The problem of pain is pervasive in many levels of our society. Physical pain is almost synonymous with life itself, where the most of us have no escape from it.

Some form of pain is easily treatable. Not forgetting that, with advances in modern pain management technique, we are more armed with an array of analgesics to combat the unwarranted nociceptive sensation. Nonetheless, while pain is ubiquitous to almost everyone – not all treatment is as straightforward as popping a painkiller.

Specifically, a complicated moral dilemma arises when treating potential drug abusers in whom conventional non-opioid analgesics do not work anymore. Should doctors prescribe opioid to manage their chronic severe pain? And should pharmacists fill and dispense opioid prescriptions without subjecting these people to excessive scrutiny and discrimination?

The modern moral dilemma

There is no sign that the magnitude of the opioid crisis is easing. This is especially evident in the US, where President Trump has recently declared the opioid crisis as a public health emergency. The excessive demand for potent opioid analgesics – be it legally prescribed or obtained from the street – had taken its toll on Americans, and the country is looking for someone to blame.

Allegations were quickly thrown at doctors and their prescribing habits.

In a survey conducted by Fortune magazine, which polled the public about their views on the crisis, it was discovered that 19% of them believed doctors who over-prescribed opioid analgesics should shoulder the responsibility. The public opinion is not unfounded. A 2016 report released by the US Substance Abuse and Mental Health Services Administration (SAMHSA) revealed that – of the 11.8million opioid abusers in 2016 – more than 97% of the misuse cases were from prescription pain reliever.

Nonetheless, it will be too simple-minded of us to put the responsibility squarely on doctors. As discussed by Travis Rieder, a research scholar at the Berman Institute of Bioethics at Johns Hopkins University, there are, in reality, two public health crises: an opioid epidemic and the underlying pain crisis.

He wrote "if opioids prevent significant suffering from pain, then the solution to the prescription opioid problem cannot simply be to stop using them. To do so would be to trade one crisis (an opioid crisis) for another (a pain crisis)."

Patient’s need for pain management

Rieder also rightly pointed out that “patients are individuals, not data points, and risks of opioid therapy – as well as the risks of not providing pain relief – are not the same for everyone." Such argument, no doubt, will resonant well with many front-line doctors and pharmacists whose work are intimately related to caring for patients, including drug abusers.

A highly influential campaign initiated by the American Pain Society, known as "Pain, The Fifth Vital Sign", had largely swayed opinion among healthcare professionals on pain management. Since then, assessment and treatment of pain became routine and opioid were promoted as one of the possible treatment options for chronic pain.

In the face of debilitating pain, the guiding principle for doctors and other allied health professionals is "to do good" – beneficence that takes patients best interest as the treatment priority. When we run out of other treatment options, withholding opioid to potential patients, including those with potential to misuse drugs, who clearly demonstrate the need for pain relief may seem to go against that fundamental ideology.

Many may argue that the risk of prescribing opioids to this niche patient group is not justified given the current full-blown crisis. Any potential benefits to the patients appear minuscule against the backdrop of an epidemic.

The critical question, then, is how to accurately assess whether the patient is truly in need of an opioid analgesic or he/she is simply faking it for the sake of a few weeks' supply. Unfortunately, it is near impossible to precisely tell the difference between the two, and the issue has sparked lengthy and heated debates till this day.

Reasonable prescribing

There are calls for reasonable prescribing and constant vigilance from both clinicians and allied health professionals to combat excessive use of opioids, including opting for non-opioid pain management or only to prescribe opioid when it is absolutely necessary.

In the end, we should acknowledge that the opioid crisis has presented a sophisticated moral dilemma that could not be resolved easily. As we hold the power to dictate whether a patient in pain should deserve the next opioid prescription, we should do so with extra care. MIMS

Read more:
America’s killer drug epidemic: How opioid overdose is (literally) ‘killing’ the nation
Tackling the opioid epidemic through education
Fentanyl: The newest drug addiction in the US is 100 times stronger than morphine

Sources:
https://www.nytimes.com/2017/10/26/us/politics/trump-opioid-crisis.html
https://www.statnews.com/2017/09/26/ethical-dilemma-doctors-ok-prescribe-opioids/
https://www.medscape.com/viewarticle/885496#vp_1
https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#summary