How to Talk to Your Doctor When You Use Substances

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When you use substances, such as alcohol or drugs, it can be difficult to get healthcare services. Doctors are known to sometimes discriminate against patients who use substances, those who have a history of substance use, or people who have other addictions. This discrimination can show up in several different ways.

Getting access to a doctor can be difficult. Many people who use substances find that they have to apply to doctor's offices to become a patient, and then never hear back from them.

Others are able to see the doctor, but they find that if they disclose their substance use history, they are unable to obtain prescriptions for medications they need, or they are refused necessary treatment, even for conditions which seem unrelated to their substance use, unless they commit to "getting clean and sober" first.

Even when you are able to see a doctor, and they provide you with treatment, visiting your doctor can sometimes be an upsetting and even traumatic experience. The doctor might ask about why you began using substances—a much longer story than you could fit into 10 minutes, and perhaps one you don't want to tell. You might feel pressured by your doctor to discontinue substance use, as this is often something your healthcare provider will be concerned about. They may ask whether you are thinking of using again, once you have become abstinent. For some people with a history of substance use, this can be enough to put them off visiting their doctor at all.

Why Do Doctors Discriminate Against Addicted Patients?

Discrimination against patients has been taking place within healthcare for decades. The more time and effort a patient requires, the more likely he or she will experience discrimination. The more that the doctor will be asked to do something that he or she may not feel comfortable doing, the more likely the patient will be discriminated against.

This is not an excuse, and it is not a suggestion that these practices are OK. If you better understand your physician's point of view, perhaps you can better understand how to get what you need.

Doctors and healthcare service providers do not get paid for spending time with you. They get paid the same amount of money whether they spend five minutes with you or an hour with you. No matter whether you have public or private insurance, each year providers negotiate how much they will be paid for each type of service they provide. And historically over the past several years, that amount of payment has gone down.

Look at it this way: In your job, you continue to do the work you are supposed to do. You continue to work all the hours you are supposed to work, yet your boss decides to pay you less this year than you were paid last year, which was less than the year before, and so on. Is this right or fair? No. But it's reality for doctors.

If you are self-employed, you know you also have to pay rent, pay your staff (including health insurance), pay for all the materials used to provide the services you offer—but you are being paid less than you were paid before. This is what doctors face.

The solution?

You still need the income you were getting before, possibly more as costs usually go up, so the only way to make up the difference is to see more patients in the day. To see more patients, you have less time with each patient. If you have less time, then you need some way to screen which patients will take too much time. This is why it is so difficult for patients who have any sort of difficulties with their medical care to see a doctor. Ironically, those in good health have easier access to healthcare. While neither right nor fair, that's how our American system of healthcare works, and to some extent, how healthcare works in other countries as well.

You might think that this does not matter—maybe you can't work  or don't want to work, and you can't relate to this. Your doctor may seem rich and successful compared to you. But they may have real concerns about whether they can sustain their practice. It costs a lot of time and money to get qualified, to set up and to run a practice, to pay for the building and the staff, and they need to see a lot of patients to make it work. 

Discrimination Related to Pain Medications

There is also a particular type of discrimination against people needing pain medications, particularly those who seem dependent on painkillers. There are federal and state laws that overrule what a doctor might like to provide versus what is considered legal. A doctor who treats pain patients with drugs can too easily fall into that gray area—and they could be arrested before anyone asks for explanations.

Doctors who over-prescribe, meaning that according to the federal standards, they are prescribing more pain medications than they are supposed to (which does not always makes sense), will lose their licenses. Even if they don't lose their licenses, any sort of interruption in their practice can cause problems, and not just for that doctor and his or her staff, but for all of his or her patients. So, most doctors will just refuse to see patients they do not know who are requesting pain medications, rather than risk everything else.

Another reason that doctors discriminate against patients requesting pain medications is out of genuine concern that those medications will be either over-used by the patient, or sold on to someone else, who could potentially be harmed or even killed. Over the past few decades, more and more people have developed addictions and other problems in relation to prescribed pain medication, and there are more people dying of overdoses, from taking too much of these medications than ever before.

Difficulties in the Therapeutic Relationship

Doctors also have a therapeutic relationship with their patients. For the relationship to be mutually beneficial, and for the doctor to be able to help the patient, there needs to be mutual trust. Many doctors feel unable to help people with addictions, and some have actually been harmed by people with addictions themselves.

Although no one should discriminate based on isolated incidents, in some situations, people with addictions have been abusive and even violent toward doctors or their staff. They may lie about the severity of their addiction or other symptoms, making it difficult for the doctor to help them properly. Addicted patients can sometimes resort to manipulative behavior, such as double doctoring, selling medications illegally, lying about their symptoms to get more prescription drugs, and stealing medical supplies and personal belongings of staff and other patients.

Although this might not be your behavior, and there may be no circumstances where you would do these things, any time this happens, it reinforces the stereotype that people with addictions or who use substances all do these things. When doctors feel the addicted person does not really want their help quitting, but just wants to take advantage of them, taking on patients who use substances can seem like more trouble than it is worth. Until people who use substances are able to change their untrustworthy image, this discrimination is likely to continue.

What to Do If You Need to See Your Doctor

The key to overcoming the stigma that people who use substances and those with addictions face is to be the exception to the stereotype. Show respect for your doctor and her or his staff. This means taking the time to make sure you are clean and tidy in your appearance, you listen before you speak, and you speak with respect to the staff and physicians.

Although you may feel frustrated or even offended by the attitude of the doctor or staff, be careful not to be insulting or even sarcastic when you speak. Substance use can affect people's self control, but this is one time when it is really worth making the effort. Remember, you are the expert on your personal experience, but the doctor is the expert of what can help you to get well.

If your visit to the doctor is not directly related to your substance use, and he or she does not ask about your substance use history, it may not be necessary to discuss it with him or her. However, often your substance use history is important, so make sure you tell them about this if asked, as well as where you are in your process of thinking about treatment.

Many doctors are moving towards non-medication treatments for a variety of conditions, both because of problems people develop as a result of taking medications—including side effects as well as addictions—and because other treatments can be more sustainable and a healthier choice in the longer term. So don't take it personally if your doctor suggests a non-medication approach to managing your condition, and give it a fair try, rather than deciding right away it is not working.

If you suffer from chronic pain and you have a history of substance use or addiction, understand that your doctor may need to explore some alternative methods of treatment that don't put you at risk of relapse. Try to keep an open mind, and recognize that chronic pain is difficult, but not impossible to treat without medications. In some cases, going on a set dose of methadone can be a way of managing pain and avoiding relapse to other opioids. In other cases, making behavioral changes and using alternative treatments, such as mindfulness based stress reduction, can be effective enough to manage. These approaches won't block pain in the same way that drugs do, but they won't cause you harm. No one can avoid pain entirely, and a non-medication approach can make life bearable without addiction.

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