The first time a patient threatened to kill me, I was a third-year medical student in a trauma surgery internship in Texas. A 22-year-old stab victim kept coming back to the trauma follow-up clinic asking for more Dilaudid, an opioid that helped dull her pain while she recovered. I told him he needed to follow up with his GP. He huffed but came back four hours later and asked to speak to me. I took him to an empty clinic room for privacy and he then asked me how I wanted to die: by a knife or a gun, or both?
The first time a patient threatened to kill me, I was a third-year medical student in a trauma surgery internship in Texas.
Patients who threaten doctors are not new. But it has become exponentially more common as opiates prescribed for pain control have become more common. As a result, we have seen increasing reports of violent threats against medical personnel to obtain drugs, and the use of firearms in these threats is common. In 2017 in Indiana, Michael Jarvis confronted Dr. Todd Graham with a semi-automatic weapon, killing Graham and then himself. A few weeks earlier, the doctor had refused to prescribe Jarvis’ wife opioids for her chronic pain. Gregory Ulrich shot five healthcare workers and detonated three pipe bombs at a clinic in Minnesota in 2021 after his doctor stopped prescribing painkillers. The stories persist, including the recent murder of Dr. Preston Phillips and three others at St. Francis Hospital in Tulsa, Oklahoma on June 1.
The shooting reportedly took place a day after the shooter complained of pain from back surgery Phillips performed the previous month. Police recovered a letter the shooter had on him detailing how he “killed Dr Phillips and everyone who got in his way”. Police did not say whether the shooter was seeking opiates for his pain.
Purdue Pharma introduced OxyContin in 1995, a version of oxycodone widely marketed to doctors as a milder, less addictive opioid pill. The company’s aggressive marketing has succeeded in normalizing the prescription of opioids for pain of any kind, despite the lack of evidence that they should be used for common conditions such as back pain and arthritis.
Even I felt comfortable writing opioid refills for the patient of a colleague I had never met or giving opioids to my 82-year-old patient with wasting arthritis of the hip. And with the increase in volume came addiction and overdoses. In 2012, 255 million prescriptions were written for opioids with a dispensing rate of 81 prescriptions per 100 people. That year, 16,000 people died from an opioid overdose. In 2016, researchers found that more than 11.5 million Americans reported misusing opioid prescriptions in the past year, highlighting that while there are valid uses for these drugs, USA simply had too many opioid pills in medicine cabinets. If this sounds familiar, think about the debate we’re having about guns in this country right now.
The worst outcome of our nation’s inability to manage the twin epidemics of opioids and guns is the complete breakdown of the doctor-patient relationship.
The nation labeled and then moved to reverse these trends by introducing incredible oversight and regulation in the form of prescription drug monitoring programs, limits on how much can be prescribed, and state medical boards investigating high volume prescribers. These efforts began to yield results, but something else began to happen: millions of drug addict patients began resorting to desperate measures of self-medication when the generous supply of prescription drugs began to dwindle. .
Patients were using fake names in different emergency rooms around the city to receive opioids; others stole from friends and relatives and too many relied on non-prescription sources, all too often proving fatal. Some doctors I’ve worked with have instituted a strict “no narcotics” policy to avoid writing prescriptions, while others said they would only prescribe for up to five days and require in-person office visits to a reassessment. Programs that could help transitioning drug patients, such as buprenorphine treatment, which can be safely administered in doctor’s offices, are still too rare due to stigma (“we don’t want drug addicts in our ward waiting period”), regulatory obstacles (before 2021, there were limits to who could prescribe the drug), financial considerations (reimbursement deemed too low) and a lack of time.
These days, doctors, myself included, have taken steps to mitigate risk and protect us and our staff. I’ve fired patients to put them out of harm’s way, worked in clinics with panic buttons, and asked to reconfigure exam rooms so I’m closest to the door. . Recent events will likely prompt more conversations about an increased security presence or additional barriers to access in hospitals and medical centers.
The worst result of our nation’s inability to manage the twin epidemics of opioids and guns is the complete breakdown of the doctor-patient relationship. Preventative measures to deal with violence such as security and panic buttons can create an immediate assumption that the patient waiting in their room or on the stretcher is guilty until proven guilty. A flag in the electronic medical record that is commonly used to educate prescribing doctors about opioid use also paints a scarlet letter before the doctor even sees their face.
In cases where the patient is a person of color, such as in the Tulsa murders, there is often additional stigma back and forth. Patients assume they will not be heard and doctors assume they are dealing with a potentially dangerous drug addict.
Social media is only deepening the divide – Google had to remove hundreds of one-star reviews of Phillips who said he deserved to die for not being empathetic or listening to the patient.
It’s no wonder the desire to transition into telehealth work and minimize the possibility of such intense interactions continues to grow. That leaves fewer doctors who can do the hard work of helping people recover.
Over the years, I have been able to hone my senses regarding patient threats that require further intervention. It’s not perfect, but it’s pretty accurate. When that sixth sense kicks in, I find myself a little more cautious, more transactional. I might schedule the patient for more frequent follow-up visits to try to prevent periods of frustration or anger from developing. These are skills that are not taught in any medical school or training program in the country. But maybe they should be.