Ethics of prescribing choices in forefront

Addiction, untreated pain are both concerns

The relief of suffering, including suffering from untreated pain, is fundamental to the idea of ethical practice in medicine, according to Nancy Berlinger, PhD, a research scholar at The Hastings Center in Garrison, NY. “The development of palliative medicine as a subspecialty, with parallels in nursing and other clinical professions, and evidence of improved outcomes through the integration of palliative modalities into standard medical treatment, support the idea of access to pain relief as a basic right of patients,” she says.

However, it is well established that some medications that are effective in pain are potentially addictive and that some pain medications are misused — for example, diverted from their intended beneficiary to another party; or abused, as when they are consumed at higher dosages or in different ways than prescribed, adds Berlinger.

Recently, a number of states have implemented electronic prescription monitoring programs, allowing physicians to determine if a patient has been prescribed opioid analgesics from other physicians in the recent past. “This information should be factored into the clinical assessment of the patient in determining the appropriateness for initiating a trial of opioid therapy,” advises Ben A. Rich, JD, PhD, professor and School of Medicine Alumni Association Endowed Chair of Bioethics at University of California — Davis Health System. “Careful monitoring and follow-up appointments are essential to assuring that these medications are being taken as directed, and that they are producing both reduced pain and increased functionality in order for their benefits to outweigh the risks.”

The term “drug-seeking” is generally used to describe a patient who makes false claims about pain in an effort to persuade physicians to prescribe opioid analgesics for which there is no legitimate medical need, notes Rich. “Viewed outside the special parlance of pain medicine, there is nothing strange or insidious about people with certain medical conditions seeking drugs known to be effective in treating or managing them — just as we engage in ‘food-seeking’ behaviors when we are hungry,” he says.

Patients might engage in such behavior because of a substance abuse disorder, for recreational use of such medications, or to divert them for financial reasons, however. “Another complicating factor is that there is no litmus paper test for distinguishing between patients with real pain who might benefit from such medications and individuals who seek them for illegitimate purposes,” says Rich. “The preferred approach involves taking a detailed medical history, conducting a physical examination, and, whenever possible, accessing medical records for the patient.”

Complicating factors

Patients requesting pain medication present in various settings, including the emergency department, primary care, outpatient specialty care, and inpatient care. “The context in which a patient presents may influence — fairly or unfairly — how a provider sees this patient,” says Berlinger. “Is this a person in pain to whom my ethical obligation is clear — namely, to treat the pain, and the person, appropriately?”

Physicians often struggle with their obligations to a person whose addiction to pain medication is a consequence of long-term medical treatment for physical pain, or when they strongly suspect that drug diversion is occurring. “Pain is exceedingly complex. It is not always possible to make a hard distinction between patients who request pain medication to treat pain and ‘drug-seeking’ patients who request medication with the intent to misuse or abuse it,” says Berlinger. The patient whose behavior suggests “drug-seeking,” such as having duplicate prescriptions from different providers, might also be a patient with an underlying medical condition that is known to cause significant pain, for example.

In some cases, someone may be stealing the patient’s medication or has coerced the patient into diverting medication, or there might be a need to revisit the patient’s medication plan or to help the patient adhere to it.

“Professionals who work in hospitals should be able to consult with their institution’s ethics service about ethical challenges in the care of patients suspected of drug-seeking,” advises Berlinger. “Ethics consultation, or a social work intervention, may also be helpful when a professional suspects that a patient’s pain is being undertreated because the patient’s medication supply is being diverted.” (See related story, p. 41, on ethical responses.)

Sources

  • Nancy Berlinger, PhD, Research Scholar, The Hastings Center, Garrison, NY. Phone (845) 424-4040, ext. 210. Fax: (845) 424-4545. E-mail: berlingern@thehastingscenter.org.
  • Gregory L. Eastwood, MD, Professor of Bioethics and Humanities, Past President, State University of New York Upstate Medical University, Syracuse, NY. Phone: (315) 464-8454. E-mail: eastwood@upstate.edu.
  • H. Steven Moffic, MD, Milwaukee, WI. Phone: (414) 352-1985. E-mail: rustevie@mac.com.
  • Ben A. Rich, JD, PhD, School of Medicine, University of California--Davis Health System. Phone: (916) 734-6010.. E-mail: barich@ucdavis.edu.

Consider ethics with responses to drug-seeking

The challenge of “drug-seeking” patients is commonplace in clinical settings for adolescents and adults, and can even present in pediatric settings via the proxy desire of a parent to use the child’s addicting medication, says H. Steven Moffic, MD, a former professor of psychiatry and family and community medicine at the Medical College of Wisconsin in Milwaukee and author of The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare (Jossey-Bass, 1997).

“Ethical responses to drug-seeking patients get at the heart of potential ethical dilemmas for physicians in trying to care for our patients,” says Moffic. “That is, how do we try to provide beneficial treatment with as little harm as possible?” Here are possible responses to a “drug-seeking” patient and ethical considerations:

• The physician can refuse to prescribe.

Significant undertreatment for chronic addiction can be as risky as contributing to the ongoing addiction or overprescribing the amount of medication, warns Moffic. “If the patient takes too little of a medication they are addicted to, they are at risk for severe withdrawal symptoms, some of which are even life-threatening, like seizures,” he says.

A refusal to prescribe is appropriate when a physician is presented with clear and convincing evidence that a patient has no legitimate medical need for such medication, or despite the need, fails or refuses to take the medication as directed, according to Ben A. Rich, JD, PhD, professor and School of Medicine Alumni Association Endowed Chair of Bioethics at University of California — Davis Health System.

“Arguably, there should be a similar refusal when a patient demands antibiotics for a condition that will not respond to them,” says Rich. “However, there is an important distinction between refusing to prescribe an opioid and refusing to provide other options for addressing a legitimate pain problem. Opioids, after all, are just one among many modalities of treatment for pain.”

Patients who categorically resist a nonopioid therapy are raising a red flag that they are more interested in the drug than in relief for their pain, with the exception of patients with sickle cell disease, says Rich. “They have well-recognized pain crises that require strong medications for relief on an urgent basis,” he says. “Their knowledge of pain medications and their insistence on prompt treatment often causes physicians to label them as drug seeking when they are really just desperate for relief.”

A 2011 Institute of Medicine report, Relieving Pain in America, indicates that undertreatment of pain is persistent and pervasive. “We also now know that inadequately treated pain can become a lifelong problem for patients and their families,” adds Rich.

Rich notes that the term “pseudoaddiction” was coined to identify patients whose pain is so severe and whose care has been so inadequate that they behave in ways that suggest they are “drug-seeking” in the illegitimate sense. “But they are, in actuality, acting rationally as genuine patients desperate to find a physician who will provide them with the analgesia that their condition requires in order for them to have an acceptable quality of life and level of function,” he says.

• The physician can terminate the physician-patient relationship.

Occasionally, a physician will consider “firing” a patient suspected of drug-seeking behavior. “Barring a patient from receiving medical services is ethically problematic, and potentially unethical, for several reasons,” says Nancy Berlinger, PhD, a research scholar at The Hastings Center in Garrison, NY. It may constitute abandonment if the facility was the patient’s only source of health care.

“It is likely to ‘turf’ the problematic patient to another provider, as cutting off a patient who is abusing or misusing drugs does not, itself, address the cause of the drug-seeking behavior,” says Berlinger. “In particular, it is likely to kick the problem to the nearest public ED, which, because it functions as a community benefit, cannot easily ‘fire’ patients.”

The professional who is considering “firing” a patient suspected of drug-seeking should instead develop an adequate and realistic care plan for this patient, recommends Berlinger. This might involve discussing addiction directly with the patient, and consulting with specialists in addiction medicine and the treatment of prescription medication abuse.

• The physician can give the patient a referral.

Any patient who shows signs of an addiction disorder should be referred to an appropriate specialist, but the problem is that in some locations there is a dearth of specialists in addiction medicine, says Rich.

“In a pinch, consultation with an addiction specialist is an option,” says Moffic. “If one suspects the patient is self-medicating an underlying psychiatric disorder, like depression or bipolar, then a psychiatrist should be consulted.”

It is important to recognize that patients who have or might be at risk for an addiction disorder can still present with serious pain issues that need to be treated along with the addiction, Rich underscores. “When the patient’s situation is complicated and challenging, referral to a pain medicine specialist and/or a specialist in addiction medicine would be appropriate,” Rich says.

Time-pressed physicians sometimes get into a habit of prescribing pain medications simply because it’s easier to do so, says Gregory L. Eastwood, MD, professor of bioethics and humanities at State University of New York Upstate Medical University in Syracuse. “What should be done in many of these situations is to provide a referral, but that is easier said than done,” Eastwood says. “Services are not always readily available all over the country.”