The Opioid Epidemic and Untreated Pain: Ethical Tensions

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I recently attended a funeral for one of my former classmates from high school who died of a heroin overdose. Tragically, there was more than one funeral that day. There had been two overdoses within my community in one week. With recent headlines such as, “21 heroin overdoses reported in Ohio in a day,” and “Maryland reports 383 overdose deaths in the first three months of 2016,” I am less surprised by such events, but increasingly alarmed.

Research shows that since 1999, consumption of hydrocodone has more than doubled and consumption of oxycodone increased by nearly 500 percent. The rate of heroin-related overdose deaths has more than quadrupled since 2002, prompting the CDC to identify the situation as an “Epidemic.” Four out of five heroin users report their path to heroin addiction began with the use of opioid pain relievers that were provider-prescribed to treat a pain condition. After becoming addicted to the prescription medication, many switched to heroin due to its lower cost on the “black market.”

This crisis has led providers to reevaluate how they treat pain in hospitalized patients. As a nurse working in a trauma intensive care unit in Baltimore, I frequently balance treating a patient’s pain while also recognizing the risk of addiction. Baltimore’s narcotic epidemic is among the worst in the country, with 748 deaths from heroin and 351 from fentanyl in 2015, and death rates continue to rise. Within this context, providers in my ICU are hesitant to provide needed opioids for postoperative acute pain even to opioid naïve patients. While there are alternatives to opioids, they may not always be as effective in treating the acute stages of postoperative pain, especially in those who also take opioids for chronic pain. The magnitude of the narcotic epidemic and our role as clinicians in responding to it cannot be ignored, but it is unethical to under-treat pain based on misplaced fear of causing opioid addiction.

Clinicians have the duty to “do no harm;” to uphold the ethical principle of non-maleficence. Our obligations should be expanded to “obligations not to impose risks of harm.”  Applying this standard of non-maleficence, it is the provider’s duty to not impose the risk of opioid addiction, overdose, and even death secondary to use of prescribed opioid pain relievers. This justification focuses on the consequentialist theory of ethics, prioritizing the maximization of the “net benefit” for the patient by temporarily not treating their pain to avoid future harm.

There is merit to reducing risk to our patients, but we also have duties to justice, beneficence, and non-maleficence that support adequately treating pain, including through appropriate opioid use when necessary. Frank Brennan et al. argue that, “alleviating pain is not merely a matter of beneficence but also forms part of the duty to prevent harm… An unreasonable failure to act is arguably negligent, a breach of human rights, and professional misconduct.” It is our obligation as providers to treat pain and relieve suffering under the principle of beneficence, or to act for the benefit of others. The principle of non-maleficence reinforces our duty to protect our patients from the consequences of untreated pain.  Inadequately treated acute pain can lead to chronic pain, which contributes to poor quality of life and risk of self-medication through opioid abuse. Brennan et al. assert that adequate pain treatment is a basic human right, and it is our duty to preserve this right.

Nurses must balance our obligations to non-maleficence, beneficence, and justice by facilitating clinician and patient education regarding the risks and benefits of opioids, obtaining informed consent where possible, when initiating opioid treatment, shift to alternative measures to reduce pain, and implementing universal access to pain specialists for all patients experiencing pain. Specialized treatment for those experiencing chronic or persistent pain may prevent patients from turning to illicit drug use to self-medicate and reduce incidences of narcotic overdose.

I became a nurse with the primary objective of relieving suffering whenever possible. I believe we can and should prioritize relieving suffering while also reducing the incidence of opioid and heroin mortality in this country. According to the American Nurses Association code of ethics, “The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.” As nurses, we have the privilege of protecting the health of the community and the individual, but also the responsibility to alleviate suffering.

ABOUT THE AUTHOR: KATHERINE BENNETT

Katherine Vaillancourt Bennett is a registered nurse and family nurse practitioner master’s degree candidate at the Johns Hopkins School of Nursing. Her background is in cardiac and pulmonary progressive care, trauma intensive care, and pediatric emergency nursing. She also holds a bachelor of arts degree in religion from Denison University.

 

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