The opioid epidemic is a growing cause of concern in the United States and much of North America. The main problem is the deaths related to the prescription overdoses, estimated to stand at 15, 000 deaths per year in 2015, and the number has increased since then. Most of the deaths are from respiratory depression and co-administration of central nervous system (SNS) depressants such as benzodiazepines. According to Gomes at al. (2017), co-administration of benzodiazepines with opioids increases the risk of the overdose death by for times, suggesting that using the two drugs together is the primary driver of the opioid epidemic that is currently mutating into a massive health crisis. The involvement of the health workers in the epidemic makes the issues complex from an ethical perspective.
Physicians prescribe opioids to relieve pain for patients suffering from certain conditions or after surgery. The drug is valued for its effectiveness and safety when used correctly. However, a problem arises in a case of abuse when a patient in need of opioids also abuses benzodiazepines. The physician may or may not be aware of the drug abuse history of the patient, which makes it harder for doctors to make an appropriate prescription. This problem has led to the introduction of the black box label on opioids to warn patients of the risk of using the drugs with benzodiazepines (Dart et al. 2015). The dilemma is whether physicians should prescribe opioids or benzodiazepines until they establish the patient has no history of the abusing either.
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Healthcare providers are part of the reason for the opioid epidemic and therefore, should help prevent opioid-related deaths by ensuring patients use them responsibly. One way of doing that is treating patients after they sign “pain contracts” that include the terms of treatment and the risks and the benefits of treatment (Schatman & Webster, 2015). The contract can also include prohibited behaviors such as the abusing benzodiazepines or any mood-altering drug or selling the drugs to others. For patients who are not complying with the terms of the contract, they risk discontinuation of treatment. The goal of this arrangement is not just punishment, but foster shared decision making where the patients understand the benefits of opioids when used well and the risk in case of abuse.
However, efforts to limit the risk of opioid abuse by healthcare workers might infringe on patient autonomy. While trying to optimize outcomes, physicians should respect the decision of the patients. If patients decide to abuse benzodiazepines, doctors cannot refuse patients pain-relieving opioids, especially in severe cases, for patients who have cancer and similar conditions. It is better in this case to establish a trusting relationship with the patient to understand their motivation for the abuse and possibly refer them for psychiatric care (Miller, 2012). The role of the physicians requires delicate balancing to offer care while respecting patient autonomy.
Another way of looking at the ethical issues is the shared responsibility for the proper use of opioids between the patient and the prescriber. While the goal of the prescriber is to relieve the pain of the patient, he or she has an additional role in minimizing the harm. Therefore, despite the autonomy of the patient, the physician can overrule the patient if the case of apparent injury or an illegal action (Stratton, Palombi, Blue & Schneiderhan, 2018). Some patients get medication and divert them for illegal use, and in such cases; physicians are under an ethical obligation to protect the patient by stopping the medication and even inviting law enforcement agencies. The patient is likewise under obligation to use medication according to the advice of the doctor.
References
Dart, R. C., Surratt, H. L., Cicero, T. J., Parrino, M. W., Severtson, S. G., Bucher-Bartelson, B., & Green, J. L. (2015). Trends in Opioid Analgesic Abuse and Mortality in the United States. New England Journal of Medicine , 372 (3), 241–248. doi: 10.1056/nejmsa1406143
Gomes, T., Juurlink, D. N., Antoniou, T., Mamdani, M. M., Paterson, J. M., & Brink, W. V. D. (2017). Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case–control study. PLOS Medicine , 14 (10). doi: 10.1371/journal.pmed.1002396
Miller, M. (2012). Patient Satisfaction, Prescription Drug Abuse, and Potential Unintended Consequences. Jama , 307 (13), 1377. doi: 10.1001/jama.2012.419
Schatman, M., & Webster, L. (2015). The health insurance industry: perpetuating the opioid crisis through policies of cost-containment and profitability. Journal of Pain Research , 153. doi: 10.2147/jpr.s83368
Stratton, T. P., Palombi, L., Blue, H., & Schneiderhan, M. E. (2018). Ethical dimensions of the prescription opioid abuse crisis. American Journal of Health-System Pharmacy , 75 (15), 1145–1150. doi: 10.2146/ajhp170704
