When I started working as a medical resident, in 2004, I heard from a patient I had inherited from a graduating resident. The patient had an appointment scheduled in a couple weeks. 

“But I need your help now,” he said. He was a former construction worker who had hurt himself on the job a couple of years earlier.  “I also need some more OxyContin to tide me over until I can see you,” he told me.  

According to the hospital computer system, the had been taking twenty milligrams of OxyContin, three times a day, for at least the last couple of years. I had rarely seen such high doses of narcotics prescribed for such long periods of time. 

I’d seen narcotics prescribed in the hospital to patients who had been injured or to those with pain from an operation or from cancer. But I didn’t have much experience with such drugs for outpatients. I figured that if the previous resident—now a fully licensed doctor—was doing this, then it must be O.K.

What I didn’t know was that my time in medical school had coincided with a boom in the prescribing of narcotics by outpatient doctors, driven partly by the pharmaceutical companies that sold those drugs. Between 1999 and 2010, sales of these “opioid analgesics”—medications like Vicodin, Percocet and OxyContin—quadrupled.

As narcotics prescriptions surged, so did deaths from opioid-analgesic overdoses—from about 4,000 to almost 17,000. Studies have shown that patients who receive narcotics for chronic pain are less likely to recover function and are less likely to go back to work. 

The potential side effects of prescription narcotics include constipation, sexual dysfunction, cognitive impairment, addiction and overdosing. When patients receive narcotics for long periods, they can even become more sensitive to pain, a condition called hyperalgesia. 

At around the same time, the companies that manufactured these narcotics began to aggressively market their products for long-term, non-cancer pain, including neck and back pain. They promoted their prescription narcotics to doctors through ads in highly regarded publications and through continuing-education courses for medical professionals. They also funded non-profits such as the American Academy of Pain Management and the American Pain Society.

The rise in prescription narcotics may have been driven partly by the pharmaceutical industry, but many patients also welcomed—and encouraged—it. 

Many people believe deeply in the power of modern medicine to cure illness and bristle at the notion that pain is a fact of life. The promise of a set of medicines that could cure pain was appealing to many patients—and, with a customer-is-always-right mentality having pervaded the doctor’s office, patients were able to pressure physicians to satisfy their requests for the pain pills they’d begun hearing about.

The pain-pill epidemic has also forced doctors like me to consider our own role. Doctors have a duty to relieve suffering and many of us became doctors to help people. But giving that help isn’t straightforward, especially when it comes to chronic pain. 

Try explaining the downsides of narcotics to a patient while declining to give him the medication he wants. He might accuse you of not understanding because you’re not the one in pain; he might question why you won’t give him what another doctor prescribed; he might give you a bad rating on a doctor-grading website. He might even accuse you of malpractice. 

None of this is rewarding for doctors: we’re frustrated that we can’t cure the pain and that our patients end up upset with us.

Doctors have a hard time saying no, whether a patient is asking for a narcotic to relieve pain or an antibiotic for the common cold. We are predisposed to say yes, even if we know it isn’t right. Some of us just don’t want to take the extra time during a busy day to explain why that prescription for a narcotic isn’t a good idea. 

Recently, I was tapering one patient’s narcotics, then discontinued them completely after two urine tests came up negative for oxycodone but positive for cocaine—suggesting he was selling the former to buy the latter.  I advised him that I would no longer be prescribing his pain medication which resulted in him transferring his care to a different primary care provider.

Although I felt justified in my decision from a healthcare and moral stance, I realized that the cycle will continue elsewhere and that in itself left me troubled and frustrated. It is time to have an open and honest dialogue with all involved parties about this epidemic plaguing our community.