The Compassionate Doctor, the Narcissistic Injury, and the Prescription Opioid Epidemic

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The Compassionate Doctor, the Narcissistic Injury, and the Prescription Opioid Epidemic

By Anna Lembke 11/30/16

In this video, we show how the doctor ignores the signs of prescription drug misuse and continues prescribing, thus perpetuating the problem.

A doctor sitting at a window, holding a folder and glasses.
Why do good doctors behave badly when confronted with drug-seeking patients?

Physicians who prescribe opioids to their patients have often been vilified as the primary force behind our current opioid epidemic, creating addiction by unthinkingly overprescribing opioids. But many factors have conspired to create the opioid epidemic, and the view that most physicians blithely overprescribe is far from the truth. The physician-patient relationship is indeed as complex as all intimate relationships, with strong and subtle feelings on both sides of the prescription pad. Anna Lembke, MD, the Program Director for the Stanford Addiction Medicine Program, helps us understand the dynamics involved in working with addicted patients…Richard Juman, PsyD

What strikes me in observing myself and my colleagues overprescribing addictive medications, is how hard it is for us to remain in a compassionate stance, and still do the right thing by patients who are misusing, overusing, or addicted to the drugs we are prescribing. In other words, why do good doctors behave badly when confronted with drug-seeking patients?

I became so fascinated with this conundrum that I devoted a couple of chapters to it in my new book on the opioid epidemic: Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It's So Hard to Stop. Among many other unseen forces driving the opioid crisis is the complex psychological dance between doctor and patient around prescribing controlled drugs.

The first important question is, why do doctors continue to prescribe opioids to patients showing signs and symptoms of misuse, overuse, or addiction?

Of course, many factors are at play influencing physician prescribing, including but not limited to a lack of time with patients, reimbursement incentives which favor prescribing, fear of negative patient reviews, and misbranding of opioids by the pharmaceutical industry.

But another often ignored factor is the doctor’s desire to maintain mutually affectionate relationships with patients, and to be regarded as a healer—one who relieves suffering.

To deny patients their usual dose of opioids can threaten the therapeutic alliance, and hence the doctor’s identity as a compassionate healer. Yet, to continue to prescribe to a patient who is misusing medications is to engage in de facto drug dealing, which also threatens a doctor’s identity. Faced with this dilemma, the doctor calls on primitive defense mechanisms, like denial and passive-aggression, to ignore warning signs of misuse and maintain the status quo.

In order to convey these more complex psychological predicaments to medical students and colleagues, we at Stanford created role-play videos to illustrate to doctors what not to do when confronted with a drug-seeking patient. I always learn more from my mistakes than my successes, so I hoped others would too. In this video, we show how the doctor ignores the signs of prescription drug misuse and continues prescribing, thus perpetuating the problem. Also evident in this video are strategies patients use to get the drugs they want, e.g. flattering the doctor and/or waiting till the last few moments of the appointment to get a refill—the filibuster technique, etc. Feel free to use these videos for your own teaching if you think they might be helpful.

So what happens when the status quo can no longer be ignored, like when the doctor is confronted with definitive evidence that the patient is misusing prescription opioids, for example engaging in doctor shopping (going around to multiple prescribers to get the same or similar drugs)?

In this scenario, the doctor experiences a narcissistic injury. This is not to say that doctors are narcissistic. Anyone can experience a narcissistic injury when their competence or core identity is threatened. The most common reaction to a narcissistic injury is narcissistic rage, as illustrated by doctors turning on drug-seeking and addicted patients and firing them instead of adding “opioid misuse” or “opioid addiction” to the patient’s problem list. Check out this video illustrating the narcissistic injury. Note the depths of the doctor’s rage toward the patient, and the patient herself questioning the doctor’s role, “Aren’t you supposed to help someone with a medical problem?”

Doctors swing from the extremes of denial that a problem exists, to abandoning the patient when a problem is detected. Neither is a helpful response. The former perpetuates unsafe prescribing, and the latter contributes to "opioid refugees"—patients left without a doctor to help them with their pain or their addiction.

The solution is middle-of-the-road mindful prescribing, in which the doctor keeps tabs on her own psychological energy around the interaction, while making sure to monitor for and respond to signs of misuse, without retaliating. If the doctor conceptualizes prescription drug misuse and addiction as just another medical problem requiring treatment, rather than an instance of betrayal, it is much easier to remain in a compassionate stance and do the right thing, i.e. help the patient gain insight into and freedom from their maladaptive drug use.

Listen to the NPR interview with Dr. Lembke, 'Drug Dealer, M.D.': Misunderstandings And Good Intentions Fueled Opioid Epidemic, here.

Anna Lembke, MD, received her undergraduate degree in Humanities from Yale University and her medical degree from Stanford University. She is on the faculty of the Stanford University School of Medicine, a diplomate of the American Board of Psychiatry and Neurology, and a diplomate of the American Board of Addiction Medicine. She is the Program Director for the Stanford Addiction Medicine Program and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She has published over 50 peer-reviewed articles, chapters, and commentaries, including in the New England Journal of Medicine, the Journal of the American Medical Association, the Journal of General Internal Medicine, and Addiction. Dr. Lembke sees patients, teaches, and does research.

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