A number of us have been discussing interesting ethical dilemmas around pain management over the last few weeks..
Am I, as a physician, obligated to treat pain?
Am I obligated to prescribe opioids if they are an appropriate medical option?
Will I be required to take training to prescribe opioids? Won’t it be easier to not take any training and just say I don’t prescribe them?
These theoretical discussions have gone on to question whether it is acceptable to bend the letter of the law in, for instance, the US, to ensure pain control. The answer, right throughout our discussions, is no!!! A categorical no!!!! The legal consequences are too great for a physician in the USA.
But let me pose another question, one that arises out of countries with limited access to opioids often because of policies that restrict physician prescribing.
Let me create the example of country X (I have never visited a country starting with X, so we are safe here). In X, the only opioid available for outpatient pain control is Morphine SR 30 mg tablets (SR means sustained release). Physicians are allowed to prescribe 30 tablets of SR morphine 30 mg every 15 days!!!. There is a concerted effort in X and neighboring countries to improve access to opioids, with foreign clinicians visiting and a growing local interest in palliative care.
Mr Mu, an X-ian who has metastatic lung cancer (the primary cause of death of male X-ians), has significant pain that is not controlled with Morphine 30 mg twice daily with additional paracetamol (acetaminophen) and a NSAID. There are no other drugs available for pain management. His pain is around 7-8 on a 1-10 scale most of the time, and he is using more and more apple brandy to dull the pain!
A community volunteer, who is visiting Mr Mu, is aware that another patient, Mrs Pi, also has lung cancer and has been taking the same dose of morphine. However she was lucky enough to receive a course of radiotherapy that has provided some pain relief and she is now using the morphine only at night. The volunteer suggests to Mrs Pi that she donate her extra tablets to Mr Mu, and that Mrs Pi, continue to have her doctor prescribe 30 tablets every 15 days? Mrs Pi agrees and our volunteer, yes RH, transports these to Mr Mu, every two weeks, who now takes 1 tablet in the morning and two at night with his pain at night dropping to a 4/10 with a great improvement in sleep and reduced alcohol intake.
What is your reaction to this? Is this an acceptable outcome, especially as the doctor is not aware of the “misuse?”
Well a month later, Mrs Pi visits with her doctor and lets slip that she is now taking only one tablet a day and ends up sharing the whole story. The doctor, on hearing the story, continues to write for the 30 tablets every 15 days, knowing that half are going to Mr Mu for improved pain control that the unfair regulations will not let his own doctor prescribe.
Is this a form of civil disobedience that we should allow? Should we be encouraging this physician to behave in this way? What is different about this physician and Gandi making salt, or those who ran the underground railway in the US during the mid 1800’s.
Surely it is only the physician and perhaps our friend Robin who are risk.
But what of the impact on the growing palliative care movement and the desire to increase opioid access if this scheme is exposed? Will their efforts, if exposed, set back the whole palliative care movement and be used as an example as to why the government needs to retain tight regulations.
Not real? Let’s not kid ourselves. What advice should we be giving our palliative care colleagues who have restrictive opioid laws when they encounter these situations?
Appreciate your comments, reactions and advice!