“We need an urgent pain consult for patient Lucy Bee in room 5621. She’s a 17-year-old drug addict and is screaming and wanting morphine,” I was told. Lucy Bee is not a real patient, but a composite of patients I have cared for either when providing pain management services on our inpatient floors, or in the operating room.
Hearing the reason for the consult, I made many assumptions, even before reviewing Lucy’s record. Most of those assumptions turned out to be wrong, as I learned she had a complicated history.
Lucy was born with congenital cardiac disease. She had undergone several operations prior to getting an orthotopic heart transplant six years ago. Her recovery from her transplant surgery was complicated and prolonged. At 15, she was found using left-over opioids from her previous surgeries in a manner other than how a physician had prescribed them. At 16, she started obtaining opioids from other sources to treat what she reported to be ongoing chest/sternal chronic pain. She felt the pain limited her enjoyment of life and ability to engage in school and other activities, and these medications helped. She reported anxiety but did not want to see a psychiatrist, psychologist, or counselor, and had not been seen by a pain specialist.
Two days prior to the pain consult, Lucy and her mother had been in a car accident, and she had sustained fractures of her right leg, arm, and ribs as well as lacerations and bruising. She was scheduled to undergo an open reduction and internal fixation (ORIF) of her right femur and casting of her right arm and complained of severe pain. The primary care team was limiting her opioids given her previous history.
So, is Lucy a drug addict? Given her history we can’t really say. What we can say is she’s someone who used opioids in a manner other than as prescribed, and the words we use to frame her care can significantly impact her treatment and outcome. It’s important to acknowledge that not all pain patients are the same, and not all people who use medications in a manner other than as prescribed are the same.
We must recognize that the language we use to describe patients with mental health disorders, particularly those with substance use disorder (SUD), is often very stigmatizing.
Terms like addict, drug abuser, drunk, alcoholic, junkie, stoner, or even substance abuser, assumes moralistic and judgmental connotation. They blame, shame, and stereotype the patient, even though increased medical and scientific evidence reveals that addiction and SUD are diagnoses best made by experts in these diseases. They are chronic diseases with high remission, recurrence, and relapse, and stigmatizing them can lead to treatment avoidance and poorer psychological outcomes and social functioning.
Several studies have documented the impact of stigmatizing language on both individuals with SUD and their caregivers’ decisions regarding treatment. It can negatively influence health care workers, including physicians, when caring for these patients, and dissuade the patient from seeking help for their SUD and other health issues. Whenever possible, person-first language, which focuses on the person not their illness, should be used. Lucy is not the drug-addicted heart transplant patient, she is a patient who has undergone a heart transplant and used opioids in a manner other than prescribed in the past for pain.
In this example, Lucy’s care was already impacted by the label of drug addict. She has suffered major trauma, but the concern over her previous nonmedical prescription opioid use (NMPOU) has prevented her from receiving appropriate and humane medical treatment. Prior to this incident, as is so common in teenagers and young adults, she was reluctant to receive appropriate treatment for NMPOU and chronic pain. If she’s labeled an addict or drug abuser, it’s even less likely that she will seek treatment. Furthermore, if she’s left to languish in terrible pain after this accident, the harm to her mental and physical health would be incalculable.
There are many great resources on what language to use and to avoid to decrease stigma and negative bias when caring for patients with SUD. Children’s hospitals are often less experienced in caring for patients with SUD, so they may have less education around best practices. Resources include:
- Words Matter: Preferred Language for Talking About Addiction and Words Matter: Terms to Use and Avoid When Talking About Addiction from the National Institute on Drug Abuse
- Language Matters to the American Medical Association
After Lucy and her family provided a detailed history at the consultation, which included eliciting their concerns and fears, Lucy reported feeling scared that she was being punished for her previous opioid misuse and would never get her pain treated properly. She felt guilt and shame for having been “weak” in the past. She was terrified of experiencing acute pain, on top of her chronic pain, and of being labeled a drug abuser. Her father was worried that she would become addicted to drugs and turn into a “junkie,” while simultaneously denying that she was a drug addict.
Prior to Lucy’s surgery, we developed a plan that optimized the use of multimodal analgesics and regional anesthesia, while not eliminating opioids completely. We acknowledged her fears, concerns, and pain, and set realistic expectations that she would probably have some pain after surgery. The goal was for it to be tolerable, not zero. We also discussed the critical role that our psychiatry and mental health care teams would have in her overall recovery. After her operations, she was treated with respect and understanding. Throughout our many interactions with her over the course of her hospitalizations, we made a conscious effort to never use the terms drug addict, drug abuser, or any other stigmatizing words. She was ultimately discharged feeling confident to begin her road to recovery.
Rita Agarwal is a pediatric anesthesiologist.