Structural Iatrogenesis — A 43-Year-Old Man with “Opioid Misuse” – Scott Stonington, M.D., Ph.D., and Diana Coffa, M.D. – February 21, 2019
Here’s a quick summary of a terrifying story:
“When he gets tangled in new restrictive policies on opioid prescribing, a factory worker with severe rheumatoid arthritis, whose pain must be managed for him to perform his job, ends up buying oxycodone from a friend.”
(I’ve quoted almost all the text of this case study because the NEJM is now behind a paywall with only 3 free articles a month, suddenly restricting our access to what our doctors are reading and upon which they base our treatments – just another screw being tightened on patients.)
Mr. O., a 43-year-old man with severe, destructive rheumatoid arthritis, had been receiving acetaminophen–hydrocodone at low doses from his primary care provider (PCP) for 15 years.
He worked in an auto-parts factory in southeastern Michigan, and pain control was essential to maintaining his employment.
His pain had been well managed on a stable regimen, and he had not shown evidence of opioid use disorder.
And then, the problems started, not with him but with his pain care.
In 2011, his primary care clinic began requiring patient–provider agreements (“pain contracts”) and regular urine drug testing.
Mr. O. participated willingly, and his tests were consistently negative for unprescribed substances.
In 2014, his insurance company began to require annual prior authorization for all controlled-substance refills.
Although there were small delays in receiving medication once a year when the authorization was due, the patient was able to keep his pain level stable on his usual regimen.
In 2016, Mr. O.’s PCP retired, and his care was transferred to another PCP in the same office, who followed the patient’s existing pain-management plan.
So far, so good.
The same year, the insurance company began requiring more frequent prior authorizations and then that prescriptions be sent to the pharmacy every 15 days.
This is unheard of. How is it that an insurance company can so massively interfere is the medical care of patients?
Even for the most expensive drugs, I’ve never heard of forcing doctors to prescribe less than monthly for ongoing medication. Of course, it’s also a financial gain for them with the constant co-pays patients are forced to pay for every separate prescription.
The new PCP was occasionally late providing these prescriptions and approving prior authorizations because of the required multistep interactions with the insurance company.
Mr. O. did not own a car and had difficulty making frequent trips to the pharmacy.
He began to have several-day gaps in medication.
During these gaps, he experienced severe pain and mild withdrawal, as a result of which he performed poorly at work and received a citation. He became very concerned about losing his job.
Mr. O. made an appointment with his PCP and requested an increase in his number of pills, wanting to “stockpile pills so that I’ll never run out.”
Poor Mr. O didn’t realize that such a logical request would flag him as a “drug-seeker”.
The PCP noted that Mr. O. seemed nervous during the conversation. She noted in the chart that the interaction “made her uncomfortable.”
So it sounds like *she* is the one that was nervous. If Mr. O was nervous it’s probably because of his very natural fear of repeatedly running out of his medication (I suppose that would qualify as “catastrophizing” too).
She knew that the previous PCP had reported that Mr. O. had shown no evidence of opioid misuse, but in the current environment of vigilance regarding the risks posed by opiates, she did not feel comfortable increasing the number of pills.
This is a cowardly doctor, sadly typical for this day and age. It’s clear she cares more about the rules than her patients.
Three months later, the patient submitted a urine sample that tested positive for unprescribed oxycodone.
When the PCP discussed the result with Mr. O., she learned that he had obtained oxycodone from a friend during one of his gaps in medication.
The following month, oxycodone was once again found in his urine.
Already overwhelmed by the frequent need for prior authorizations, and noting that Mr. O. had “violated his contract” by submitting two urine samples containing unprescribed opioids, the PCP referred him to a local pain clinic.
All pain patients know by now this is the death knell for their effective pain relief. Pain clinics are notorious for coercing patients to have risky “interventional” procedures that can lead to even more pain.
The wait time for an appointment at the clinic was 4 months. The PCP continued to provide prescriptions during that period, planning to stop prescribing as soon as Mr. O. had his first appointment.
This is actually unusually kind because most patients are cut off immediately after a “breaking the “opioid contract” they were coerced to sign.
How sad that a doctor simply “doing the right thing” has become so rare.
When he arrived at the pain clinic, Mr. O. learned that it had a policy of not prescribing opioids for the first two visits.
What kind of insane cruelty is this?
How can any doctor allow “standard operating procedures” take precedence over proper medical care and a necessary medication (and one with horrid withdrawals) is simply stopped?
Facing a prolonged period without his usual regimen, and having previously failed to obtain any “extra” acetaminophen–hydrocodone from his PCP, Mr. O. began purchasing his full narcotic regimen (in the form of oxycodone) from a friend.
Social Analysis Concept: Structural Iatrogenesis
Through a series of events, Mr. O.’s therapeutic relationship with his PCP deteriorated, and he became compelled to obtain medications outside the medical setting
This shift was not precipitated by physiological changes in Mr. O.’s disease, need for medication, or personal attributes.
Rather, it was caused by structural forces outside his control, ranging from:
- clinic policies (pain agreements, a drug-testing initiative, a moratorium on prescribing)
- to corporate bureaucracies (insurance companies, factory management)
- to larger-scale social forces (poverty, lack of availability of transportation, lack of opportunities for work appropriate for someone with a painful condition).
We call this type of harm “structural iatrogenesis”.
Mr. O.’s poor outcome was determined by social forces and structures outside his control.
In Mr. O.’s case, many of these structures had been instituted to protect patients at risk for opioid use disorder:
- clinicians acted according to prevailing standards of care in chronic pain management;
- his prior clinic’s pain contract and urine drug screens were meant to prevent deviation from prescribed opioid use that might place him at risk for overdose or addiction;
- the pain clinic’s protocol of delayed prescribing was meant to prevent patients from “shopping” for opioid prescriptions;
- prior authorizations required by the insurance company were intended to reduce overprescription of potentially harmful (and costly) medications.
But these systems were not beneficial to Mr. O. in the context of his economically and socially precarious life, which was shaped by a lack of transportation and a need to perform painful manual labor for economic survival.
Structural iatrogenesis is a type of “structural violence,” defined as the systematic infliction of disproportionate harm on certain people by large-scale social forces such as resource distribution and hierarchies of race, gender, or language.
“Iatrogenesis” points to the causation of such harm by bureaucratic systems that are potentially under clinicians’ or health systems’ control
Clinical Implications: Stopping Structural Iatrogenesis
Generalizing from Mr. O.’s case, we would offer the following approach:
- Recognize and alter structures that systematically harm patients.
Clinicians may be the first to identify a structure that is systematically harming patients and can then advocate for or directly effect change.
if Mr. O.’s PCP noticed that her clinic’s opioid-prescribing policy generated frequent gaps in medication coverage for patients in general, she could have advocated for a new approach.
It’s important, however, to avoid the pitfall of thinking that structural harm emerges only from “broken” systems. All structures carry a risk of harm, even when they are functioning “properly.”
This anti-opioid “system” was designed to do exactly what it did.
Mr. O. was prevented from “doctor shopping” (and penalized even when he did not) or using other means to relieve his pain (after his medications were reduced to the point he couldn’t perform at work).
The policy in Mr. O.’s PCP’s office might have been working well for most patients, but it turned out to be a poor fit for Mr. O.
This is the danger of the drive to standardize everything to make it cheaper.
- Bend policies according to context.
Attempts to standardize clinical care in order to ensure high quality [that’s a lie; standardization is to lower costs] often inadvertently lump complex phenomena into simplistic categories.
Such oversimplification, in turn, can create structures within clinical care that harm patients more than help them.
This is another problem with computer-aided medical care: almost all aspects of care are fitted into pre-defined categories, which necessarily simplify or summarize the full situation.
By questioning how such categories (such as “opioid misuse”) apply to particular patients and types of patients, clinicians can work to reduce the risk of structural iatrogenesis.
The trouble is that, just like in Nazi Germany, there were powerful forces demanding compliance from workers (doctors are little more than “providers” these days) by threatening to fire any that don’t “follow orders”.
Workers end up facing a terrible choice of losing their job/career or participating in immoral acts that inflict suffering.
The label of “opioid misuser,” for example, negatively affected Mr. O.’s care by failing to acknowledge reasons that he might be acquiring medications outside the clinic.
Similarly, clinic policies that penalize patients for arriving late to appointments disproportionately harm people who don’t own a car or control their work schedule.
Instead, one might identify patients with particular vulnerabilities and adjust policies on the basis of their life context.
- Address implicit agendas head-on.
Mr. O.’s care deteriorated when he was labeled an “opioid misuser.”
This designation was putatively a clinical diagnosis,…
This is absolutely *not* a “clinical diagnosis”; it’s merely a suspicion supported by one red flag. It’s like seeing a patient drink a soda with several cookies and making a “clinical diagnosis” of diabetes.
…but it also marked a tacit category shift from “good patient” to “bad patient,” reflecting the mixing of clinical reasoning with moral judgment.
Similarly, the insurance company’s rationale for requiring more frequent prescriptions mixed a harm-reduction agenda (reducing risk for addiction and death) with a profit motive (reducing payouts for medications).
I’m so happy to have a medical journal article point out that much of the harm patients suffer is due to profit motives. Most journal articles are afraid to mention that, even though it’s becoming a more and more important factor in all social services.
Mr. O’s poor clinical outcome was due in part to tensions between these implicit agendas.
Clinicians often consider such agendas to be outside their purview, but given that they have such a significant impact on clinical outcomes, it may be more effective clinically to identify these agendas, assess their interactions, and decide which ones to prioritize.
Too many doctors have sat idly by as the atrocious restrictions on opioid prescriptions spread far and wide.
Too many doctors seemed to think “it’s not my problem”, even as their patients without pain relief committed suicide.
Too many doctors “just followed orders” instead of standing up against these harmful policies when they were first enacted.
If “just following orders” wasn’t a good enough defense for Nazis, why should it be good enough for doctors?
The staff of Mr. O.’s clinic, for example, could recognize the moral judgment involved in the diagnosis of “opioid misuse” and instead set an explicit goal of identifying behaviors that could increase a patient’s risk of addition, overdose, or dangerous side effects.
Unfortunately, most “staff” is grossly underpaid and overworked. They don’t have the time or energy to keep going “above and beyond” their official job descriptions.
Even if they protested the treatment of patients, they’d be swimming against the tide and potentially get labeled as “troublemakers” (which happened to me when I stood up for my company’s customers as they were left without service due to my company’s understaffing).
And after having that label slapped on me, all my subsequent actions were judged through this lens, and eventually led to losing my job.
At Mr. O.’s next visit, his PCP expressed concern about risks of overdose and legal harm from use of unprescribed oxycodone.
It’s great that someone is finally showing concern for Mr. O’s medical issue.
She persuaded him to return to the pain clinic, and in the meantime she agreed to continue prescribing his opioids.
Kudos to this brave doctor, willing to fight the system to care for her patient.
A medical assistant appealed for an exemption to the insurance company’s 15-day prescription rule, citing Mr. O.’s lack of transportation, fragile work circumstances, and long-standing treatment.
It’s crazy that a patient had to risk death from street drugs *before* his problems were addressed.
At the time we wrote this article, it remained unclear whether these modifications would stabilize Mr. O.’s treatment and prevent his use of unprescribed opioids.
At least these changes would make it possible for Mr. O to stick with only medical prescription drugs. For his own safety, I would assume he will – unless the cost of it exceeds his ability to pay.
From the Departments of Anthropology and Internal Medicine, University of Michigan, and the Veterans Administration Medical Center, Ann Arbor (S.S.); and the Department of Family and Community Medicine, University of California, San Francisco, San Francisco (D.C.)