Ethical opioids: What are today's standards of care?

All physicians have encountered a patient who is in pain or on pain medications. Pain is universal, and its alleviation is an age-old charge for physicians. To ease pain is to ease suffering and discomfort.

In the current age of opioid crisis and epidemic, however, prescription pads can feed dependence. Understandably, prescribing opioids can be a source of consternation for physicians. The prescription of opioids is fraught with ethical challenges. According to CDC data, more than 70% of drug overdose deaths in 2019 involved an opioid.

“Opioid misuse has become one of the gravest and most consequential public health threats facing the United States today,” wrote the authors of one study.

The Hulu miniseries Dopesick recently brought America’s opioid epidemic into the public consciousness anew, shining a harsh spotlight on its origins—how the painkiller OxyContin ravaged a downtrodden Virginia mining town and unleashed a national opioid crisis, with insight into the boardrooms of Purdue Pharma, the now-infamous Sackler family, and the roles of lawyers, the DEA, and the FDA.   

But, that said, opioids do have their place in the modern healthcare system.

Various stakeholders have advised physicians on considerations for prescribing opioids and how to do so in an ethical fashion. Here are some of the high points.

How to prescribe opioids

To begin with, it’s important to dispel the notion that opioids can never be prescribed. According to the CDC, “Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse or overdose from these drugs.”

The CDC Guideline for Prescribing Opioids for Chronic Pain offers guidance on prescribing opioids to adults aged 18 years and older in primary contexts. The focus of such prescription is chronic pain (ie, pain lasting more than 3 months or past normal tissue healing). Of note, this advice does not cover cancer treatment or palliative/end-of-life care. 

Here is what the CDC advises, outlined into three main focus areas:

• First, it’s important to determine when to initiate or continue with opioid treatment in patients with chronic pain. Treatment goals should be set, risks and benefits discussed, and nonopioid treatments considered.

• Opioid selection and dosages should be carefully considered. Other important factors include duration of treatment, follow-up, and discontinuation.

• When assessing risks or harms, risk factors and mitigation should be assessed. Other steps could include the use of drug testing and treatments for opioid use disorder in some populations. Of note, benzodiazepine co-prescription and drug monitoring are other issues.

Extending the WHO analgesic ladder

In 1986, the WHO formulated an algorithm for how to manage cancer-related and other intractable/refractory pain in a stepwise fashion.

1. Begin with nonopioid analgesics plus or minus nonpharmacologic approaches for mild pain.

2. Continue to weak opioids like codeine with or without nonopioids for mild-to-moderate pain.

3. Reserve strong opioids such as oxycodone plus or minus nonopioid analgesics for moderate to severe pain.

In later years, a fourth rung was introduced that constituted interventional pain management.  

In a 2020 article published in the AMA Journal of Ethics, experts contended that advances in surgery make it a better option to treat pain. According to the authors, surgery now provides a long-term, cost-effective means to curb the risks of opioid prescription, and a paradigm shift toward surgery instead of the WHO analgesic ladder should be considered. The authors also promoted the input of multidisciplinary teams including ethicists to assess pain concerns.

Institutional multidisciplinary teams could help develop comprehensive, personalized plans for patients with pain syndromes. These teams encompass a multimodal approach vs the step-wise approach of the WHO. They could include primary care pain specialists, physicians, neurosurgeons, and ethicists.

“In a broader sense, it would be important to have clinical ethicists provide input on (1) the value and consequences of choosing surgery vs nonsurgical options for pain management, (2) the risk of delay in offering surgery due to concerns about surgical complications vs the risk of initiating or continuing medical treatment, and (3) the value of introducing various alternative management strategies early with the patient’s involvement in decision-making process,” wrote the authors.

Considerations for opioid tapering

Legacy patients who are on opioids for a long period of time and desire to continue this treatment represent a special ethical case, according to another 2020 article published in the AMA Journal of Ethics. 

Although it may be tempting to taper these patients off opioids without their consent, this approach could be ethically impermissible. The choice to continue prescribing opioids lies in the distinction between initiation and continuance of patients on opioid therapy.

“This distinction is morally relevant for at least two reasons,” according to the authors. “[F]irst, because long-term opioid therapy patients can have profound physical dependence; and second, because what patients are entitled to can be affected by how they have been treated by the health care system in the past.”

In other words, feeling a duty to taper could directly harm a patient with physical dependence. (Some patients who are denied opioids have gone on to commit suicide.) Additionally, opioid dependence in these patients is iatrogenic, thus sympathetic, respectful care is necessary.

“Legacy patients are owed a certain amount of deference in choosing their treatment as a result of the situation in which the medical community has placed them,” wrote the authors.

Bottom line

The prescription of opioids is a complex web of ethical considerations. Many of these issues are nuanced, with approaches personalized. If you have access to a multidisciplinary team including medical ethicists at your institution, it may be a good idea to approach these experts with questions. Click here to read more from the AMA on facets of ethical opioid use.

Finally, check out How doctors can spot addiction in their patients, on MDLinx.