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How we talk about opioids can affect a patient’s treatment

More than 4,000 Arizonans overdosed on opioids last year, according to the state Department of Health Services. The agency says opioids led to more than 1,700 deaths in Arizona.

Policymakers have tried to mitigate the crisis, with steps like limiting the number of pills physicians can prescribe and the types of providers that can prescribe them.

Peter Torres says his research suggests how patients and their doctors talk about opioids could also play a role. Torres is an assistant professor in the Linguistics and Applied Linguistics Program in the English Department at Arizona State University.

Interview highlights

Do you find that physicians and patients talk differently about this kind of medication and this kind of treatment of pain than they do about other meds or conditions?

PETER TORRES: Yes, definitely. Yeah, because it's such a fraught issue. Patients pretty much come into the medical interaction or in their medical visits knowing very well that their cry for help might be perceived as a drug seeking behavior, right? Whether or not they are taking the opioids for pain or they are taking it because they want it, right. They are very aware that the crisis is happening. And so they have to adjust the way they speak about opioids.

And the problem with chronic pain is ... it's not easily visible. It's not like you can show off to your doctor and show a bruise or a cut and say, "OK, I'm in pain." This is something that is not objectively measurable. And at the same time, it's not physically visible.

And so not only do patients rely on their speech to express their pain and to convince the doctors that they need those opioids, physicians also have to rely on the way patients are expressing their pain when making prescribing decisions.

There also doesn't seem to be sort of a shared language to describe pain. A lot of doctors will talk about pain on scale of 1 to 10. What that one person considers a 10, somebody else might consider a 2, but they could be feeling the exact same thing.

TORRES: Exactly. Yeah, there's a lot of there's, there's a lot of cultural aspects that go to this as well. And also some gender aspects and, and so we have all these subjectivity on how we assign numbers to our pain, and it's not always necessarily going to be the same. And physicians have to adjust to the way we are expressing our pain and the way we are talking about our pain. But that's the problem with — especially in diverse areas where there are different people from different communities. When we are unfamiliar with how people talk about their pain or just how they use language, we might accidentally take their cry for help as a drug seeking behavior.

And that's actually what I found in one of my research, where I look at different doctor-patient interactions and how people talk about their pain. And it seems like, well, what we, what I found is that people who are from a community of color are less likely to be prescribed with medications, particularly with opioids. And white-identifying patients are more likely to be offered opioids without even asking for them.

Are there differences in the way people talk? Not necessarily the words they're using, but just sort of the voice they're using or the tone they're using when they're talking about this kind of thing?

TORRES: Yes. Yes. Yes. So, so what I found from my study is that a lot of women do use vocal fry when they express their pain. For those of you who are not familiar with vocal fry, you know, vocal fry has been, has been popularized by perhaps her image of Kim Kardashian, right? When you talk like this or you like you the lower end of your voice to create those creaky sounding voices, which are used by women a lot. But are stigmatized when women are using it. While on the other end, men use it a lot. I use it a lot.

I don't know if you're hearing it but I, I do talk like that. But we found — well, I found — that women are using creaky voice or vocal fry when they're expressing their pain, it seems to be effective enough to express pain, and it seems like it's the appropriate way to express pain based on how physicians are prescribing.

How does the relationship a patient has with their physician play into this?

TORRES: So, studies have shown that when there's a great relationship or collaborative relationship between patients and physicians, it actually is more likely to lead to alternative pain treatment that can wean patients off of opiates, right? But nowadays, with more stricter policies, that's actually conflicting with the collaborative relationships that patients and physicians have, because physicians now have to negotiate between treating their patients and making sure that they remain in good relationship with their patients. But then at the same time telling their patients, "Well, I might have to cut you off with opiates." Which we all know is probably not the best recipe for collaborative relationship. It just leads to more tension.

And because of my research on patients' voice and how they express pain, physicians are being more keen to listening to these cues that a lot of them have told me they never really paid attention before, but now they're paying more attention. So that when they are finding that perhaps patients are having difficulty expressing themselves or being uncomfortable because they are switching their pitch, for example, then accuse the physicians to lead back the conversation to their joint agreement or to their shared agreement when it comes to pain treatment.

Does that affect how the conversations go? Does that affect the, the language that either physicians or patients use or maybe the tone in which they're, they're speaking to each other when the law, when public policy comes into it?

TORRES: Yes. Yes. So the physicians are finding themselves having to change the way they discuss opiates or changing the way they implement these policies. I've noticed a lot of hedging, a lot of physicians are pretty much trying to speak about policies broadly now. So even if they have a close relationship with their patient, in some states, they have to ask for drug testing now. So these regular drug tests forces physicians to ask their patients to conduct a drug test, which they have never done before. And then that kind of leads to uncomfortable conversations. So what physicians do is they try to blame it on the policies, try to frame the patient as if they're part of a community.

Like, "Oh, you all who are taking opiates just have to take it." Right? Or sometimes they will be using inclusive language like, "We just have to take it," like, "We just have to do it, if you have time after you know, our appointment to go upstairs and do the drug screening."

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Mark Brodie is a co-host of The Show, KJZZ’s locally produced news magazine. Since starting at KJZZ in 2002, Brodie has been a host, reporter and producer, including several years covering the Arizona Legislature, based at the Capitol.