Withholding Opioids From Patients
Withholding Opioids From Patients
Question
I just read the latest piece on Overuse of the ED for Pain Medication. What evidence supports the refusal of opioids for treatment of pain crises in cases of chronic pain as a treatment policy? Is it ethically defensible to withhold from all patients what may be the most effective treatment for pain crises because a small minority of patients may abuse this treatment?
—Martha J. Gaie, PhD, RN, Madison, Wisconsin
These questions illustrate a prevalent dichotomy that exists when healthcare institutions implement internal policies that seem to conflict with statewide governmental and regulatory policies that encourage the safe and effective treatment of chronic pain, including the use of opioid therapy. Indeed, most state medical regulatory agencies have issued such policies, either in the form of regulations or guidelines/policy statements, to communicate to their licensees that opioid therapy is an accepted treatment and that this practice will not result in disciplinary sanctions. A list of these policies for each state, as well as the actual policy language itself, is available at: http://www.painpolicy.wisc.edu/matrix.htm.
The Ohio County Hospital's institutional guideline, which was referenced in the piece on the Overuse of ED [emergency department] for Pain Medication, does recognize the importance of patients and their primary care physicians working together to minimize the likelihood of lost, expired, or nonrefilled prescriptions. When these situations are anticipated and prevented in the clinical setting, it can reduce the frequency of crises that lead to seeking treatment through the ED. Of course, a pain crisis can occur that is not predicted and that can motivate a patient to present at the ED, which then warrants proper medical treatment. Physicians often are hampered by the practical difficulty of distinguishing, especially in an ED setting, the person with genuine pain from someone who is feigning pain to obtain prescription medications for nonmedical purposes. There is then the compounding complexity of "pseudoaddiction," which has come to describe patients with legitimate pain who do not achieve adequate relief through their primary treatment and, as a result, develop the aberrant drug-seeking behaviors characteristic of people with true addiction. This clinical reality, coupled with some practitioners' beliefs that the medical use of opioids will do little to improve pain, physical functioning, or quality of life or invariably leads to addiction, creates a reluctance to view these important medications as a viable treatment option in an ED setting.
Although it is generally accepted that physicians have an ethical imperative to relieve suffering, including pain when possible, in these instances the "War on Drugs" often prevails over the "War on Pain." Moreover, it is likely that this situation will persist absent an accurate understanding of the characteristics that comprise addiction and abuse that is more easily translatable into valid patient evaluation procedures in the ED setting. Developments in risk assessment measures are an important component of advancing toward the balanced objective of maintaining a justifiable commitment to reducing the public safety consequences of the non-medical use of prescription opioids while, at the same time, preserving public health through the appropriate management of chronic pain conditions.
Question
I just read the latest piece on Overuse of the ED for Pain Medication. What evidence supports the refusal of opioids for treatment of pain crises in cases of chronic pain as a treatment policy? Is it ethically defensible to withhold from all patients what may be the most effective treatment for pain crises because a small minority of patients may abuse this treatment?
—Martha J. Gaie, PhD, RN, Madison, Wisconsin
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Response from Aaron M. Gilson, MS, MSSW, PhD
Senior Scientist, Paul P. Carbone Comprehensive Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin |
These questions illustrate a prevalent dichotomy that exists when healthcare institutions implement internal policies that seem to conflict with statewide governmental and regulatory policies that encourage the safe and effective treatment of chronic pain, including the use of opioid therapy. Indeed, most state medical regulatory agencies have issued such policies, either in the form of regulations or guidelines/policy statements, to communicate to their licensees that opioid therapy is an accepted treatment and that this practice will not result in disciplinary sanctions. A list of these policies for each state, as well as the actual policy language itself, is available at: http://www.painpolicy.wisc.edu/matrix.htm.
The Ohio County Hospital's institutional guideline, which was referenced in the piece on the Overuse of ED [emergency department] for Pain Medication, does recognize the importance of patients and their primary care physicians working together to minimize the likelihood of lost, expired, or nonrefilled prescriptions. When these situations are anticipated and prevented in the clinical setting, it can reduce the frequency of crises that lead to seeking treatment through the ED. Of course, a pain crisis can occur that is not predicted and that can motivate a patient to present at the ED, which then warrants proper medical treatment. Physicians often are hampered by the practical difficulty of distinguishing, especially in an ED setting, the person with genuine pain from someone who is feigning pain to obtain prescription medications for nonmedical purposes. There is then the compounding complexity of "pseudoaddiction," which has come to describe patients with legitimate pain who do not achieve adequate relief through their primary treatment and, as a result, develop the aberrant drug-seeking behaviors characteristic of people with true addiction. This clinical reality, coupled with some practitioners' beliefs that the medical use of opioids will do little to improve pain, physical functioning, or quality of life or invariably leads to addiction, creates a reluctance to view these important medications as a viable treatment option in an ED setting.
Although it is generally accepted that physicians have an ethical imperative to relieve suffering, including pain when possible, in these instances the "War on Drugs" often prevails over the "War on Pain." Moreover, it is likely that this situation will persist absent an accurate understanding of the characteristics that comprise addiction and abuse that is more easily translatable into valid patient evaluation procedures in the ED setting. Developments in risk assessment measures are an important component of advancing toward the balanced objective of maintaining a justifiable commitment to reducing the public safety consequences of the non-medical use of prescription opioids while, at the same time, preserving public health through the appropriate management of chronic pain conditions.
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