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Ethical Responsibilities of Physicians in the Opioid Crisis

Published online by Cambridge University Press:  01 January 2021

Abstract

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Type
Columns: Currents in Contemporary Bioethics
Copyright
Copyright © American Society of Law, Medicine and Ethics 2017

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References

Centers for Disease Control and Prevention, National Center for Health Statistics, “Provisional Counts of Drug Overdose Deaths, as of 8/6/2017,” available at <https://www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdf> (last visited Sept. 6, 2017). See Katz, J., “New Count of 2016 Drug Deaths Shows Accelerated Rate,” New York Times, Sept. 3, 2017, at 14. It should be noted that the data slightly overestimate the number of deaths by substance because some overdose fatalities were the result of multiple drugs; but the data are based on state reports, which have a completeness of reporting of > 90%, and therefore slightly undercount the number of fatalities. It is not known precisely whether the over-counting and under-counting precisely cancel out. See Provisional Counts, supra at 2, Notes on Data Quality.+(last+visited+Sept.+6,+2017).+See+Katz,+J.,+“New+Count+of+2016+Drug+Deaths+Shows+Accelerated+Rate,”+New+York+Times,+Sept.+3,+2017,+at+14.+It+should+be+noted+that+the+data+slightly+overestimate+the+number+of+deaths+by+substance+because+some+overdose+fatalities+were+the+result+of+multiple+drugs;+but+the+data+are+based+on+state+reports,+which+have+a+completeness+of+reporting+of+>+90%,+and+therefore+slightly+undercount+the+number+of+fatalities.+It+is+not+known+precisely+whether+the+over-counting+and+under-counting+precisely+cancel+out.+See+Provisional+Counts,+supra+at+2,+Notes+on+Data+Quality.>Google Scholar
Centers for Disease Control and Prevention, Prescription Opioid Overdose Data, Dec. 16, 2016, available at <https://www.cdc.gov/drugoverdose/data/overdoes.html> (last visited Sept. 16, 2017).+(last+visited+Sept.+16,+2017).>Google Scholar
Dowell, D., Haegerich, T. M., and Chou, R., “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016,” Morbidity and Mortality Weekly Reports Recommendation Reports 65, no. 1 (2016): 1-49.Google Scholar
Centers for Disease Control and Prevention, Annual Surveillance Report of Drug-Related Risks and Outcomes: United States, 2017, at 9 (2017).Google Scholar
Han, B. et al., “Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health,” Annals of Internal Medicine 167, no. 5 (2017): 293-302.CrossRefGoogle Scholar
U.S. Department of Health and Human Services, Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (2016), HHS Publication SMA 16-4984, NSDUH Series H-51 (Rockville, MD: SAMHSA)Google Scholar
See generally Musto, D. F., Drugs in America: A Documentary History (New York: New York University Press, 2002).Google Scholar
See Case, A. and Deaton, A., “Rising Morbidity and Mortality in Midlife among White Non-Hispanic Americans in the 21st Century,” Proceedings of the National Academy of Sciences USA 112, no. 49 (2015): 15078-15083. See also Bible, M., “Is the US Facing an Epidemic of ‘Deaths of Despair’? These Researchers Say Yes,” The Guardian (March 28, 2017), available at <http://www.theguardian.com/us-news/2017/mar/28/deaths-of-despair-us-jobs-alcohol-suicide> (last visited Sept. 8, 2017).CrossRefGoogle Scholar
See Roux, A.V. Diez, “Despair as a Cause of Death: More Complex than It First Appears,” American Journal of Public Health 107, no. 10 (2017): 1566-1567; Erwin, P. C., “Despair in the American Heartland? A Focus on Rural Health,” American Journal of Public Health 107, no. 10 (2017): 1533–1534.Google Scholar
CDC, supra note 4, at 10.Google Scholar
See Kolodny, A. and Frieden, T. R., “Ten Steps the Federal Government Should Take Now to Reverse the Opioid Addiction Epidemic,” Journal of the American Medical Association (2017), doi: 10.1001/jama.2017.14567.Google Scholar
See Rothstein, M. A., “The Opioid Crisis and the Need for Compassion in Pain Management,” American Journal of Public Health 107, no. 8 (2017): 1253-1254.CrossRefGoogle Scholar
See Rosenblum, A. et al., “Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions,” Experimental and Clinical Psychopharmacology 16, no. 5 (2009): 405-416.Google Scholar
Muhari, P., Gfroerer, J., and Davies, M. C., “Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States,” CHHSQ Data Review 2013, available at <https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm> (last visited Sept. 22, 2017).+(last+visited+Sept.+22,+2017).>Google Scholar
A small number of high-volume prescribers can do significant harm. Medicare’s top 20 OxyContin prescribers in 2010 wrote 17,000 Oxy-Contin prescriptions and more than 56,000 prescriptions for narcotics of all kinds. National Academies of Sciences, Engineering, and Medicine, Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use (Washington, DC: National Academies Press 2017): 223 [hereinafter cited as National Academies]. Between 2013 and 2015, opioid manufacturers made payments of $46 million to 68,000 physicians. Fox, M., “Many Doctors Get Goodies from Opioid Makers,” NBCNews.com, Aug. 10, 2017, available at <http://www.nbcnews.com/pages/print> (last visited Sept. 22, 2017).Google Scholar
See Van Zee, A., “The Promotion of OxyContin: Commercial Triumph, Public Health Tragedy,” American Journal of Public Health 99, no. 2 (1999): 221-227.Google Scholar
“Compared with the progressive advancement of medical education surrounding such fields as cardiology and oncology, advances in pain management education are entirely absent or minimally developed — often limited to a few hours of didactic lectures over multiple years of training.” National Academies, supra note 15, at 293. One study demonstrated that physicians who trained at low-ranked medical schools wrote three times as many opioid prescriptions as those who trained at top-tier schools, clearly suggesting that better instruction might have limited the magnitude of the crisis. See Siemaszko, C., “Doctors from Top Medical Schools Prescribe Fewer Opioid Pain-killers,” NBCNews.com, Aug. 15, 2017, available at <http://www.nbcnews.com/pages/print> (last visited Sept. 22, 2017).+(last+visited+Sept.+22,+2017).>Google Scholar
Thomas, K. and Ornstein, C., “Insurers Putting Cost over Safety with Painkillers,” N.Y. Times, Sept. 18, 2017, at 1.Google Scholar
See Levy, B. et al., “Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012,” American Journal of Preventive Medicine 49, no. 3 (2015): 409-413; McCauley, J. L. et al., “Dental Opioid Prescribing and Multiple Opioid Prescriptions among Dental Patients,” Journal of the American Dental Association 147, no. 7 (2016): 537–544.Google Scholar
See Edelman, A., “Pet Connection: Opioid Addicts Score Drugs from the Local Vet,” NBCNews.com, Sept. 2, 2017, available at <https://www.nbc-news.com/pages/print> (last visited Sept. 3, 2017).+(last+visited+Sept.+3,+2017).>Google Scholar
21 U.S.C. § 801 et seq.Google Scholar
429 U.S. 589 (1977).Google Scholar
Pub. L. No. 109-60 (2005).Google Scholar
Bao, Y. et al., “Prescription Drug Monitoring Programs Are Associated with Sustained Reductions in Opioid Prescribing by Physicians,” Health Affairs 35, no. 6 (2016): 1045-1051.CrossRefGoogle Scholar
Wen, H. et al., “States with Prescription Drug Monitoring Mandates Saw a Reduction in Opioids Prescribed to Medicaid Enrollees,” Health Affairs 36, no. 4 (2017): 733-741.CrossRefGoogle Scholar
Haffajee, R., Jena, A. B., and Weiner, S. G., “Mandatory Use of Prescription Drug Monitoring Programs,” Journal of the American Medical Association 313, no. 9 (2015): 891-892, 891. See also Haffajee, R. L., “Preventing Opioid Misuse with Prescription Drug Monitoring Programs: A Framework for Evaluating the Success of State Public Health Laws,” Hastings Law Journal 67, no. 6 (2016): 1621–1694.Google Scholar
Mandatory Use, supra note 26, at 892.Google Scholar
Lanser, P. and Gesell, S., “Pain Management: The Fifth Vital Sign,” Healthcare Benchmarks 8, no. 6 (2001): 68-70. The four traditional vital signs are temperature, respiration rate, blood pressure, and pulse rate.Google Scholar
Van Zee, supra note 16.Google Scholar
Centers for Disease Control and Prevention, Guideline for Prescribing Opioids for Chronic Pain (2016), available at <www.cdc.gov/drugoverdose/prescribing/guideline.html> (last visited Sept. 23, 2017). See also Dowell, D., Haegerich, T., and Chou, R., “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016,” Journal of the American Medical Association 315, no. 15 (2016): 1624-1645.Google Scholar
CDC Guideline, supra note 30, provision 1.Google Scholar
Kroenke, K. and Cheville, A., “Management of Chronic Pain in the Aftermath of the Opioid Backlash,” Journal of the American Medical Association 317, no. 23 (2017): 2365-2366, 2366.Google Scholar
Often, this takes the form of telling patients that all painkillers must be prescribed by a pain management specialist. As of January 2017, however, there were only 2,300 physicians who were board certified by the American Board of Pain Management, available at <http://abpm.org/faq> (last visited Sept. 28, 2017), and 6,000 members of the American Academy of Pain Management, available at <https://health-finder.gov/FindServices/organizations/organizations.aspx?code=HR3001> (last visited Sept. 28, 2017). Even if a pain management physician can be located, the added delay, burden, and expense compounds the pain and distress of the patient.+(last+visited+Sept.+28,+2017),+and+6,000+members+of+the+American+Academy+of+Pain+Management,+available+at++(last+visited+Sept.+28,+2017).+Even+if+a+pain+management+physician+can+be+located,+the+added+delay,+burden,+and+expense+compounds+the+pain+and+distress+of+the+patient.>Google Scholar
See Cornish, R. et al., “Risk of Death During and After Opiate Substitution Treatment in Primary Care: Prospective Observational Study in UK General Practice Research Database,” British Medical Journal 341 (2010: doi: 10.1136/bmj.e5475).Google Scholar
National Academies, supra note 15, at 53.Google Scholar
American Medical Association, Code of Medical Ethics of the American Medical Association 2014-2015 edition, § 10.015, at 409 (Chicago: American Medical Association, 2015).Google Scholar
See Brennan, F., Carr, D., and Cousins, M., “Access to Pain Management – Still Very Much a Human Right,” Pain Medicine 17 (2016): 1785-1789, doi: 10.1093/pm/pnw222.CrossRefGoogle Scholar
See Roskos, S. E. et al., “Literacy Demands and Formatting Characteristics of Opioid Contracts in Chronic Nonmalignant Pain Management,” Journal of Pain 8, no. 10 (2007): 753-758 (opioid contracts are frequently written in language that is not understandable by patients). Legally, it is likely that the contracts would be deemed unenforceable adhesion contracts because of the compulsion to sign by the weaker party (i.e., patients). See Collen, M., “Opioid Contracts and Random Drug Testing for People with Chronic Pain – Think Twice,” Journal of Law, Medicine & Ethics 40, no. 4 (2009): 841–845.CrossRefGoogle Scholar
Arnold, R. M., Han, P.K.J., and Seltzer, D., “Opioid Contracts in Chronic Non-malignant Pain Management: Objectives and Uncertainties,” American Journal of Medicine 119, no. 4 (2006): 292-296, 295.CrossRefGoogle Scholar
See AMA Code of Ethics, supra note 36, § 8.115Google Scholar
Rapoport, A. B. and Rowley, C. F., “Stretching the Scope – Becoming Frontline Addiction-Medicine Providers,” New England Journal of Medicine 377, no. 8 (2017): 705-707, 706.Google Scholar
Merely adopting a strategy of referring patients to pain management specialists will not work because of the large number of individuals with OUD and the small number of specialists. See note 34 supra.Google Scholar
Many physicians and institutions already have dedicated considerable efforts and resources to help in treating OUD in their patients. On a national basis, however, these efforts are not nearly enough to combat addiction.Google Scholar
Rapoport and Rowley, supra note 42, at 706-707.Google Scholar
“The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest and above obligations to other groups, and to advocate for their patients’ welfare. Within the patient-physician relationship, a physician is ethically bound to use sound medical judgment, holding the best interests of the patient as paramount.” AMA Code of Ethics, supra note 36, § 10.015Google Scholar