I work in East Tennessee, a region known for country music, whiskey, a portion of the Appalachian Mountains, and being the heart of the opioid crisis. Disturbing headlines like “Opioid abuse has death grip on Tennessee” and “There are more opioid prescriptions than people in Tennessee” fill newspapers and television news. Prescriber practices have become increasingly scrutinized, with additional continuing education requirements to maintain state licensure. Many primary care clinics have started refusing to write prescriptions for pain medications, and, as a result, pain management and Suboxone clinics are opening on a regular basis.
A few months ago, I met a 54-year-old woman for an initial consultation in my palliative care clinic. Before meeting her, I had learned about the disease afflicting her body: cervical cancer metastatic to the liver, a bulky primary tumor causing significant pain, and significantly impaired cardiac function. The oncologist felt that chemotherapy was not an option because of comorbidities and asked me to see the patient about controlling her symptoms and discussing her options moving forward.
I have worked as a PA in oncology for 10 years, so I am well aware of how difficult it is to navigate end-of-life and goals of care discussions during a new patient and provider relationship. When I entered the room, the patient met me with a “hello,” followed by frustration and a string of expletives that were used as everyday conversation and not out of anger. Her daughter, who lives with her, looked at me with a skeptical smile, multicolored hair, and multiple facial piercings. The patient told me that she had lived on “18 to 24 beers and couple packs of cigarettes per day” before her diagnosis a couple weeks ago. I identified the potential biases that were arising in me based on their appearance and demeanor and consciously placed them aside to listen to the patient and her daughter.
After discussing why surgery and chemotherapy were not an option and evaluating her symptoms, I discussed pain management approaches and the differences between hospice and palliative care. Her daughter interjected, “Momma is not signing up for hospice in my house. They just dope you up and kill you.” The patient deferred to her daughter's opinion, and she left with a pain management plan as well as ideas for sleep and anxiety management. She agreed to see me as an alternative to home hospice for the foreseeable future, opting to maintain a full code status.
Two weeks after my initial visit with the patient, she was admitted to an outside hospital for increasing abdominal pain and severe constipation. She was found to have an enlarging primary tumor causing significant bowel narrowing and a new rectovaginal fistula. She called my clinic and asked for pain medications before being discharged from the hospital. I, appropriately, turned down her request for medication because I had anticipated that her pain regimen had changed during this hospitalization and that she would be given pain medication before being discharged. Three days after her discharge from the hospital, I walked into the examination room to see her doubled over in pain. As it turns out, the attending had not given her any pain medication at the time of her hospital discharge, and she had been waiting until her appointment with me.
I was frustrated that the attending did not appropriately manage my patient's symptoms and had contributed to increased suffering, and I felt sad that provider bias and fear might have contributed to that decision. In her room, I actively listened to her curse the inpatient team and heard about her pain and new fistula symptoms. I took the time to ask her how she was coping with the diagnosis and new symptoms. As this hardened, life-worn woman began to sob, she said, “How are you only the first person to ask me this? I don't deserve this cancer. What am I supposed to do? Wait to die?” I never expected her to break down and cry because of a simple question. In that moment, I felt her vulnerability and humanity.
As an oncology palliative care provider, I have numerous patients with histories of drug and alcohol abuse. That doesn't mean that I don't help control their symptoms, even as I am transparent with them about my concerns at our initial meeting and regularly conduct drug screenings and monitor the state prescription database. We can be aware of stereotypes but we also need to see past the external appearance of a patient and, potentially, even their history.
As providers, we all feel the tension between the responsibility to avoid contributing to the opioid crisis and the responsibility to alleviate a patient's suffering. However, with the ever-increasing pressure and attention to opioid abuse, I know some patients are suffering unnecessarily because of prescribers' unconscious biases and fears.