Some problems in prescribing narcotic drugs: The doctor-patient relationship
Most patients who excessively and unreasonably demand narcotic drugs from their physicians suffer from marked emotional disturbance. This disturbance frequently takes the form of conscious or unconscious anger against social institutions and their representatives, such as the doctor. As a result of the nature and extent of this reaction on the part of the patient, a crisis can be created in the doctor-patient relationship which can be detrimental to both if not understood. We will discuss this crisis as one aspect of the problems of proper narcotic usage by physicians.
In previous articles [ 1] , [ 2] we outlined some of the difficulties faced by a general practitioner when called upon to supply a patient with narcotic drugs. His reluctance to use such drugs seems to be based on inadequate medical-school training, a misunderstanding of the nature of narcotic abuse, and a fear of moral and legal censure. The fear of censure is a realistic one, and is based on the complex and occasionally contradictory legislation and Supreme Court decisions made since the passage of the Harrison Narcotic Act in 1914 and on the Federal Bureau of Narcotics' policy associating narcotics users with criminal behaviour.
Since the 1962 Conference on Narcotic and Drug abuse, [ 3] strenuous efforts have been made towards a fresh, unhampered consideration of all drug dependency problems. There have been encouraging developments on both the legal and clinical sides of the problem.
On the clinical side, one recent study [ 1] placed the patients who came to the attention of practising physicians on a continuum, so that it would be easier to see each individual problem and not be confused by the stereotype of the heroin addict who actually makes up only a small percentage of the total narcotic dependency cases. It was suggested that an understanding of narcotic abuse must include this entire spectrum of narcotic dependency, not just one much-publicized segment of it.
1 Assistant Director, Psychiatric Service, Beth Israel Hospital, Boston, Massachusetts; Assistant Clinical Professor of Psychiatry, Faculty of Medicine, Harvard University; Faculty, Boston Psychoanalytic Society and Institute, Inc.
2Fellow in Internal Medicine, University of Texas South - western Medical School, Dallas, Texas.
In addition, the World Health Organization [ 4] has recently recognized that the classic definition of addiction - an overwhelming desire to continue taking the drug (compulsion), a tendency to increase the dose (tolerance), and a physical dependency reflected in a withdrawal syndrome when it is withheld - is inadequate, just as the attempt to distinguish between physiological addiction and psychological habituation is unclear and misleading. It has suggested instead the use of the broader term and concept of drug dependency, which would include all of our continuum, as well as a whole range of other drugs, such as marihuana, tranquillizers, energizers, and alcohol. The larger concept of dependency permits the relationship between drug use and abuse to be studied with less regard of the moral and legal questions, permitting more emphasis on the patient's reaction to any drug.
There are straws in the wind that the emotional tangle connected with the moral and legal questions is being unravelled, and that the physician will be given more freedom to use his judgment in dispensing narcotics. Given this freedom, will the physician be able to cope with narcotics problems effectively?
On the basis of our study of over 400 patients in whom narcotic usage is the main problem for the patient and the physician, we find that a major barrier to effective treatment is the development of a pathological doctor-patient relationship. Our purpose here is to examine this relationship in the hope that an understanding of it will lead to better medical care.
We feel we are pointing to a potentially serious difficulty in the doctor-patient relationship. Without exception, the people in our study can be characterized as deeply angry and distinctly hostile to and aggressive toward their physicians. These feelings may be expressed in many different ways: overt anger, whining, unreasonable demands, or attempts at control. The actual expressions may not be any different from what a physician normally anticipates from patients who, as a result of fears associated with illness, behave childishly; but the persistence, depth, and intensity of such feelings expressed by this group of patients is striking. For many years Lawrence Kolb's [ 6] division of the personality structure of people with narcotic problems into medical addicts, psychoneurotic addicts and psychopathic addicts has been regarded as definitive, but this classification does not help us much in understanding the interaction between doctor and patient. To understand the doctor-addict relationship, it is essential to take into account that the patient's underlying resentment of the physician prevents the formation of a positive relationship. This hostility seems to be more central than differences in psychopathology or character traits. Physicians who have not thoroughly understood it as part of the whole syndrome of narcotic drug dependency, are likely to respond to these patients by getting angry themselves.
These patients deserve not only good medical treatment for an unpleasant illness, drug dependency, but also often require a differential diagnosis between various diseases as well as between what is organic and what is functional, that may be crucial to the treatment. In order both to make the diagnosis and to carry out the treatment, the doctor must keep his head and, while undeniably feeling annoyance, must maintain his professional objectivity.
The sort of difficulties that may arise are illustrated in the case of one patient of whom we are aware who is highly intelligent and had extensive medical knowledge, being a research worker in the para-medical field himself. He used his medical understanding of the abdominal pains to which he was victim by getting a physician who was seeing him for the first time to prescribe morphine. When the specific condition was cured, history taking and a detailed check-up indicated evidence of psychiatric disorder but the patient refused utterly to have anything to do with psychiatric treatment. He subsequently tried to wheedle narcotics prescriptions out of the same physician by giving convincing descriptions of other physical pain. He was able to prevail upon the physician the first time but then the latter refused to continue such prescribing until the patient would allow thorough analyses to be made and also accept psychiatric consultation. For almost a month the doctor had to suffer telephone calls sometimes in the middle of the night when the patient pleaded for a narcotic prescription and, being successively refused, became more and more insulting and objectionable. At the end of a very trying period for the doctor, he accepted a thorough medical checkup and a psychiatric referral.
After his relationship with this patient had been reasonably regulated if not resolved, the doctor admitted that remaining calm while listening to him had been the most difficult thing he had done during his years as a medical practitioner. He felt too that, if he had not anticipated such an outburst as part of the patient's condition, he would have exploded himself, told the patient to take himself elsewhere, and would have been unable to do his duty of seeing that the patient got the best possible care.
This may seem like an exceptional case, but the fact is that all narcotic cases are exceptional. The cases which really represent a drug dependency problem fall outside the scope of everyday practice. Such people inevitably have serious emotional problems, although often they should not be, or cannot be, treated by a psychiatrist: should not be, because often the problems are complicated by physiological symptoms which must not be overlooked or played down; cannot be because many of these patients have had previous experiences with psychiatrists which have not worked out well and they refuse such treatment. Only the medical doctor can deal with many of the cases in their entirety. On the other hand, with many of these patients, as in the case discussed above, initial medical treatment can be directed toward an acceptable psychiatric referral. But if a psychiatric referral is made before the patient is prepared, he is likely to feel that his complaints are not being taken seriously, or that he is being called a malingerer or, most unpleasant, that he is demanding the drugs for psychological and not physiological reasons. While all of these possibilities exist in the minds of the physicians, if they convey them to the unprepared patient he will feel that his dignity has been impaired and will vent his latent fury in one form or another. Therefore, even if it is to prepare these patients for future psychiatric attention, the medical practitioner takes the responsibility for extremely touchy cases, cases which require him more than most to step out of his everyday medical role and to be aware of and in control of some very unpleasant feelings.
In cases such as the one we have described, the general practising physician finds himself called upon to treat someone he finds objectionable, but to whom in all conscience he is unable to refuse treatment. For such patients he represents all the authorities in our society, and in their dealings with him they will be expressing their anger, their wish to tyrannize over these authorities either by strength or weakness. This is all part of their disease picture and has to be accepted as such, just as the odour of the breath of a patient with uremia has to be accepted as a part of that condition. However, if the physician does not understand this, he is likely to react as a human being rather than as a physician to these patients and to do himself and them an injustice.
It is obvious that there is no single approach to the treatment of narcotic dependency problems. Each case must be treated individually within the framework of the patient's and physician's personalities and understanding of the situation.
Physicians face may problems whenever they feel it necessary to supply a patient with narcotic drugs. Besides the historical, legal and emotional complications, the kind of patient who asks for narcotics tends to show marked emotional disturbance, characterized by extreme anger which is likely to focus upon his relationship with his doctor. Unless the irrationality of the patient's feelings is understood by the physician, the situation may deteriorate rather than serve therapeutic ends.
Advisory Council of Judges of the National Council on Crime and Delinquency, Policy Statement, U.S. Gov't Printing Office, Washington, D.C., 1964, 280 pp.006
Kolb, L., "Types and Characteristics of Drug Addicts ", Ment. Hygiene 9 : 300 ff., 1925.