Ethical dimensions of the prescription opioid abuse crisis

The number of deaths by drug overdose in the United States tripled between 1999 and 2014 and reached a historic peak in 2015.1 Opioids were involved in nearly two thirds of these deaths despite few rigorous examinations of the benefits of opioid treatment for pain lasting greater than 3 months.1,2 Economic downturns and rural health disparities have been associated with the increase in opioid overdoses.3–8 However, other considerations from an ethics standpoint have also contributed to the current opioid crisis. Ethics is the study of right and wrong behaviors.9 An ethical dilemma arises when a difficult choice between competing moral needs must be made.10 This commentary will address some of the ethical considerations related to the current prescription opioid abuse crisis11 and the ethical dilemma of adequately addressing a patient’s chronic noncancer pain without possibly setting the stage for addiction to opioid medications. Influencing prescribers. Many prescribers are undereducated regarding the appropriate use of opioids for treating pain.12 Prior to 1980, opioids were primarily prescribed by surgeons to treat immediate postoperative pain or prescribed for treatment of cancer-related pain.13 However, during the 1980s pain management “thought leader” Russell Portenoy, M.D., began presenting seminars promoting an increased role for opioid pain relievers in treating chronic noncancer pain, arguing that no dose of opioids was too high.14 Portenoy cited a 1980 letter to the editor of the New England Journal of Medicine that noted that less than 1% of patients treated with opioids became addicted.15 Portenoy also cited his own retrospective review of 38 cases in which patients’ chronic noncancer pain was treated with opioids, arguing that this case series provided evidence that opioids were effective for treating chronic pain.16 However, during this time Portenoy had financial ties to more than 12 pharmaceutical manufacturers, including those producing opioid pain relievers. These relationships were not disclosed during Portenoy’s presentations.14