“This Is How We Make Monsters”

By Kathy Jean Schultz 07/11/17

A doctor and nurse clash over how to manage pain in a patient with a history of addiction.

man in hospital bed with drip IV
Despite the general consensus that addiction is a disease, stigma is still alive and well even within the field of healthcare.

Writing in the June 2017 issue of The New England Journal of Medicine, Dr. Susan Glod describes treating a man with a history of drug misuse who was dying of cancer. Glod had misgivings about prescribing opioid pain medication, knowing his history. She also knew his pain was unbearable, and that opioids were the only way to blunt it: “The tumor spread rapidly, threading its way through his liver, lungs, and spine.” Glod, an internist and palliative care specialist, writes that the man, “Jerry,” had undergone months of chemotherapy treatment, but ultimately knew it had not worked, and that he was dying. “He hoped that the chemotherapy would allow him a little more time with his young daughter and teenage son.”

As Jerry spiraled into debilitating pain, Glod made the difficult decision to switch from non-opioid painkillers to prescribing opioids. Jerry’s nurse did not agree with Glod’s decision. In a voice loud enough for the patient himself to hear, the nurse told Glod, “This is how we make monsters.”

On his deathbed, Glod recounts, “His body containing tumor more than anything else, he was told he is a monster.”

Shortly before that, the nurse had reminded Glod, “You know he’s an addict.” The doctor recalled that moment and her own response:

I let the silence grow. We were standing outside the open door to his room. I knew he could hear us. “I know he has used cocaine. His tumor is spreading. He has a reason to have pain, and we should try to control it.”

(The nurse) turned away and spoke loudly enough for both me and Jerry to hear. “This is how we make monsters.”

When I turned back to Jerry’s room, he and I locked eyes. He was weeping.

Jerry is not innocent, nor does he claim to be. His vilification, however, is the result of an all-or-nothing approach to pain management under which the pendulum has swung from one unsustainable end of the spectrum to the other in the past two decades.

Glod understood the nurse’s concern — if not the woman’s action to ensure Jerry heard about it. When she logged into his bedside computer that day, a display read:

This patient has a documented history of substance misuse. Are you sure you want to order this medication?  Two options appeared below the query:“Yes, continue with this order” and “No, cancel this order.”

Glod stood at the bedside computer. “I clicked ‘Yes, continue with this order’ and went to find his nurse,” she writes. “The nurse was understandably apprehensive about the dose I had ordered; anyone would be. I agreed that the dose was high, described his home regimen, explained the need for [equivalent] dosing, and agreed to review the dose with our pharmacy staff, but nothing I said seemed to assuage her apprehension.”

Jerry had first met Glod after getting his diagnosis of widespread cancer. He told her about his past cocaine use, which took place before his diagnosis. He also told her he was opposed to using any controlled substance for pain. As his tumor grew, his pain intensified. For the next few months, Glod honored his request and prescribed a variety of non-opioid treatments — everything from nerve blockers to massage. When the pain became so intolerable he could no longer travel to the hospital for chemotherapy, he agreed to start an opioid. If there was any way to allay the pain enough to continue chemo, he reasoned that he might able to see his kids longer. Nonetheless, he dreaded coming in for chemo because it meant repeated questions about his past, and criticism of the opioid dosage Glod was prescribing.

Jerry had an aggressive, malignant tumor, which differs from non-aggressive tumors or non-malignant tumors. Doctors’ use of medication to ease pain for known drug misusers varies in each personal situation. In some cases, people with a substance use disorder who were accustomed to highly potent substances need higher doses of sedatives. Alcohol misusers might sometimes need higher doses of anesthetic before surgery. Balancing these factors weaves its way into every doctor’s life, and is further complicated by patients who are in pain but trying to avoid opioid addiction. If addiction is defined as craving for medically unnecessary and damaging substances, the possibility of becoming addicted may not apply to someone who is dying, as they won’t be alive to crave or misuse.

“The opioid epidemic is a national crisis that should not be underestimated,” Glod says. “But its solution will require careful thought, consideration, and most important, development of meaningful interventions to improve both pain management and substance-misuse prevention.”

About her dying patient’s having to hear the nurse, Glod concludes: “He, too, is a victim of this epidemic.” The title of her article echoes that: The Other Victims of the Opioid Epidemic.

People with addiction can exhaust the patience and even the humanity of many people, including hospital nurses who care for them, spouses and lovers who are humiliated by them, children who are terrified, parents who are bankrupted, employers who are robbed, EMTs who repeatedly rescue, and local officials who finance repeated rescues. A city councilman in Ohio recently proposed a three-strikes drug overdose rule for calling 911: His city spends $2 million each year transporting people who have overdosed, by ambulance, to get medical help, and he asked whether the city could afford to continue to send ambulances for 911 callers who have overdosed and been transported more than twice before. “Let overdoses die?” was the headline on many accounts of this proposal.

Was it necessary to call a dying father a “monster”? Perhaps not, but maybe realistic given community frustration. The opioid epidemic’s tentacles extend into and wrap around hidden grievances and resentments — and thoughtless utterances.

“Everyone involved in a dying patient's care should understand that emotions can shape and fuel pain,” according to a 2017 article in HealthDay. “Anxiety — certainly a common emotion near the end of life — can make pain feel especially intense. While anxiety fuels pain, peace of mind can bring great relief. . . . Reassurance and forgiveness are some of the most powerful pain relievers ever utilized.”

Another powerful pain reliever could be walking away, out of a patient’s hearing range, before airing opinions.

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