NM-312
BALANCING THE SCALES: THE OPIOID EPIDEMIC AND THE ETHICS OF PAIN MANAGEMENT
1Latin I, 2Oke A, 1Rubin K, 1Seidman P
1University Hospitals Cleveland Medical Center/Rainbow Babies and Children's Hospital, Cleveland, OH, USA; 2University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, Ohio, USA
The growing opioid epidemic in the United States has led to significant financial and societal impact for both healthcare providers and patients of all ages. Research shows that 12.5% of adolescents new to illegal substance abuse started with prescription opioids(1). News media has heightened public awareness of the issue, and opioid related deaths now surpass motor vehicle deaths(2). As a result, opioid use for pain management is undergoing scrutiny both by providers and patients. State governments have implemented legislation limiting prescriptive practice. Patients’ fear of addiction has escalated usage of “non-opioid directives†notifying health care professionals that they are not to be prescribed opioid medications.
We treated a 15 y/o male, ejected in an MVA who sustained multiple long bone fractures, rib fractures, a pulmonary contusion, and a concussion. Through care, multiple surgical procedures, pain was treated with a dilaudid PCA, scheduled acetaminophen, and benzodiazepines as needed. His mother voiced her objection of opioids for pain management due to fear for potential future drug use and addiction. She demanded that all opioids and benzodiazepines be discontinued, leading to inadequate pain control. As a result, the patient was unable to tolerate dressing changes or perform physical and occupational therapy. The hospital bioethics team intervened, explaining that the medical team has an ethical obligation to provide medically appropriate care in the best interest of the patient, including pain medication, while balancing the parent’s right to make an informed refusal of treatment. Opioid, gabapentin, and benzodiazepines were resumed after much discussion regarding addiction, tolerance, and weaning. 45 days after injury the patient was discharged with gabapentin, diazepam, and oxycodone. Four months after injury, the patient’s wounds were well healed. He remained on pregabalin for treatment of diffuse axonal brain injury, but suffered no complaints of pain.
Acute moderate to severe pain requires prompt and adequate treatment, often with opioids, to achieve pain reduction to acceptable levels, facilitating recovery from the underlying disorder. While the campaign against the opioid epidemic is necessary to decrease the association between prescribed opioids and their abuse or transition to illegal drug use(3), excessive concern for addiction and dependence often leads to undertreatment of acute pain. Failure to adequately treat acute pain often results in increased morbidity, mortality, and may lead to the development of chronic pain(4,5). Health care providers must recognize the need for appropriate opioid administration, especially in the acute pain setting, recognize risk factors for abuse, and educate patients and parents to mitigate these challenges.
1. Whiteside, LK, Russo, J, et al. J Adlosc Health 2016 Jan 58(1):92-97
2. Rudd, RA. et al. CDC MMWR Morb & Mort Wkly Rep. 2016 Jan;64(50)1378-1382.
3. Sharma, B. et al. Child Adol Psychiatry Clin N Am. 2016 Jul;25(3):473-87
4. Verghese, ST. et al. J Pain Res 2010; 3 105-123.
5. Strassels SA. Adv Stud Pharm. 2008;5(2):48-51
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