Physicians face ethical balancing act with pain management
MDs asking for opioid contracts, urine tests
Due to suspicions that some patients are "drug-seeking," and the fear of being accused of improper subscribing of pain medications to substance-abusing patients, some physicians are asking patients to sign opioid contracts or take urine tests before agreeing to prescribe pain medications.
Prescription opioid use skyrocketed from 2000 to 2010, but the identification and treatment of pain has failed to improve, according to a recent study.1
Matthew Daubresse, MHS, the study’s lead author and a research data analyst at the Johns Hopkins Bloomberg School of Public Health’s Center for Drug Safety and Effectiveness in Baltimore, says the findings were surprising, especially given that there was no significant change in the proportion of doctor’s office visits with pain or in the proportion of pain visits treated with pain relievers.
"Clinicians and patients should be fully aware of the trade-offs between different pain relievers," says Daubresse. "There are important risks associated with use of prescription opioids. Clinicians have an ethical obligation to be aware of these risks, and reserve use of these drugs only when clinically indicated." In September 2013, the Food and Drug Administration announced new labeling changes and post-market study requirements for extended-release and long-acting opioid analgesics.
The study’s findings also demonstrate the ethical implications of efforts to improve the identification and treatment of pain, says Daubresse, as these efforts may have contributed to an over-reliance on prescription opioids and reductions in the use of safer alternatives to opioids like ibuprofen and acetaminophen.
Robert L. DuPont, MD, president of the Institute for Behavior and Health in Rockville, MD, says physicians have an ethical responsibility to their patients and to their communities when the medicines they prescribe may harm their patients or others. "Giving addicts drugs of abuse is not helping them. Addiction is a disease of much suffering," says DuPont. "A substantial percentage of prescribed controlled substances is diverted for non-medical use. This misuse produces addiction and deaths, including overdose deaths."
DuPont says drug testing helps physicians identify patients who are not actually using the drugs prescribed for them, and patients who are using other drugs of abuse. "Patients identified as drug abusers, or addicts, deserve and need help," he says. "Drug testing can help physicians move that process along to better outcomes for their patients and their communities."
Physicians sometimes unwittingly provide potentially addicting and deadly drugs to patients who lie to them. "Drug testing is a useful tool to help physicians do a better job," says DuPont. "It is desirable for physicians to let patients know that drug testing is part of the care provided, and why this is so. The patient should also be informed about the consequences of a positive test result in advance of any testing."
Obligation to limit harm
Physicians have ethical obligations to try to relieve their patient’s pain and to limit preventable harm when prescribing pain medication, says Nathan Allen, MD, assistant professor of medicine and medical ethics at Baylor College of Medicine in Houston, TX. "Systematically, the medical profession has not been highly successful in meeting these twin obligations," he says. "Many patients’ pain is managed sub-optimally. Prescription pain medication misuse has become a rapidly growing problem in the United States."
Urine drug testing presents these ethical challenges, says Allen:
• Physicians’ ethical obligations as fiduciaries for their patients require them to place their patients’ interests before their own, generally speaking.
"For [physicians’] self-interests to be legitimate or given significant weight, they should be both highly impactful, reasonably probable, and the mechanism for addressing them as minimally impactful on the patient as possible," he says. "Legal and regulatory concerns are highly impactful, but they are both unlikely for a physician in general and highly unlikely in any single patient encounter." (See related story, p. 127, on whether opioid contracts are fundamentally unethical.)
• Minority patients are at greater risk of not receiving appropriate pain management, and may be more likely to be given urine drug tests than non-minority patients.
"This forms a justice consideration, as urine drug testing may risk accentuating disparities in care further," says Allen.
• Patient autonomy is threatened, whether pain medication is provided or not.
Providers risk impeding patient autonomy if they unilaterally determine that the risks of prescribing pain medication outweigh the benefits in a patient with addiction, and the same is true if providers offer a medication that an addicted patient may not be able to refuse. "How physicians balance these concerns is a tricky ethical challenge," says Allen.
• There is a threat to the trust underlying the doctor-patient relationship.
"Physicians risk using urine drug testing to find out Which patients are lying to me?’ rather than to identify patients at risk of harm and who may need treatment for another serious disease — drug addiction," says Allen. If urine drug testing is going to be used, then it is important to establish a uniform practice pattern, and disclose to the patient in advance that testing will be done and how it will be used.
Daubresse emphasizes that opioid contracts and urine tests represent only a few of the many tools available to physicians to address the ethical and practical issues related to providing analgesia.
"Other tools include risk assessments, clinical judgment, the World Health Organization’s analgesic ladder, and prescription drug-monitoring programs," he says. "Physicians must decide which of these tools is most appropriate for the patient being seen, using his or her own moral compass."
- Daubresse M, Chang HY, Yu Y, et al. Ambulatory diagnosis and treatment of non-malignant pain in the United States, 2000-2010. Med Care 2013;51:870-878.
- Nathan Allen, MD, Assistant Professor of Medicine and Medical Ethics, Baylor College of Medicine, Houston, TX. Phone: (832) 324-5690. E-mail: firstname.lastname@example.org.
- Matthew Daubresse, MHS, Research Data Analyst, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore. Phone: (410) 502-9052. E-mail: email@example.com.
- Robert L. DuPont, MD, President, Institute for Behavior and Health, Inc., Rockville, MD. E-mail: firstname.lastname@example.org.
- Anita Ho, PhD, Associate Professor, Centre for Applied Ethics, University of British Columbia/Director, Ethics Services, Providence Health Care, Vancouver, Canada. Phone: (604) 822-4049. E-mail: email@example.com.