I’m in severe pain.” “My pain is 10 on a scale of 1 to 10.” “I really need some pain medication.”
Due to a growing epidemic of opioid addiction, it’s possible that physicians will react to such statements skeptically.
“Efforts to address widespread opioid abuse can have a potentially corrosive effect on patient-physician interactions,” says Bette Crigger, PhD, director of ethics policy for the Chicago-based American Medical Association (AMA) and secretary for the AMA’s Council on Ethical and Judicial Affairs.
If physicians perceive they are distrusted by law enforcement authorities or state medical boards, this can negatively affect both professional morale and patient care.
“When physicians are dissuaded from providing care for chronic pain through fear of being subjected to disciplinary action, or even possible criminal prosecution, patients suffer,” says Crigger. Constant messages about the dangers of overprescription of opioids, and stories of disciplinary action taken against physicians, risks creating a “climate of distrust,” she adds.
“Physicians can too readily become skeptical of patients who present with pain, even when the physician is willing to provide pain care,” says Crigger. Some physicians ask patients to adhere to a pain contract or submit to routine drug screening, as a condition to maintain a patient/physician relationship. “This can undermine both dignity and trust,” says Crigger.
Nearly nine out of 10 physicians said they “strongly supported” requiring patients to get opioids from a single prescriber and/or pharmacy, two-thirds strongly supported the use of patient contracts, and more than half strongly supported the use of urine testing for chronic opioid users, according to a June 2015 study from Johns Hopkins Bloomberg School of Public Health that surveyed 1,000 primary care physicians.1
Another ethical concern is the prospect of physicians functioning as informants for, or agents of, law enforcement. “Prescription registries are not intended for this purpose, of course, but do carry implications for patient confidentiality,” says Crigger. Even the perception that registries could compromise privacy or the primacy of the patient’s interests can be damaging, she says.
The AMA Council on Ethical and Judicial Affairs has identified the following issues of concern with respect to opioid abuse:
• The possibility of inappropriate prescribing.
“The possibility for inappropriate prescribing online exacerbates this concern,” says Crigger. Conducting an appropriate examination and diagnostic assessment is necessary to ensure that physicians fully understand the patient’s medical condition. “This is the foundation for a comprehensive, effective plan of pain care before issuing an opioid prescription,” says Crigger.
• The need for appropriate monitoring of the patient’s condition and response to the care plan so that treatment can be adjusted as needed.
• The need for accurate, timely documentation of clinical findings and the details and rationale of the specific care plan.
Physicians may lack the ability to recognize drug-seeking behavior and respond appropriately. “Efforts may be needed to ensure that physicians have access to appropriate training and resources to refine their skills in this area,” says Crigger.
- Hwang CS, Turner LW, Kruszewski SP, et al. Primary care physicians and prescription opioid abuse: A national survey. The Clinical Journal of Pain, 2015; 1 DOI: 10.1097/AJP.0000000000000268.
- Bette Crigger, PhD, Director, Ethics Policy, Secretary, Council on Ethical and Judicial Affairs, American Medical Association, Chicago, IL. Phone: (312) 464-5223. Fax: (312) 224-6911. Email: [email protected].
