Ethics of Informed Consent for Opioid Discontinuation
Patients addicted to opioids often find themselves with nowhere to turn when they try to discontinue the medication.
“Unfortunately, for most of the past three decades, prescribers have not been providing this information to patients,” says Anna Lembke, MD, program director of Stanford (CA) University’s addiction medicine fellowship.
Physicians themselves were unaware of the risks. “They were taught that as long as the patient was being prescribed an opioid for a medical condition, their risk of addiction and adverse consequences was less than 1%,” says Lembke.
About a quarter of patients receiving opioids from a doctor will begin to misuse them, and approximately 10% will become addicted.1 Sixty percent of 809 long-term opioid users said doctors offered no advice on how or when to stop taking the drugs, found a 2016 survey conducted by The Washington Post and the Kaiser Family Foundation.2
On the local, state, and federal levels, says Lembke, “we are not doing an adequate job helping patients who have already become dependent on opioids through a doctor’s prescription.”
Many individuals on high-dose, long-term opioid therapy experience co-occurring psychiatric disorders. “The process of the opioid taper destabilizes not only their pain condition, but also their mental health,” says Lembke.
Opioid tapering must occur in a “humane and safe way,” says Lembke.
This is a slow process — months to years, in some cases — including mental health support and alternative pain therapies. “Not just prescribers, but also third-party payers, have an ethical obligation to conduct safe and humane opioid tapers,” says Lembke.
Any person who takes an opioid medication for an extended period of time can be expected to develop a physiological dependence on it, says Ben A. Rich, JD, MA, PhD, emeritus professor of medicine (bioethics) and school of medicine alumni association endowed chair of bioethics at UC Davis School of Medicine in Sacramento.
“This is not a pathological condition. It is the reason why patients who are discontinuing such medications must be weaned from them slowly,” says Rich.
The addiction potential of opioids, based on inadequate and flawed data, was seriously underestimated during the 1990s and early 2000s. “This misinformation was exacerbated by promotional undertakings by the pharmaceutical companies that manufactured these medications,” Rich says.
Physicians were strongly urged to consider prescribing strong opioids for chronic pain patients, even before less risky nonopioid medications and physical therapy were given a reasonable chance. “Physicians were admonished by national professional organizations, as well as the pharmaceutical industry, to recognize their ethical obligation to promptly and effectively address their patients’ complaints of pain,” adds Rich.
Rich says physicians have ethical and professional obligations to:
• provide patients with safe and effective strategies for withdrawing from opioids;
• monitor how well patients understand their role in the withdrawal process;
• meet regularly with patients to review progress toward successful withdrawal.
“If the opioid epidemic has any silver lining, it’s that it has forced medical schools to take the problem of addiction seriously,” says Lembke. Many medical schools are currently revamping curricula to teach addiction medicine, with a particular focus on safe opioid prescribing.
“Without the knowledge and skills, doctors will not be able to help, even when ethically mandated to do so,” says Lembke.
REFERENCES
1. Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain 2015; 156(4):569-576.
2. Survey of Long-Term Prescription Painkiller Users and Their Household Members. The Washington Post/Kaiser Family Foundation, 2016. Available at: https://wapo.st/2gJvF5T.
SOURCES
• Anna Lembke, MD, Program Director, Addiction Medicine Fellowship, Stanford (CA) University. Phone: (650) 725-9570. Email: [email protected].
• Ben A. Rich, JD, MA, PhD, Emeritus Professor of Medicine (Bioethics)/School of Medicine Alumni Association Endowed Chair of Bioethics, UC Davis School of Medicine, Sacramento. Email: [email protected].
Patients addicted to opioids often find themselves with nowhere to turn when they try to discontinue the medication.
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