Responding to Unsafe Opioid Use: Abandon the Drug, Not the Patient
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Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; 2Departments of Internal Medicine and Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
J Gen Intern Med DOI: 10.1007/s11606-020-06281-4 © Society of General Internal Medicine 2020
have a legal and ethical duty to protect their P hysicians patients and support them during times of clinical need; the decision to end a doctor-patient relationship should not be made lightly. However, in a recent survey of 794 primary care practices, 90% reported discharging patients in the previous two years, often for opioid-related issues.1 Disruptive or inappropriate behavior was the most common reason for discharge (81%), but 78% reported dismissing patients for violations of a chronic pain or controlled substance agreement. We find this practice worrisome, particularly since many controlled substance agreements use coercive and stigmatizing language that patients may reluctantly sign or have trouble understanding.2 Although violent, threatening, or disruptive behavior may be a valid reason to discharge patients in certain circumstances, opioid misuse should rarely rise to this threshold. Surprisingly, prominent medical societies such as the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP) remain largely silent on this issue. Only a now-expired ethics case study from the ACP touches upon opioid-related discharge practices.3 And yet, the data suggest that providers often respond to patients with aberrant opioid use behaviors as if they were intentionally disrupting a medical practice rather than exhibiting an underlying pain or substance use problem. This misunderstanding is likely indicative of the opioid knowledge gap and stigma surrounding opioid addiction that is so pervasive across the United States. According to a 2018 national survey, over 53 million people aged 12 or older
Previous Presentation This manuscript has not been previously published and is not under consideration in any other peer-reviewed media. Received May 26, 2020 Accepted September 28, 2020
used illicit drugs within the past year and nearly 10 million misused pain medications, so the impact of substance and opioid misuse and the importance of safe opioid prescribing cannot be overstated.4 Additionally, as recently as the 2010’s, medical schools were sorely lacking in their pain curricula, allotting a median of only nine teaching hours on pain and its management.5 Furthermore, pain education modules are frequently bundled in with other core curricula and rarely addressed in full. A recent systematic review of pain education in medical schools across the world concluded that in the USA and the UK, 96% of medical schools had no compulsory dedicated teaching on pain medicine.6 It is therefore unsurprising that physicians might feel ill-prepared to address opioid prescribing and misuse in an informed and ethical manner. To address this challenge, we need to appreciate the
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