Ethical questions often emerge when treating patients’ pain with opioids or treating them for substance-use disorder—questions that do not arise in other parts of practice.
Experts have explored ethical issues in opioid prescribing and pain management in the AMA Journal of Ethics® (@JournalofEthics) and have examined numerous perspectives on related issues, such as providing care where the health and justice systems intersect, racial bias in treating pain, and the use of screening tools and surveillance.
“When Should Screening and Surveillance Be Used during Pregnancy?” Despite reasoned opposition to punishing pregnant women from all major medical and public health organizations, pregnant women who use illicit drugs remain vulnerable to disdain, discrimination and criminal prosecution. Diagnostic screening and surveillance technologies intended to deter women from using drugs have actually deterred women from seeking prenatal care and in-hospital births. If healthy births and breastfeeding are desired maternal-child health outcomes, physicians have responsibilities to ensure pregnant women’s access to the full range of evidence-based drug treatments.
“Why It’s Inappropriate Not to Treat Incarcerated Patients with Opioid Agonist Therapy.”Opioid agonist therapy within correctional facilities that is initiated prerelease has been found to be beneficial, yet few incarcerated persons receive this evidence-based treatment. In fact, most correctional facilities forcibly withdraw stable patients from therapy, which results in negative health outcomes for individuals and communities.
Physicians have roles in advocating for change to decriminalize addiction and increase access to evidence-based care for people addicted to opioids who are under correctional supervision. (The AMA has adopted policy supporting medication-assisted treatment for prisoners with opioid-use disorder.)
“A Clinical Ethics Approach to Opioid Treatment of Chronic Noncancer Pain.” In a relatively data-thin area of practice like chronic opioid therapy, it makes most sense to apply approaches to patient care that emphasize patient autonomy, shared decision-making, collaborative goal setting, attention to psychosocial factors, and quality of life enhancement. As this article suggests, goal setting is critical and must be broader than pain reduction. Goals must be specific, meaningful and personal—for example, being able to sit through a movie or walk a child to a bus stop.
“Opioids for Nonmalignant Chronic Pain.” As physicians consider when to prescribe opioids, it is prudent to use a screening tool that evaluates a patient’s risk of opioid misuse.
As argued in this article, if screening suggests that the patient is at lower risk of developing opioid-use disorder, a physician should still evaluate whether opioids are the best treatment for the patients’ pain, provide them information about alternative treatments and have a plan for the structure of care and patient monitoring. Physicians who are uncomfortable continuing to prescribe opioids for a patient do not have a duty to do so, but they should never abandon patients. Physicians should discuss risks of and alternatives to continued opioid treatment and refer patients who insist on continued opioid treatment.
“Education to Identify and Combat Racial Bias in Pain Treatment.” Racial disparities in health care and pain treatment are widely documented. African-American patients in particular receive lower-quality pain treatment due to institutional factors as well as bias from individual professionals. Collaboration, research and attention to health professional formation and development are likely the most valuable tools in reducing racial bias and eliminating disparities.
“Do Physicians Have an Ethical Duty to Repair Relationships with So-Called ‘Difficult’ Patients?” The 2016 winner of the AMA Journal of Ethics annual Conley Contest considers how to respond to pain for a hospitalized patient with a history of opioid use. Because of the qualitative aspect of pain, physicians are especially subject to errors of bias and perception, the author argues. This is one reason why the physician has an ethical responsibility to work to try to repair damaged patient-physician relationships.
The AMA Journal of Ethics is editorially independent from the AMA. Viewpoints expressed in these articles are those of the authors and do not necessarily reflect the views and policies of the AMA.
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Learn more about how the AMA Opioid Task Force is working to reverse the opioid epidemic through education, treatment, reducing stigma and more.