In the United States, the number of opioid abusers is approximately 2.5 million people, and it has been constantly growing within recent decades, as the number of new abusers grew by a striking 225 percent between 1992 and 2000 (Lembke, 2012). Opioid abusers are people who consume opioids in dangerous amounts with highly adverse potential effects; these people include consumers of illegal drugs and patients receiving opioids under prescription primarily for the purpose of relieving chronic pain. It is known that opioids cause tolerance and addiction; abuse and misuse can lead to overdose and death. With the recognition of these negative effects, the debate on the use of opioids for medical purposes has been rather heated recently. In order to discuss the matter of opioid dependence in chronic pain patients, it is necessary to explore what opioids are, what risks are associated with using them, how dependence can be addressed if it has already been developed by a patient, and how the dependence and actions that need to be taken to address it correspond to the modern principles of medical ethics.
In order to be classified as an opioid, a drug needs to affect particular receptors in the brain, peripheral nervous system, and digestive tract known as opioid receptors (Sullivan & Howe, 2013). These drugs can be of natural or synthetic origin. Originally, what later became known as opioids was derived from opium, a substance produced from the resin of the opium poppy, and this is one of the most ancient drugs used by humans. It is now believed that opium was used to relieve pain and for ritual purposes, as opium can seriously affect the consciousness and perception of a person who consumes it. The use of various substances associated with opium continues until today for medical purposes, primarily for pain relief, and it should also be mentioned that such substances, morphine first of all, are used to produce heroin. Therefore, there are two major areas of opioids use: medical and illegal. The latter includes production, distribution, trafficking, and consumption of illegal drugs.
Apart from pain relief, the medical use of opioids may include suppression of diarrhea and treatment of opioid addictions. Opioids are known to be psychoactive, i.e. to affect a person’s mind, and a remarkable effect of their use is euphoria. Due to this characteristic, many resort to the use of opioids for recreational purposes, which can be dangerous due to the opioids’ outstanding ability to cause tolerance and addiction. However, addiction can occur not only in situations in which opioids are consumed for recreational purposes (such as heroin use) but also under the conditions of medical use (see Risks of Opioid Use). Most of the known opioids are controlled substances today.
Risks of Opioid Use
The most important risk of using opioids for whichever purpose is dependence that they cause. Long-term consumption leads to increased tolerance, i.e. larger doses need to be consumed for achieving the same result. Discontinuation of opioids leads to a withdrawal syndrome. With both physiological and psychological dependences, opioid use disorder is a serious condition, and this is why it is necessary to consider negative consequences, such as addiction, when administering opioids for medical purposes, either for inpatients or outpatients. One of the main considerations in this area is to prevent opioid abuse among patients, and a significant aspect of prevention is identifying abuse predictors. Kaye et al. (2017) stress that there are negative effects of opioid abuse on patients (as it is a life-threatening condition), physicians (as it undermines particular treatment plans as well as the medical use of opioids in general), and society (as it worsens the demographic situation and creates environments in which criminal behaviors are more likely to occur).
Kaye at al. (2017) explain that one of the ways of preventing opioid abuse is to define and measure certain characteristics among patients receiving opioids, and those characteristics would allow identifying those of the patients who require extensive attention, should be given opioids with especial carefulness, or should not be given them at all, i.e. a different treatment plan should be developed. Such characteristics are complex, and an accordingly complicated set of instruments should be designed for identifying and measuring predictors because “no single test or instrument can reliably and accurately predict those patients unsuitable for opioid therapy or pinpoint those requiring heightened degrees of surveillance and monitoring throughout their therapy” (Kaye et al., 2017, p. S111). These instruments may include assessing previous substance abuse (either associated with prescribed drugs or illegal substances) and evaluating drug-related behaviors (including, for example, previously recorded aberrant, socially unacceptable actions committed in the state of intoxication from drugs or with the purpose to obtain a new dose). In practice, risk evaluation factors are identified through drug testing, monitoring programs focused on prescriptions, and applying proper precautions to ensure the appropriateness of opioid therapy.
The need to ensure this appropriateness is particularly relevant today. The effects of opioids have been profoundly studied within recent decades, and the regulation of these drugs has been intensified compared to the early and mid-20th century when morphine and related drugs were used more widely and distributed more freely, but despite this, there are still serious problems that even allow researchers to claim that “[t]here is an epidemic of opioid abuse in the United States” (Wilkerson, Kim, Windsor, & Mareiniss, 2016, p. e1). Some practitioners argue that medical use of opioids tends to increase the levels of addiction and to cause various other adverse effects, which is why these practitioners recommend fully excluding opioids from any treatments and replacing them with other, less dangerous pain relievers (or other medicines depending on what opioids are used for in a given case).
While it is commonly known that, among people addicted to heavy drugs, especially heroin, death from overdose is widespread, it is often overlooked that overdose and death can often be consequences of the medical use of opioids, too. The upward trend of such complications that has been observed since the beginning of the 21st century is attributed to the increasing rate of opioid prescriptions, which, in turn, is explained by the pressure experienced by health care providers to avoid undertreatment of pain (Wilkerson et al., 2016). It has been widely recognized that pain is a major complication and negative effect of a disease for a patient, which is why, in patient-centered care, pain relief has become a more important theme. With the growing demand for pain relief, many practitioners are forced to prescribe opioids, as the efforts of academic and professional medical communities were rather insufficient for creating safer pain relievers that would produce similarly intensive effects without causing such tolerance and addiction and generating such high risks of abuse and overdose.
Addressing the Opioid Dependence
As it was previously established, one of the major reasons for the increase in opioid prescriptions and subsequently their negative effects, such as addiction and misuse, is the growing pressure on practitioners. Lembke (2012) claims that some practitioner might even know that their patients abuse prescribed opioid drugs or transfer them to other people acting as drug dealers or members of drug dealing networks, but those practitioners still prescribe such medications to these patients. The author identifies three reasons for this negative phenomenon: “[r]ecent changes in medicine’s philosophy of pain treatment, cultural trends in Americans’ attitudes toward suffering, and financial disincentives for treating addiction” (Lembke, 2012, p. 1580). First of all, the attitude change consists in the fact that, 200 years ago, pain was considered to be a healthy activity of an organism and a sign of vital processes in a patient combating a disease. However, as the 20th century provided extended access to pain relief, avoiding suffering became a normal practice.
Further, with the development of patient-centered care models, it was acknowledged that patients’ comfort is one of the main purposes of health care, along with patient safety and effective treatment, which is why pain relief came to be seen not only as an option but also as a need in treatment. Therefore, practitioners feel obliged to relieve pain as much as they can in their patients, which is why physicians have to resort to opioids despite the fact that they are fully aware of the effect of these drugs. Even when addictions are suspected, doctors may prescribe opioids to patients who report severe pain, and it should be acknowledged that not only doctors are victims in this situation, as they cannot ignore patients reporting severe pain, but also patients, as they pursue new doses of what they are addicted to without receiving proper treatment for dependence.
It should be recognized that the dependence is both physiological and psychological. It means that the consumption of opioids leads to the desire to consume them more, and discontinuation causes severe symptoms such as depression, anxiety, nausea, vomiting, abdominal cramping, and diarrhea. From the psychological perspective, long-term opioid use causes inability of an organism to function properly in a way that makes a person feel good, which is why new doses are constantly needed to support the mental and emotional state of a person.
Therefore, people suffering from opioid addiction should be provided with proper treatment, which normally includes replacing an opioid they have been receiving with a less strong one. Since this replacement therapy is associated with the use of opioid drugs, too, it should be appropriately regulated, e.g. by limiting the period during which a patient can be given opioids. These regulations show that major efforts of researchers and health care providers in the area of opioid use are focused on designing safer opioid prescribing policies and guidelines. In this regard, what should be established first of all is that long-term opioid therapies are essentially harmful, as they do not cure diseases but do cause negative consequences, such as abuse, addiction, and misuse (Sullivan & Howe, 2013). Therefore, practitioners should be careful when prescribing opioids because “long-term opioid therapy has no natural endpoint, [and] once long-term opioid therapy is established, it can go on for years” (Sullivan & Howe, 2013, p. S99). In case of addiction, replacement therapy is highly advised. Before establishing long-term opioid therapy, it should be ensured that there are considerable and demonstrable benefits for a patient from previous medical opioid use, and these benefits should be clearly explained and made measurable in practice guidelines. They primarily include substantial pain relief (opioids are not always effective as pain relievers), mood improvement, proper physiological functioning, and proper social functioning. Only when remarkable benefits are observed, long-term therapy can be considered; otherwise, according to Sullivan and Howe (2013), the risk of dependence is unjustified.
As it has been shown, a major consideration in opioid use among chronic pain patients is ethics. Shifts in medical ethics are exactly the factors that contributed to the growing opioid use within recent decades. However, it is not recommended by researchers or health care providers to return to the 19th-century paradigm in which pain was considered an inevitable component of treatment. Instead of technically reducing opioid use-related problems, such as growing rates of addictions and misuse, it is proposed to pay more attention to preventing these problems, and a primary instrument of such prevention is designing better policies regulating when opioid therapy can be used and when it should be avoided. This corresponds to the modern principles of medical ethics because, on the one hand, dooming patients to suffering by not prescribing opioids in cases in which they are needed or discontinuing opioids in cases in which discontinuation causes severe withdrawal symptoms is unethical, but, on the other hand, establishing opioid therapy for patients who can be treated by other means or who have risks of developing strong addictions is unethical, too.
Therefore, opioid prescribing practices are a matter of “an ethical balance” (Kotalik, 2012, p. 381). A way to find this balance is to establish criteria for demonstrable justifiability of opioid prescriptions. Kotalik (2012) recommends to physicians to be always guided by the universal ethical principles of beneficence, nonmaleficence, respect for autonomy, and justice. Prescribing opioids is often the easy way, but with the growing recognition of opioids’ adverse effects even in the cases of medical use and with more frequents reports of abuse and misuse, opioid prescription should be avoided if there are other pain relief options for a patient. This practice will comply with the beneficence and nonmaleficence principles of medical ethics.
The use of opioids for medical purposes is associated with an ethical dilemma: pain should be relieved in patients who chronically suffer from it, but serious dependence should be avoided. What is mainly recommended by researchers and practitioners is to develop guidelines and procedures to analyze every chronic pain case and assess whether or not the patient is suitable for opioid therapy (for example, predisposition to addiction and previous substance abuse history are indicators of unsuitability). Further, if a patient already receives opioids, it should be ensured that the benefits are substantial; if they are not, opioids should be discontinued because their further use will lead to tolerance and addiction without substantially improving the state of a patient. Overall, it should be recognized that opioids are a dangerous solution, and there is an epidemic of their abuse, which is why better guidelines need to be developed to ensure that the risk of dependence is reduced for chronic pain patients, and, if the dependence is already in place, that it is properly treated.
Kaye, A. D., Jones, M. R., Kaye, A. M., Ripoll, J. G., Jones, D. E., Galan, V., … Manchikanti, L. (2017). Prescription opioid abuse in chronic pain: An updated review of opioid abuse predictors and strategies to curb opioid abuse (part 2). Pain Physician, 20(2S), S111-S133.
Kotalik, J. (2012). Controlling pain and reducing misuse of opioids: Ethical considerations. Canadian Family Physician, 58(4), 381-385.
Lembke, A. (2012). Why doctors prescribe opioids to known opioid abusers. New England Journal of Medicine, 367(17), 1580-1581.
Sullivan, M. D., & Howe, C. Q. (2013). Opioid therapy for chronic pain in the United States: Promises and perils. Pain, 154(1), S94-S100.
Wilkerson, R. G., Kim, H. K., Windsor, T. A., & Mareiniss, D. P. (2016). The opioid epidemic in the United States. Emergency Medicine Clinics of North America, 34(2), e1-e23.