A 46 yo M with diabetes, hypertension, a 30 pack year smoking history, and low back pain that has been treated with oxycodone ever since a failed back operation 1.5 years ago presents to your office for routine follow-up. It's 10am, the hospital allots 15 minutes for routine appointments, and your next patient is in the waiting room. You are his physician -- what do you prioritize?
Smoking, diabetes, and hypertension are a perfect storm for a heart attack in the next 10 years, so how much time do you want to spend optimizing antihypertensive meds and glucose control? You could talk to him about quitting smoking, which is pretty high-yield since it would lower his cardiovascular and cancer risk. On the other hand, he doesn't seem particularly motivated to quit right now.
You would like to see him exercise more and eat better, since his blood sugars are not too bad yet, and you might be able to spare him daily insulin injections. But, his back pain is so bad that walking is difficult and exercise is out of the question. Tylenol and ibuprofen only "take the edge off". Oxycodone is the one thing that seems to really help. He asks you to refill his prescription, especially because "the pain is so bad at night, I can't sleep without it".
His quality-of-life is already poor, and it would become miserable if you took away his opioid script without providing some other form of pain control. You believe that he might benefit from physical therapy and time. He is willing to try PT, but he is adamant that he will not be able to "do all of the stretches and stuff" without taking oxycodone beforehand.
You now have 7 minutes to come up with a plan he agrees on (you're there to help him, after all), put in your orders, and read up on the next patient. How do you want to allocate your time? What if you suggest cutting down on his oxycodone regimen and he pushes back?
I don't know if there is a good answer. But these situations happen all the time, and someone has to make a decision. Most doctors are normal people. The different backgrounds, personalities, willingness to engage in confrontation or teaching, and varying degrees of concern for public health vs. individual patient needs, etc. lead to a variety of approaches. In the end, I think that pharma payments have a marginal effect on most doctors who have families, bosses, insurance constraints, a full waiting room, and are faced with the patient above.