Focus on ethics of narcotics prescribing

Over- and under-treatment are both concerns

Prescribing potentially addictive medications "is often a very challenging situation for physicians," says David A. Fleming, MD, MA, FACP, professor and chairman of the Department of Internal Medicine and director of the Center for Health Ethics at University of Missouri in Columbia. "We have to pause and take time to connect with the patient and think the situation through, to come up with the right response. It is very important that we are prescribing for the right reasons."

The number of narcotic prescriptions in America has increased dramatically in recent years, and prescription drug abuse is the nation's fastest-growing drug problem.1,2 This increased demand may be based on the intensified marketing efforts of the pharmaceutical industry through direct-to-consumer advertising, according to a recent study.3

If a patient asks for narcotics that the provider doesn't believe is medically indicated, Fleming says it is reasonable to instruct the patient to go back to the provider who originally prescribed the medication and ask if they will continue it. "If the patient says, I tried that, but my other doctor wouldn't give that to me anymore,' that often helps to validate the decision I make not to prescribe," he says.

It's clearly unethical if a provider prescribes a controlled substance for financial gain or other self-serving reasons. However, addiction can result from sound medical practice when narcotics and other controlled substances are given for legitimate reasons, says Fleming. "Patients often become addicted to narcotics when prescribed and taken for long periods," he says.

Physicians might inappropriately prescribe narcotics because patients demand these when they are drug-seeking for illegitimate reasons, or even when they feel their pain is not adequately relieved, says Fleming. "We should be careful not to respond to threats or coercive behavior," says Fleming. "When it's appropriate to treat, we should treat. It's also easy to take the path of least resistance when under pressure or when busy, but it's OK to say no sometimes." If providers believe they have the evidence needed to make a medical decision whether to prescribe or not to prescribe, they should feel comfortable making the appropriate decision in spite of those pressures, he says.

If a patient gives a reasonably plausible explanation for why a prescription needs to be refilled, it may be faster for the physician to prescribe and get to the next patient than to carefully consider the situation. "That is a slippery slope that we can go down very quickly when we are not being objective," says Fleming. "Not every patient with back pain is the same. Different patients have different needs, different findings, and different levels of pain." Physicians need to customize responses to the specific needs and concerns of every individual patient, he emphasizes.

"Physicians are increasingly under pressure to offer prescriptions for controlled substances. The public is used to getting what they want and need to make them feel better, younger, and more productive," says Fleming. "We must be ever vigilant that what we are giving patients is medically indicated and ethically appropriate." (See related story, below, on unethical prescribing practices.)

Pain undertreated

Even if a chronic pain patient has been taking narcotics long-term and is asking for more medication, providers have to avoid being judgmental, says Fleming. "Because a patient comes to us unkempt, unbathed, or covered in tattoos, we should not jump to the conclusion that they are trying to game the system. There may be very legitimate reasons for a request to refill or provide a new prescription for narcotics," he says.

Narcotics can be overused and misused, acknowledges Fleming, but under-treatment of pain remains a serious concern.4 "Patients with chronic illness or conditions that cannot be cured may experience severe pain, but for various personal reasons they are hesitant to take narcotics because they don't want to become addicted," he says. "Physicians have an obligation to advocate for the use of controlled substances like narcotics when they are medically indicated."

Physicians might also under-prescribe narcotics when patients legitimately need them because they fear sanctions, says Fleming. "The problem is that the pendulum may have swung the other way in our prescribing habits," he says. "The evidence is very strong that we still under-treat pain." n

References

  1. United States. Office of National Drug Control Policy. Epidemic: Responding to America's prescription drug abuse crisis. Washington, DC: Executive Office of the President of the United States, [Office of National Drug Control Policy], 2011.
  2. Centers for Disease Control and Prevention. Policy impact: Prescription painkiller overdoses. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/homeandrecreationalsafety/rxbrief/index.html.
  3. Greene JA, Kesselheim AS. Pharmaceutical marketing and the new social media. N Engl J Med 2010;363(22):2087-2089.
  4. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC. The National Academies Press: 2011.

Sources/Resources

  • Harold J. Bursztajn, MD, Associate Clinical Professor of Psychiatry, Harvard Medical School, Boston. Phone: (617) 492-8366. Email: harold_bursztajn@hms.harvard.edu.
  • David A. Fleming, MD, MA, FACP, Professor and Chairman, Department of Internal Medicine/Director, Center for Health Ethics, School of Medicine, University of Missouri, Columbia. Phone: (573) 884-2013. Email: flemingd@health.missouri.edu.
  • New guidelines from the Food and Drug Administration include requirements for prescriber continuing education and patient counseling for prescribing of potentially addictive medications. (To view the FDA guidelines, go to www.fda.gov. Click on "Drugs," "Drug Safety and Availability," "Information by Drug Class," and "Opioid Analgesics — Risk Evaluation and Mitigation Strategies (REMS) for Extended-Release and Long-Acting Opioids.")

Avoid these unethical prescribing practices

Prescribing potentially addictive medications without obtaining adequate informed consent that covers risks including addiction and withdrawal is a clearly unethical practice, according to Harold J. Bursztajn, MD, associate clinical professor of psychiatry at Harvard Medical School in Boston and president of the American Unit of the United Nations Educational, Scientific and Cultural Organization (UNESCO) Bioethics Chair in Cambridge, MA.1 He says these are other unethical prescribing practices:

  • Failure to present the risks of withdrawal and side effects of non-schedule II medications such as atypical antipsychotics;
  • Failure to rule out drug-seeking behavior in patients who show impairments consistent with drug-seeking;
  • Stigmatizing all chronic pain patients as drug-seeking;
  • Failure to inform patients of potential conflicts of interest based on direct or indirect ties between the prescribing physician and the pharmaceutical company;
  • Failure to perform an adequate medical and psychiatric evaluation to rule out treatable causes of chronic pain or sleeplessness;
  • Failure to rule out comorbid medical and psychiatric disorders;
  • Failure to inform the patient about potential cognitive and motor impairments relevant to daily function.
  • "Providers should educate patients as to risks of addiction, and alternative non-addictive treatment modalities vital to the standard of care," says Bursztajn.2

References

  1. Bursztajn HJ, Brodsky A. Ethical and legal dimensions of benzodiazepine prescription. Psychiatric Ann 1998;28(3):121-128.
  2. Johnson B, Bursztajn HJ, Paul R, et al. Reducing the risk of addiction to prescribed medications. Psychiatr Times 2007;24(4).