant in healthcare, and shameless advocate for more creativity in medicine. What’s Left Out is his latest fiction collection.


Writing and an emergency medicine life

April 3, 2016

I’m an emergency physician and a writer of fiction, and there is an inherent paradox in these two activities. When writing, I work with words on a page to create lives that readers will hopefully care deeply about. Meanwhile, when I’m working in the emergency department, there are moments when I’m faced with real people experiencing real suffering and I wonder why I don’t care more.

The great writer Tobias Wolff once said, “When I sit down to write, I discover things that I have, for one reason or another, not admitted, not seen, not reflected on sufficiently.”

And that’s the essence and beauty of writing, whether it’s writing fiction, an essay, or random notebook scribbling. By laying down words into sentences and sentences into paragraphs, I find myself thinking differently, making previously unseen connections, and discovering untended fears and blemishes. Read the rest of this entry »


Cool Under Pressure

March 8, 2016

Cool under pressure. The best emergency physicians are cool under pressure. That was me – or so I thought.

One day this past winter, while stepping out of a shower, I noticed a small cadre of ants on the bathroom floor. These were not the big black carpenter ants from the back yard that were common in summer. No. These were those tiny brown ants. There were perhaps thirty of them reconnoitering below as I toweled off.

Kill ’em. A few minutes later I had laid out two bait stations that came from a bright orange box claiming that the poison inside would “kill the queen.” Beyond question, it must have been potent stuff if it could wipe out a whole monarchy. My war against the ants was on. Read the rest of this entry »


Fatigue, not just for the weary

February 29, 2016

Nothing makes me feel old like a night shift.

Even though I say that all the time to my residents, I think that ‘old’ probably isn’t the right word. I think that what I really mean to say is fatigued.

Fatigue (n.) fa·tigue \fə-ˈtēg\: 1) labor; 2) weariness or exhaustion from labor, exertion or stress; 3) tendency of a material to break under repeated stress

The tendency of a material to break under repeated stress. Nine A.M. after a long 12 hour overnight shift in the Emergency Department, I sit in front of my computer and stop to wonder if it’s possible for me to break under repeated stress. We hear stories of this or that ER doc who cracked under pressure and quit the field or the other ER doc who had a nervous breakdown in the ambulance bay. Eventually you start to wonder exactly how much repeated stress that might take.

Read the rest of this entry »


Uneasy alliance: pain, opioids and trust

January 13, 2016

We, as a society, can’t ignore these numbers: over 47,000 human lives lost prematurely in one year from drug overdoses, a 7% spike over the previous year, with opioid painkillers and heroin driving much of this tragic surge. If this trend isn’t disturbing enough, four out of five new heroin abusers began their habit by abusing painkillers.

These numbers have faces. Caring for patients who abuse and overdose from opiates and other drugs are a growing constant in my practice. Meanwhile, pain is a common reason why patients come to the emergency department and alleviating their pain, or making it bearable, might require an opioid painkiller.

This sets up a tense interior dialogue whenever I’m considering an opioid. Am I treating pain or feeding an addiction, or maybe both? Am I fulfilling a moral gesture by providing comfort to someone in distress or contributing to the supply chain in the illicit pill economy, or perhaps both? For this patient, on what side of the firestorm would I find the burn from being wrong most bearable?

These are often unanswerable questions, and stumbling to a response often leaves me sick with feelings of anxiety and inadequacy. Read the rest of this entry »


Healthy Selfies?

January 4, 2016

As a practicing emergency physician for the past 27 years, I have used technology to care for emergency patients in many different ways. Recently, I got a dose of technology from the other side.  A college student, who was so intoxicated that her friends thought she might stop breathing, was brought by ambulance to our hospital.  After a few hours, she sobered up enough to ask if she could take a selfie with me in the emergency department. Despite the great opportunity to be in a new realm of Facebook, Instagram, or Twitter friends, I politely refused. But, it got me thinking.

Surely, the mushroom cloud of selfies that is e-streaming around the planet can have more than a self-indulgent purpose.  Can selfies be used to educate about health and promote healthy behaviors?  Maybe I should have agreed to that selfie with the recovering college student while I held up a sign that said “Know Your Limits – Don’t Binge Drink!” Read the rest of this entry »


Practicing Medicine by Ear

December 15, 2015

My grandmother was an aspiring mezzo-soprano opera singer in Italy before World War II. After the German Army was driven out of Naples, she met and later married an American GI, settling down in central Maine, where they started a family. Like many of the immigrants in the area, my grandparents worked in the local mills making everything from shoes to blankets. My grandmother never gave up singing and was renowned for stunning her coworkers with renditions of classic arias that rose above the rhythmic chatter of sewing machines and looms. I have rich memories from my childhood of Sundays with my Nonna. We would make fresh pasta and sauce together and her booming voice would saturate the kitchen with the melodies of her youth.

By comparison, my own musical career got off to a less impressive start. At times I “played” the piano, violin and even the recorder, all with little success. Then, quite by accident, I discovered vocal music. I had always liked theater, and when they needed singers for the school musical, I was cast in the show. From then on I was a singer, eventually landing a coveted spot in a summer supergroup of some of the best college a cappella singers in country. I accomplished all of this without formal vocal training or expertise in music theory. A childhood surrounded by musicians resulted in my learning to sing by ear. Without being able to read music, I could tell you what the next note would be because I knew which note “fit” the chord.

Looking back, my approach to clinical medicine in the emergency department, mirrored my early days in music: I practiced medicine by Read the rest of this entry »


A Journey to Kale and Quinoa

December 7, 2015

Michael, a man in his late fifties, presented to my emergency department with left-sided arm and leg weakness suggesting a stroke. The symptoms began the night before, but he was still able to walk. He got himself to bed, neglecting to mention anything to his wife Dana. The next morning, he woke with a headache and his weakness had worsened. He was no longer able to escape his wife’s attention. On presentation, his blood pressure was markedly elevated at 207/112. His exam demonstrated mild left arm and leg weakness and subtle sensory changes. His workup was normal except a head and neck CT angiogram with scattered atherosclerotic disease, with no stenosis or brain ischemia. An aspirin was given and his blood pressure managed.

Michael had only visited with a physician twice in twelve years. His misconception of health as the absence of a named disease led him to avoid doctors. He, like so many of our patients, had central obesity, the result of a typical American diet and lack of exercise. He admitted to stress related to work. I learned weeks later that the source of much of his stress ran layers deep.

Read the rest of this entry »


Back to the Bedside

November 30, 2015

When I survey our academic emergency physicians each year about what they most enjoy about their jobs, the number one answer is always “clinical care” or “taking care of ED patients.” It doesn’t matter whether they’re administrators, educators, researchers or primary clinician-educators. They were drawn to emergency medicine by the broad and deep challenges that roll or walk through our doors. Caring for ill and injured patients efficiently and compassionately requires establishing trust with patients and families. Developing a diagnosis and treatment plan begins with tending to the patient’s story and the findings on physical exam. They really love bedside medicine, but find themselves pulled away from time with their patients.

At the risk of sounding curmudgeonly, I think that many medical “advances” threaten the basic bedside connection that is so essential to being a good emergency physician. Were I to ask my colleagues in the ED, “How many of you think the EHR has made you a better doctor?” I suspect the silence would be deafening. The demands of the electronic health record (EHR) mean that emergency physicians spend much more time palpating a keyboard than an abdomen or injured extremity. The words that we might have been sharing with patients are now often dictated into a microphone or worse, become lost in a train of expletives directed at an illogical, unruly EHR.

Read the rest of this entry »


Survival of the Fittest

November 19, 2015

An observation that I and many of my emergency medicine colleagues have made about vacations: we need them. We need them for wellness, to recharge, to recover. Great saves, terrible tragedies, we witness it all and it can wear on you. Unfortunately, when vacation plans are made, it is not uncommon to find oneself working even more shifts before the break to offset our absence on the schedule, making the time away absolutely critical by the time it rolls around.

And so after ten shifts in thirteen days, I find myself exhausted, unprepared, nervous, on a hot, humid bus that is supposed to be taking us to the dock but instead slows unexpectedly. A land iguana, a golden brown ancient dinosaur, creeps off of the road into the side brush. Piling off the bus, we are directed toward a concrete platform adorned with huge lounging marine iguanas. I gather my belongings and catch myself from stumbling, nearly stepping on an iguana’s whiplike tail that seems to have appeared right next to me. It spits salt water at me in retaliation but does not move. Sally lightfoots scuttle along the jagged shore, red as the lava the rocks once were. When I ask which boat is ours, I am interrupted by shouts of “Blue footed boobie!” causing me to forget the question I just asked. This is the first hour in the Galapagos.

Read the rest of this entry »