By Michael T. Puenini, MD, CCHP-A and Dean Rieger, MD, MPH
Posted on August 31, 2009 –
Ethics of Analgesia, Part One
Physicians in correctional health care settings are increasingly faced with patients who have been on prescription and non-prescription opioid drugs on the outside and may be addicts or have pain complaints which had been treated with opiates in the past. While opiates are essential in the treatment of severe acute pain, the benefit of this class of medication in chronic pain is not well proven. What’s a correctional health care professional to do? Consider the following:
Case Number one:
A 30 year old man has chronic trauma related unhealed wounds of his legs that have been present for the last four years. He has no circulatory problems. He presents to the prison clinic with complaints of pain that comes from the wounds. He is a newly incarcerated individual who is in prison on drug charges and who wants my Oxycodone, a medication which apparently had been prescribed to him outside by a general internist. He has been off opiates for three months while in jail and has experienced no apparent ill effects. Your evaluation reveals a healthy young man with deep skin wounds on both legs. A review of the records and a thorough exam reveal no reason for the persistence of the wounds.
Some might argue differently, but in this case, we believe that the imperative of physician beneficence would demand that the medical provider NOT provide opiates to this patient. While he has skin wounds, they should have healed months or years ago, and it is possible that he has sabotaged his own care to procure opiates from his doctor. DSM IV definitions of addiction apply—he has continued drug use despite negative consequences and before incarceration has been unable to control his use. We would argue that his presence in prison signifies a major loss for this patient, and thus, a major addiction. Excellent care of the wounds, and drug treatment (with maintenance of his established abstinence) are the indicated treatment for his current condition.
This will be difficult. The strategy of taking a somewhat adversarial approach with this patient in his treatment will hopefully be supplanted with a more collaborative relationship in the future. The ethics of taking this directive if not parental approach to the treatment of our adult patients could be a topic for further discussion.
Case Number two:
A 52 year old, known to be a regular seeker of medical attention from prior multiple incarcerations, presents to the jail clinic loudly complaining of multiple aches and pains all over her body, apparently histrionic and drug seeking. She has a known drug history, and has been in and out of jail for many years. She has untreated Hepatitis C, is obese, demonstrates impaired glucose tolerance and has been a heavy smoker since childhood. Over the years, she has presented to the jail clinic multiple times and is known for her histrionic behavior. Physical findings are non-specific. The doctor orders some tests and x-rays of the painful limbs and prescribes a non-opioid pain medication. The patient leaves the clinic angry.
Several days later, her tests results return, showing bone lesions with a probable primary lung cancer. The doctor prescribes long acting opiates and obtains an oncology consultation. Here the principle of beneficence requires the physician to treat the acute pain which has its origin in the metastatic disease.
This is a classic description of pseudo addiction, a hazard for doctors and patients alike in a correctional health care setting. Her histrionic and drug-seeking behaviors were indeed similar to behaviors displayed by drug addicts seeking unnecessary analgesia, and similar to her behavior during previous confinements. While the medical provider initially, although understandably, misinterpreted her symptoms, he listened and attended to the patient ordering appropriate testing. The histrionics clearly were a potential barrier to good care. The physician practiced good medicine despite the temptation to label and judge the patient.
Withholding opiates in the setting of a histrionic, drug seeking patient with non-specific findings is also reasonable medical treatment. Above all, do no harm; this is the principle of non-maleficence. Certainly, feeding opiates to every demanding patient with pain complaints is potentially harmful to the patient and to the institution. On the other hand, good patient care demands that a patient with documented metastatic bone disease be treated as required to relieve pain, even with long term opioid analgesia. Prior behaviors and addiction are essentially immaterial in this case.
But then, the reader should have noticed that your columnists have seemed to pass over the essential and most difficult of the pain patients that we see daily in correctional settings. The examples in this discussion range from pain created solely for the purpose of receiving narcotics to pain caused by bone cancer. More commonly we see patients who have substance abuse histories and whose claims about pain or impaired ADL’s don’t quite fit with what we learn from the medical history or see on examination. These are the patients who challenge us to identify objective findings in the midst of obvious manipulation. Often, we feel ourselves travelling the seemingly unmarked territory of our patients’ addictions with the manipulation that goes with it.
Keeping in mind the primary ethical considerations of beneficence, non-maleficence, and patient autonomy, we can often resolve the thorny question of what’s a doctor to do. We’ll attempt to consider more difficult cases in our next column.
We’d sure appreciate your input.
mike.t.puerini@doc.state.or.us
drieger@correctcaresolutions.com
