What is the U.S. Opioid Epidemic?

Almost two million Americans are now addicted to opioids. The National Institute on Drug Abuse notes that over 100 people die each day in the U.S. from opioid overdoses. This unprecedented level of abuse -- which involves not only heroin, but also prescription pain relievers such as OxyContin, Percocet, morphine, codeine, and fentanyl -- has become a national crisis. Along with that crisis is the unethical issues that have paved how to allow this crisis to continue to rise. Some of the unethical standards that caused 47,600 deaths in 2017 and have allowed the opioid crisis to get there I will be discussing are conflicts of interest, non-maleficence, ethical approach to prescribing, beneficence, and autonomy.

Conflicts of interest

According to American Medical Association the primary objective of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration. Under no circumstances may physicians place their own financial interests above the welfare of their patients. Conflicts of interest occurs when the doctor’s primary goal of protecting and increasing the health of patients comes second to their own financial gain. Physicians during the height of the crisis received huge kickbacks from big pharma and drug reps. According to Forbes one doctor received $200K in total payments in 2016 paid by pharmaceutical companies. This conflict of interest is a massive ethical violation and has caused more pain meds being prescribed then actually needed. For a long time, physicians have denied the allegations that pharmaceutical companies gave physicians payment to prescribe their brand of pills. An analysis conducted by ProPublica found for the first time that physicians who received some type payment from pharmaceutical companies do prescribe drugs differently than their colleagues who don’t. And the more the prescribe the more money they receive, on average, the more brand-name medications they prescribe. Also, if you ever want to see what kind of kickbacks your physician has received the government created a website called https://openpaymentsdata.cms.gov/ so you can look for yourself.

Non-Malefience

Physicians must uphold the ethical principal of non-maleficence or “do no harm;” Physicians obligations should be to not impose risk or harm. If physicians apply the ethical standard of non-maleficence, it is their duty to not impose the risk of opioid addiction, overdose, and even death secondary to use of prescribed opioid pain relievers. This justification focuses on the consequentialist theory of ethics, prioritizing the maximization of the “net benefit” for the patient by temporarily not treating their pain to avoid future harm. Due to physicians not understanding or knowing their patients they have just pushed pills down their throats. If physicians adequately treated pain, got to the root of the issues causing the pain the need to prescribe opioids in astronomical numbers would not be needed. Physicians who inadequately treat acute pain lead can lead to chronic pain, which contributes to poor quality of life and risk of self-medication through opioid abuse. Adequate pain treatment is a basic human right, and it is the duty of the physicians to preserve this right. However, if opioids are needed then prescribe the appropriate opioid to use when necessary.

Ethical Approach to Prescribing

The basic ethical obligation is to acquire knowledge, skills, and tools to assist in deciding what medication and dose a physician should prescribe. Physicians prescribe drugs to treat their patients and usually of patients with a single issue, this rarely leads to complications. The patient takes the drug and gets better. However, cases arise, when the patient involved is an addict or has multiple drugs they are prescribe and taking simultaneously. What should the physician do? Ideally, the ethical approach would entail a careful, measured approach to prescription writing that does not take place. Physicians rarely know what drugs their patients take, as demonstrated by a study of 120 cases of a hospital in Ontario, in which 37% of patients took drugs outside their physician’s knowledge. As I stated physicians need to get to know their patients and find the root cause for the pain and why they need to use opioids. If physicians can find alternatives to using prescription meds then patients could get away from such addictive meds. There are alternatives to using opioids that may be suitable for some patients. These include the use of less-addictive or non-addictive drugs such as acetaminophen, ibuprofen, naproxen. And cognitive behavioral therapy, stress management, and relaxation techniques can help patients learn how to modify triggers that increase pain. I know and understand people need the use of opioids to help them in their everyday lives, however because of the abuse this has severely cause a knee jerk reaction and limited them from getting the medication they need.

Principle of Beneficience

This principle specifies that a health care professional should provide net benefit to the patient. It might seem to be the easiest principle to apply because physicians are usually familiar with the benefits of opioid therapy, as they are well documented in literature. However, some physicians have seemed uneducated in realm of prescribing opioid in excessive manner. I do understand that even with experience, empathy for a patient’s suffering, and an open mind, it is not simple to estimate the benefits that a particular patient can obtain from opioids. The problem, as we all know, is that pain is a subjective symptom, and no objective testing is available outside of research facilities. Yet, physicians still continue to prescribe opioids to patients that may truly not need them. Physicians need to ask patients if they have received pain medication from other practitioners, and the timing and quantity of previous prescriptions. They need to be proactive and get engaged with the patients. Physicians legally may seek truthful and complete disclosure, and should warn their patients that making false statements constitutes breaking the law. A physician concerned that a patient is “double doctoring” for these drugs should request a signed statement of disclosure so that the patient knows the seriousness of giving false information about opioids prescribed by other practitioners.

Respect for Autonomy

This principle reminds us not to impose any intervention on a competent patient. The main expression of the respect for autonomy is the process of informed consent to, or informed decline of, a treatment, although a higher level of respect for autonomy is achieved by shared decision making between physician and patient. The principle of autonomy supports the practice of giving patients as broad a choice of pain treatments as can be medically justified. Many patients, if made aware of the risks associated with using opioids, might themselves choose less potent but safer medications. Respect for autonomy does not mean that the patient dictates what the physician will prescribe. Physicians need not give in and prescribe any medication against sound medical judgment. That is unethical and a disservice to patients and contradicts the principle of nonmaleficence. If the patient continues to demand an opioid prescription that the physician decides is improper, the physician should discharge the patient from the practice. Discharge from medical care might lead to the patient accessing drugs illegally, and might bar the patient from access to medical services in the area however the physician would be ethically correct and not risk his practice. If discharging the patient is impossible the physician could get a second opinion from a colleague, or the physician could contact a local drug depended agency to help the patient deal with their addiction.

In the end I know and understand physicians are not the only ones to blame or who may have violated the ethical practices of conflicts of interest, non-maleficence, ethical approach to prescribing, beneficence, and autonomy, but they could have prevented it. New physicians take the Hippocratic Oath daily and if they stay true to that oath then maybe this crisis could have been prevented all along.

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