Ethics, Opioids, and the Overdose Epidemic

This entire book was derived from a presentation with the same title (Pain, Drugs, and Ethics) that I have presented at several national pain conferences. It shares my perspectives of what happened in the field of pain management since 2000, how things have changed with respect to the use of opioid analgesics to treat pain, and the role that ethics could have played, and should play in decision-making about how pain care is delivered. When I was approached to author this book, my intention was to have it align with my lecture presentation as much as possible, and that has been the roadmap for what both I and Dr. Migdal have written, and what we teach our medical students. It is important to keep in mind that the contents of this chapter are my perspectives alone, and do not represent any educational institution, regulatory agency, or other organization. My goal with this chapter is to try to give you my perspectives based on what I have witnessed, my thoughts about what has happened, and ultimately leave you to come to your own conclusions—except when it comes to utilizing ethical principles to guide the care delivered to people with pain, which is somewhere between a plea and a mandate from me to you. This chapter is a retrospective of observations and reflections involving the “dynamic” relationship between opioid analgesics, their use to treat patients with pain, the role of ethics in their use, and of course, the relationship between opioid prescribing and the overdose epidemic that continues to plague our nation today. I made the decision to write this chapter in the first person for several reasons. Primarily, there is so much that has been written and discussed about this subject matter that it could have been the subject of a book entirely on its own. Additionally, so much of what has been written and the actions that have been taken with regard to opioid analgesia are commonly based on opinion, or desire to express opinion, and it is important to note that my selection of references might not necessarily be a comprehensive representation of the different opinions that exist. In fact, even at the time of this writing, things are being written in the scientific literature, posted on social media, written in the mainstream media, and discussed by experts, regulators, and policymakers almost on a daily basis. This illustrates the degree to which things are in a constant state of change with respect to the subject matter covered in this chapter. There are certain things which are referenced in this chapter, but the majority of what is written are things that I have witnessed personally.