OBJECTIVE: Caring for patients who are active drug users is challenging. To better understand the often difficult relationships between
illicit drug-using patients and their physicians, we sought to identify major issues that emerge during their interactions
in a teaching hospital.
DESIGN: Exploratory qualitative analysis of data from direct observation of patient care interactions and interviews with drug-using
patients and their physicians.
SETTING: The inpatient internal medicine service of an urban public teaching hospital.
PARTICIPANTS: Nineteen patients with recent active drug use, primarily opiate use, and their 8 physician teams.
RESULTS: Four major themes emerged. First, physicians feared being deceived by drug-using patients. In particular, they questioned
whether patients’ requests for opiates to treat pain or withdrawal might result from addictive behavior rather than from “medically
indicated” need. Second, they lacked a standard approach to commonly encountered clinical issues, especially the assessment
and treatment of pain and opiate withdrawal. Because patients’ subjective report of symptoms is suspect, physicians struggled
to find criteria for appropriate opiate prescription. Third, physicians avoided engaging patients regarding key complaints,
and expressed discomfort and uncertainty in their approach to these patients. Fourth, drug-using patients were sensitive to
the possibility of poor medical care, often interpreting physician inconsistency or hospital inefficiency as signs of intentional
mistreatment.
CONCLUSION: Physicians and drug-using patients in the teaching hospital setting display mutual mistrust, especially concerning opiate
prescription. Physicians’ fear of deception, inconsistency and avoidance interacts with patients’ concern that they are mistreated
and stigmatized. Medical education should focus greater attention on addiction medicine and pain management.
Key Words injection drug use - physician-patient relations - attitude of health personnel - trust - pain treatment - ethnography
An earlier version of this work was presented at the Society of General Internal Medicine Annual Meeting, Chicago, Ill, April
24, 1998.
This work was supported in part by grants from the Robert Wood Johnson Foundation. At the time of this research, Dr. Merill
was a Robert Wood Johnson Clinical Scholar. The views, opinions, and conclusions in this article are those of the authors,
and do not necessarily reflect those of the Robert Wood Johnson Foundation.