Published by The New England Journal of Medicine

I’d seen Jerry in pain before, but never like this. He lay prostrate on the gurney in the emergency department, his hands clenched in silent prayer. I laid an apologetic hand on his shoulder and told him we would do what we could to help. Then I logged in to the bedside computer to order his pain medication.

When I clicked the “sign” button, a message appeared on the screen.

“This patient has a documented history of substance misuse. Are you sure you want to order this medication?” Two options appeared below the query: “Yes, continue with this order” and “No, cancel this order.”

It was true, of course. Jerry was the first to admit that he had used cocaine in the past, before his cancer diagnosis. In fact, it was one of the first things he told me when we met in the palliative medicine clinic, shortly after his escalating back and abdominal pain led to a diagnosis of widely metastatic cancer. During the same appointment, he told me how opposed he was to using any sort of controlled substance for his pain. Over the next few months, he submitted gamely to any nonopioid therapy I could offer, from nerve blocks to adjuvant analgesics to reiki and massage. Finally, when the pain became so bad that he couldn’t travel for his chemotherapy infusions, he agreed to start an opioid.