Structural Iatrogenesis — a 43-Year-Old Man with “Opioid Misuse” Scott Stonington, M.D., Ph.D., and Diana Coffa, M.D.
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The NEW ENGLAND JOURNAL of MEDICINE Perspective February 21, 2019 Case Studies in Social Medicine Structural Iatrogenesis — A 43-Year-Old Man with “Opioid Misuse” Scott Stonington, M.D., Ph.D., and Diana Coffa, M.D. Structural Iatrogenesis Mr. O., a 43-year-old man with se- in receiving medication once a vere, destructive rheumatoid arthri- year when the authorization was tis, had been receiving acetamin- due, the patient was able to keep ophen–hydrocodone at low doses his pain level stable on his usual from his primary care provider regimen. (PCP) for 15 years. He worked in In 2016, Mr. O.’s PCP retired, an auto-parts factory in south- and his care was transferred to eastern Michigan, and pain con- another PCP in the same office, trol was essential to maintaining who followed the patient’s exist- his employment. His pain had ing pain-management plan. The been well managed on a stable same year, the insurance company regimen, and he had not shown began requiring more frequent evidence of opioid use disorder. prior authorizations and then that In 2011, his primary care clinic prescriptions be sent to the phar- began requiring patient–provider macy every 15 days. The new PCP agreements (“pain contracts”) and was occasionally late providing regular urine drug testing. Mr. O. these prescriptions and approv- participated willingly, and his ing prior authorizations because tests were consistently negative for of the required multistep interac- unprescribed substances. In 2014, tions with the insurance compa- his insurance company began to ny. Mr. O. did not own a car and require annual prior authorization had difficulty making frequent for all controlled-substance refills. trips to the pharmacy. He began Although there were small delays to have several-day gaps in medi- n engl j med 380;8 nejm.org February 21, 2019 701 The New England Journal of Medicine Downloaded from nejm.org by ROBIN TITTLE on March 5, 2020. For personal use only. No other uses without permission. Copyright © 2019 Massachusetts Medical Society. All rights reserved. PERSPECTIVE Structural Iatrogenesis cation. During these gaps, he ex- ilance regarding the risks posed scribed opioids, the PCP referred perienced severe pain and mild by opiates, she did not feel com- him to a local pain clinic. withdrawal, as a result of which fortable increasing the number of The wait time for an appoint- he performed poorly at work and pills. ment at the clinic was 4 months. received a citation. He became very Three months later, the patient The PCP continued to provide pre- concerned about losing his job. submitted a urine sample that scriptions during that period, plan- Mr. O. made an appointment tested positive for unprescribed ning to stop prescribing as soon with his PCP and requested an oxycodone. When the PCP dis- as Mr. O. had his first appoint- increase in his number of pills, cussed the result with Mr. O., she ment. When he arrived at the pain wanting to “stockpile pills so that learned that he had obtained oxy- clinic, Mr. O. learned that it had a I’ll never run out.” The PCP noted codone from a friend during one policy of not prescribing opioids that Mr. O. seemed nervous dur- of his gaps in medication. The for the first two visits. Facing a ing the conversation. She noted following month, oxycodone was prolonged period without his usu- in the chart that the interaction once again found in his urine. Al- al regimen, and having previously “made her uncomfortable.” She ready overwhelmed by the frequent failed to obtain any “extra” aceta- knew that the previous PCP had need for prior authorizations, and minophen–hydrocodone from his reported that Mr. O. had shown noting that Mr. O. had “violated PCP, Mr. O. began purchasing his no evidence of opioid misuse, but his contract” by submitting two full narcotic regimen (in the form in the current environment of vig- urine samples containing unpre- of oxycodone) from a friend. 702 n engl j med 380;8 nejm.org February 21, 2019 The New England Journal of Medicine Downloaded from nejm.org by ROBIN TITTLE on March 5, 2020. For personal use only. No other uses without permission. Copyright © 2019 Massachusetts Medical Society. All rights reserved. PERSPECTIVE Structural Iatrogenesis Social Analysis Concept: Structural Iatrogenesis Through a series of events, Mr. of the term “structure” empha- place him at risk for overdose or O.’s therapeutic relationship with sizes that Mr. O.’s poor outcome addiction; the pain clinic’s proto- his PCP deteriorated, and he be- was determined by social forces col of delayed prescribing was came compelled to obtain medi- and structures outside his con- meant to prevent patients from cations outside the medical set- trol. The term “iatrogenesis” spe- “shopping” for opioid prescrip- ting, which in turn increased his cifically focuses on the harmful tions; prior authorizations required risk of overdose, as well as his risk role of bureaucratic structures by the insurance company were of arrest for possession of unpre- within medicine itself. In Mr. O.’s intended to reduce overprescrip- scribed opioids. This shift was tion of potentially harmful (and not precipitated by physiological costly) medications. But these sys- changes in Mr. O.’s disease, need Structural iatrogenesis is tems were not beneficial to Mr. for medication, or personal attri- the causing of clinical harm O. in the context of his economi- butes. Rather, it was caused by to patients by bureaucratic cally and socially precarious life, structural forces outside his con- which was shaped by a lack of systems within medicine, trol, ranging from clinic policies transportation and a need to per- (pain agreements, a drug-testing including those intended form painful manual labor for initiative, a moratorium on pre- to benefit them. economic survival. scribing) to corporate bureaucra- Structural iatrogenesis is a type cies (insurance companies, fac- of “structural violence,” defined tory management) to larger-scale case, many of these structures as the systematic infliction of dis- social forces (poverty, lack of avail- had been instituted to protect pa- proportionate harm on certain ability of transportation, lack of tients at risk for opioid use disor- people by large-scale social forces opportunities for work appropri- der: clinicians acted according to such as resource distribution and ate for someone with a painful prevailing standards of care in hierarchies of race, gender, or lan- condition). chronic pain management; his guage.2,3 “Iatrogenesis” points to We call this type of harm prior clinic’s pain contract and the causation of such harm by “structural iatrogenesis” (see box). urine drug screens were meant bureaucratic systems that are Drawing on a long history of so- to prevent deviation from pre- potentially under clinicians’ or cial science scholarship,1 the use scribed opioid use that might health systems’ control.4 Clinical Implications: Stopping Structural Iatrogenesis Clinicians who identify structural women undergo pelvic exams be- have advocated for a new ap- iatrogenesis may alter structures fore receiving hormonal contra- proach. It’s important, however, or create action plans to prevent ception. Some clinicians noted to avoid the pitfall of thinking them from causing harm. Gen- that these exams were a barrier to that structural harm emerges eralizing from Mr. O.’s case, we contraceptive access and stopped only from “broken” systems. All would offer the following ap- requiring them in their own clin- structures carry a risk of harm, proach: ics. By the 1990s, these local even when they are functioning 1. Recognize and alter structures changes led to removal of the “properly.” The policy in Mr. O.’s that systematically harm patients. recommendation from national PCP’s office might have been Clinicians may be the first to policy, which increased access to working well for most patients, identify a structure that is sys- contraception and rates of effec- but it turned out to be a poor fit tematically harming patients and tive use.5 for Mr. O. can then advocate for or directly Similarly, if Mr. O.’s PCP no- 2. Bend policies according to con- effect change. For example, in ticed that her clinic’s opioid-pre- text. Attempts to standardize clin- the 1980s, the Food and Drug scribing policy generated frequent ical care in order to ensure high Administration and physician or- gaps in medication coverage for quality often inadvertently lump ganizations recommended that patients in general, she could complex phenomena into sim- n engl j med 380;8 nejm.org February 21, 2019 703 The New England Journal of Medicine Downloaded from nejm.org by ROBIN TITTLE on March 5, 2020. For personal use only. No other uses without permission. Copyright © 2019 Massachusetts Medical Society. All rights reserved. PERSPECTIVE Structural Iatrogenesis plistic categories. Such oversim- hemoglobin levels, may ignore motive (reducing payouts for plification, in turn, can create complex disease interactions and medications). Mr. O’s poor clini- structures within clinical care the social factors contributing to cal outcome was due in part to that harm patients more than diabetes and may create an in- tensions between these implicit help them. By questioning how centive for clinicians to drop agendas. Clinicians often con- such categories (such as “opioid particularly sick patients. In- sider such agendas to be outside misuse”) apply to particular pa- stead, one might identify patients their purview, but given that they tients and types of patients, cli- with particular vulnerabilities have such a significant impact on nicians can work to reduce the and adjust policies on the basis clinical outcomes, it may be risk of structural iatrogenesis. of their life context. more effective clinically to iden- The label of “opioid misuser,” for 3.