Opioid Prescribing: Navigating the Ethical Battlefield

As concerns continue to mount regarding opioid overdose, misuse, and abuse, laws and guidelines regulating the prescribing of painkillers to patients have become stricter. Prescribers of narcotics are faced with more than just ethical dilemmas when making the decision to treat a patient with opiates; they are also being challenged on the legal front.

“Whether we are speaking in clinical, moral, ethical, or legal terms, the fundamental question remains: What is best for my patient?” said Stephen J. Ziegler, PhD, JD, associate professor in the Department of Public Policy at Indiana State University.

Kevin Barnard, a member of the National Association of Drug Diversion Investigators and formerly of the San Diego Police Department, and Jennifer Bolen, JD, a former US District Attorney and expert on medico-legal issues related to pain management, joined Ziegler in a panel discussion that centered around how physicians should handle situations in which they believe a patient is diverting or abusing pain medications, or both.

With healthcare providers battling these issues on a daily basis, many in the medical community are wondering how decisions can be made effectively and efficiently. Recognizing when a patient is attempting to mislead a physician into providing painkillers is a responsibility of the prescriber. However, being able to make an educated decision to do what is best for the patient is not always easy.

“In many ways it comes down to how well equipped the physician is to perform patient assessment and screening for abuse; how well the physician understands and how easily the physician can access integrated care, including behavioral health support; and how much of the physician's focus is money oriented vs patient centered,” Ms. Bolen said.

However, too much caution when considering medication for patients with pain can be harmful, as well.

“Clinicians who withhold the prescribing of opioids because they wrongly suspect that their patient is diverting have caused their patient to suffer, while clinicians who fail to take reasonable precautions to prevent abuse are fueling the abuse of opioids,” Dr. Ziegler warns.

Although it might save time, a strategy that avoids opioids entirely could essentially result in negative consequences for prescribers. Blatantly ignoring potential treatment options for a patient with pain could have both ethical and legal ramifications.

“For some clinicians, a blanket policy of withholding opioids may seem to be the safest route,” Dr. Ziegler explained. “Such an approach would reduce the amount of time they have to spend with a patient and it avoids any concern that their prescription will be diverted.”

“But such policies are not only unethical because they subordinate the patient's needs, they can also expose the clinician to accusations of medical malpractice,” Dr. Ziegler cautioned.

The strategy behind prescribing opioids isn't necessarily a clear one. There are numerous patient- and pharmacologic-related issues for a physician to consider before deciding whether or not to treat an individual with prescription painkillers.

“Ensuring access while preventing the abuse of opioids is not a zero-sum game and will remain an ongoing challenge for clinicians,” he said. “Patient assessment, screening for abuse, and integrated care all have a part in good patient care. Clinicians are not expected to be perfect, just reasonable.”


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