Opioids and the Moral Issue for Physicians

The opioid epidemic in the United States is worsening. Opioid-related and drug overdose deaths continue to increase, with over 500,000 individuals having passed away within the last two decades. The number of deaths from prescription opioids has quadrupled and nowadays in the United States, an individual dies from opioid overdose every 19 minutes!

Opiates are alkaloids that derive from the opium poppy. They are a natural pain remedy that several types of drugs are made from. Types of opiates include morphine, heroin, opium, and codeine. Opioids, on the other hand, are synthetic pain medications that work similar to opiates. Types of opioids include methadone, vicodin, and oxycodone. When it comes to opiates vs opioids, opiates have a higher incidence of abuse due to their potential of activating opioid receptor sites. Used appropriately, they can help relieve painful symptoms; however, when taken excessively, they can lead to addiction.

The opioid epidemic, also known as the opioid crisis, is the swift rise of prescription and non-prescription opioids in the United States and Canada. The epidemic began in the 1990s, when physicians became more aware of the burdens of pain. At this time, pharmaceutical companies saw an opportunity to increase sales and they targeted doctors with deceptive marketing about the safety and efficiency of opioids in treating pain. Several physicians, intrigued by the idea of helping difficult to treat patients, abide. As of this year, health experts reveal that since the opioid crisis is becoming more severe, another 500,000 individuals could die from the epidemic in the coming decade.

Pain is one of the most common reasons why patients seek your help and relief of pain is ultimately your primary obligation. Yet over the last few decades, as newer opioids were being developed, physicians began adjusting to a different form of prescribing, for chronic pain as well. Unfortunately, misusing prescription opioids has become what is known as “a public health crisis”. Statistics show that the U.S. opioid epidemic of 2015 had led to:

• 12.5 million individuals misusing prescription opioids;
• 2.1 million individuals using prescription opioids for the first time;
• More than 15,000 deaths resulting from overdose of commonly prescribed opioids;
• More than 78 billion dollars in economic costs;

In a recent study, researchers looked into the medical records of around 10,000 patients with chronic pain, being treated within the years of 1997 and 2005. The study found that 51 patients had experienced overdose, of which 6 were fatal. While the overall risk of overdose was a relatively small percentage, it clearly showed a connection to the initial dose of medication being prescribed. The patients receiving the higher doses were 9x more likely to overdose than those receiving lower doses. “The overall risk among people who continued to use opioids was 0.25% per year (or two overdoses per 1,000 people)” said Michael Von Korff, co-author of the study and senior investigator at the Group Health Research Institute in Seattle.

According to findings presented at the American Academy of Pain Medicine’s yearly meeting, methadone, a drug being used to treat chronic pain, was responsible for more than 5% of opioid prescriptions in the United States between the years of 1999 and 2009. Moreover, it accounted for over 30% of opioid-related deaths. The risk of this particular drug is significantly higher than others because it is less expensive and attracts less enquiry.

Today, one of the main challenges that physicians, such as you, face is how to respond to the opioid epidemic without harming patients in pain. As a healthcare professional, it is your duty to preserve the role of opioid prescriptions by educating yourself and your patients on safety and legal regulations. Patients who have been on high doses of opioids for years pose a rather difficult challenge. Half believe that the opioids are improving their health, while the other half fear they will experience withdrawal symptoms if their medication is taken away. If managed poorly, such patient populations can result in drastic consequences. Of course, opioids cannot be eliminated altogether and so the United States health system has started to create comprehensive approaches to reduce the risk of misusing and abusing opioid prescriptions.

The opioid risk tool (ORT) is a self-reporting tool specifically designed for adult patients in clinical settings, in order to assess the risk of opioid abuse. The tool looks at patients prescribed opioids for chronic pain treatment and takes into account several factors such as age, personal history of substance abuse, family history of substance abuse, history of preadolescence sexual abuse, and psychological disease. Patients are then categorized as either low risk or high risk of future opioid abuse behavior. The ORT can be put into use and evaluated in under 1 minute; however, it can only be assessed in patient populations with chronic pain.

The SAMHSA – the Substance Abuse and Mental Health Services Administration – offers an educational course for physicians for responsible opioid prescribing. It addresses specific strategies for managing difficult patient situations. Moreover, Drug Monitoring Programs (PDMP) now help to monitor prescribing patterns of physicians as well as the frequency and quantity of prescriptions filled by patients. Finally, encouraging patient referrals to pain management programs or addiction specialists whenever necessary is an effective way to manage their conditions in the long run. Being involved in such programs can help you learn to take more notice of increased requests for prescription refills and identify signs of drug abuse or dependence the next time that a patient walks through your door. If opioid prescription is at low risk, you can direct patients towards pain-management treatments that do not involve drugs. Such treatments include physiotherapy, psychological counseling, complementary therapies, and more.

Above all, you must be willing to manage all prescriptions and not write or recommend more than is needed. You must also be willing to work with other health care professionals whenever necessary in order to ensure your patients receive the best care available. To help you address the opioid epidemic in your area, you should consider:

• Limiting the quantity of prescription opioids;
• Recommending non-opioid alternatives for chronic pain management;
• Being thorough with patients during follow-up appointments;
• Teaming up with pharmacists and checking their state’s PDMP;
• Raising awareness of opioid misuse and abuse among patients and their families;
• Identifying and educating patients at high risk of opioid addiction;
• Educating patients about chronic pain management treatments;
• Learning to recognize signs of excessive opioid use;
• Providing medical expertise among your community;
• Working closely with organizations in your community to raise awareness about the opioid epidemic;
• Being open to new approaches that involve health care expertise in prescription opioids;

Opioids can be the best treatment approach for a number of patients with pain; however, their widespread misuse has started to spiral out of control. Therefore, electronic prescribing and patient monitoring programs have become a universal use in identifying and preventing drug misuse. Such tools have the abilities to predict trends and ensure patients’ pain is thoroughly reviewed and properly managed. While the population of patients who require long-term opioid use is relatively small, there are those who are vulnerable to drug misuse and abuse. This is where you come in. As a physician, you have an obligation to provide patients’ relief from suffering, but it must also be equally balanced with your obligation not to expose patients to addiction or create opportunities for drug misuse. You must take into account rights, responsibilities, and moral values, henceforth engaging in an ethical framework to make appropriate decisions when it comes to opioid prescribing. Not all types of pain respond well to drug-related treatments and there are several measures that you can recommend to relieve symptoms and improve quality of life without the use of opioids. By educating your patients, you can help them to understand the risks of certain treatments, all the while establishing solid physician-patient relationships with respect to medical decisions and recommendations.