Fear and Opioids in Academic Medicine

Regard for power implies disregard for those without power; part 3

This is the fourth and final of our essays on power. The first three are here and here. I’ve been thrilled to feature some of our readers. We hope you have enjoyed these.

Adam Cifu

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“I’m nervous. I don’t know what will happen.”

I, then a 50-year-old associate professor of medicine, said those words over the phone to a friend late one night in 2017. It was the night before a health ethics conference at a university. A Canadian expert, with a reputation for castigating North America’s opioid prescribing, had flown in to balance out the presentation I would give.

“Well,” my friend advised, “if you’re feeling nervous right now, that is because the thing you are about to do might upset people, and that takes courage.”

It felt like I was hearing this for the very first time. 

Why was I unsettled? I feared I was putting myself in tension with powerful people and institutions. By 2017, I had started to take a position that was uncomfortable for me, not because I didn’t believe it but because I knew it displeased others. Drug overdoses were on track to take the lives of over 70,000 in the US. The Centers for Disease Control and Prevention had declared “at least HALF of all opioid overdose deaths involve a prescription opioid.”¹

Policy advocates, bereaved families, physicians, and many others offered definitive guidance: reduce prescribing to save lives. Governor Pete Shumlin of Vermont, speaking in 2016, captured the zeitgeist:

“We didn’t have a heroin crisis in America before OxyContin was approved and started being handed out like candy. If politicians would lead a more rational conversation about how we manage pain in America, we could fix the majority of this problem with a click of our fingers”

I had always considered opioid prescribing perilous. I published research on misuse of prescriptions, and profiled the two-decade torrent of prescriptions. Of course deceptive marketing played a role, but US prescribing habits reflected the US medical profession’s own ailment. We had helped create a reimbursement system that favors procedures, scans and devices, and penalizes time spent listening to patients. We did that ourselves, long before OxyContin and Purdue-Pharma.

Our reaction to this crisis reflected our pathologic attachment to quick fixes. There was a rapid rise in the termination and reduction of prescribed opioids in patients who had been on them for years, many of them disabled by complex conditions no one had fully sought to understand.

From these reductions, whether they proceeded quickly or slowly, I saw terrible outcomes. Patients were medically destabilized or traumatized by a health care system that had not earned their trust in the first place.

I argued that across-the-board reductions in long-term recipients embodied a medical practice built on social contagion, not compelling clinical evidence. Later papers substantiated these warnings.

To be clear, a substantial number of patients who reduce doses obtain good outcomes. It is often those who want and seek that change, and whose doctors engage with a posture of respect for them and their pain. But in the US, such cautious respect has been too rare. That’s partly because authorities enshrined across-the-board reductions as policy, or preached tapers as a kind of “tough love” toward patients they see as irrational.

My advocacy drew divergent reactions from my peers. Many colleagues spurred me forward, privately confessing they didn’t feel safe speaking up despite fear that they were being pressured to harm their patients. Some admitted that they had already done so.

And yet, often enough, someone – usually a doctor with regional or national prestige -- would call me, or call a colleague, or call one of my bosses to complain. They would suggest I was misguided, dishonest, or perhaps bought and paid for. I remember every episode:

A doctor acting as plaintiff’s witness in the opioid litigation called to ask if an op-ed of mine was encouraged, in any way, by a publicity firm. (It was not).

After my colleagues and I began research to understand the post-opioid suicides, another physician – again a paid expert witness in ongoing opioid litigation -- denounced our study in our local paper.

Another expert wrote me a private letter to condemn my public advocacy. A few months later, that expert’s name appeared on a scientific panel that had reviewed my team’s application for research funding. 

The fact that these interactions rattled me is not surprising. I did not gain entry to medical school and attain the rank of professor by rebelling against the powerful. Respect for the standards by which one is judged is adaptive in academic medicine. However, this respect can be maladaptive when it leads to respect for people or policies that do not deserve it.

But “regard for power implies disregard for those without power,” and there is something in me that has always recoiled against making the short end of the stick even shorter for whoever is already on that end.

This something in me still persists, even after the indignities of crawling my way into the medical profession left me with a lot more respect for the powerful than I’d ever had before medical school. Cautious professionals, it turns out, try not to burn what they’ve built. 

And yet, part of me rages at seeing people mistreated.

If one has the misfortune of worrying about irritating the powerful while also resenting what they do, there’s a skinny but still walkable path forward. I challenge, but usually with the support of allies. I ask those allies to scrutinize what I wish to say. Once, the night before visiting the Centers for Disease Control and Prevention to urge them to clarify their misfiring 2016 opioid prescribing guideline, I sent my slides to a colleague with a simple subject line: “Please check for BS.” Clear, fact-based statements mitigate emotional resistance.

The friend who counseled me that night in 2017 is not the first to ever observe that fear and courage can be two sides of the same coin. He might, however, have been the first one I heard, in a way that made sense to me. He reminded me of the obvious, and allowed me to act as I wanted to, decisively and with less regard for the powerful.

Stefan G. Kertesz is professor of medicine at University of Alabama at Birmingham Heersink School of Medicine and practices in the Birmingham Alabama Veterans Health Care System. His views do not represent formal positions of the federal government. His team’s study of suicide after prescription opioid change, CSI:OPIOIDs seeks interviews. Learn more here. Dr. Kertesz is on X: @StefanKertesz

1. They later corrected this when it became clear they had miscounted fentanyl deaths.