Making Sense of Bioethics: Column 159: Opioids, Pain Management, and Addiction - Balancing Ethical

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Almost two million Americans are now addicted to opioids. The National Institute on Drug Abuse notes that more than 100 people die each day in the U.S. from opioid over­doses. This unprecedented lev­el of abuse — which involves not only heroin, but also prescription pain re­lievers such as OxyContin, Percocet, morphine, codeine, and fentanyl — has become a national crisis. Report­edly, about 80 percent of heroin ad­dicts first misused pre­scription opi­oids. Yet for many pa­tients, no pain-relieving options more effective than opioids exist. Figuring out how to use these pow­erful pharmacological agents in an appropriate and ethical manner is urgent and imperative.

At a minimum, a three-pronged approach is required. One prong in­volves working with medi­cal profes­sionals to limit the use and availabil­ity of these drugs by modifying pre­scribing practices. A second involves making patients more aware of the risks of addiction and increasing their involvement in monitoring their medications and managing de­cisions about their care. A third in­volves making effective addiction treatment and outreach programs accessible to those caught in the throes of chemical depend­ency.

With regard to reducing opi­oid availability, in recent years medi­cal professionals have been seek­ing to establish guidelines for pre­scribing opiates that take into account the number of pills typi­cally needed to get through a sur­gery or treatment. For example, recovery from more complex stomach surgeries might require 60 opioid pills, while an appen­dectomy or hernia might only require 15-20. Although pre­scrip­tion guidelines can be helpful, they clearly can’t be fixed in stone, as individual patients will have var­ying pain management needs. Some nurses recall well the days when concerns about addic­tion could result in under-medicated patients watching the clock and writhing in pain until the time of the next dose. Un­managed pain is a spiritual assault on the dignity of a person, and plays right into the hands of as­sisted suicide advo­cates.

Careful titration of pain med­ications, whether for surgery or chronic pain, also helps to avoid overmedicating patients and ren­dering them lethargic or semi-co­matose; in terminal situa­tions, pa­tients still have the right to prepare for their death while fully con­scious, and they should not gener­ally be deprived of con­scious­ness or alertness except to mitigate ex­cruciating or otherwise uncontrol­lable pain.

In certain cases, of course, it may not matter if a person be­comes addicted to pain medica­tions. If a patient has only a few weeks of life remaining, and he or she is ex­perienc­ing intractable pain such that high doses of opioids are the most ef­fec­tive approach, addiction during his or her final days and hours would not gener­ally raise ethical concerns.

There are alternatives to the use of opioids that may be suitable for some patients. These include the use of less-addictive or non-addictive drugs such as acetaminophen, ibu­profen, naproxen, or anesthetics and blockers at the pain site. Cognitive be­havioral therapy, stress manage­ment and relaxation techniques can help pa­tients learn how to modify triggers that increase pain. Specialists some­times remind us that bringing pain down to a tolerable level should be the goal, rather than trying to eliminate it entirely, which in many cases may not even be possible. Some patients may require assistance to come to accept even a limited amount of pain.

A San Diego-based pilot pro­gram to reduce the over-prescription of opioids included the novel step of notifying physicians when one of their patients had died from an over­dose. The San Diego medical exam­iner would send health care profes­sionals a letter in this format: 

“This is a courtesy communica­tion to inform you that your pa­tient [Name, Date of Birth] died on [Date]. Prescription drug overdose was either the primary cause or contributed to the death.” 

In follow up studies, physicians who received these letters were found to prescribe at significantly decreased levels, and they were also less likely to start new patients on opioids at all. Re­searchers speculated that, like eve­ry­one else, physicians tend to assess health and safety risks differently when bad outcomes spring readily to mind. At the same time, taking steps to restrict opioid availability can back­fire, with devastating conse­quences for chronic pain patients who may now end up being refused opioid pre­scriptions they need and have relied on for years. 

The proper use of pain medica­tions, in the final analysis, requires a balanced approach, attending to ob­jective indications from the patient, so clinicians can offer sufficient com­fort and remediation of their pain. Patients must also take responsibility for their own pain management deci­sions, be­coming informed about, and aware of, the challenges and risks. When the goal is to provide the low­est dose of opioids for the shortest amount of time, in direct response to the level and severity of the pain, pa­tients are likely to have better treat­ment out­comes with diminished risks of addic­tion.

Copyright © 2020, The National Catholic Bioethics Center, Philadelphia, PA. All rights reserved.

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