Forced Tapering of Opioids Ethically Impermissible

Is Nonconsensual Tapering of High-Dose Opioid Therapy Justifiable? | Journal of Ethics | American Medical Association – by Travis N. Rieder, PhD – Aug 2020

This case considers a so-called legacy patient, one whose behaviors and symptoms express a legacy of past, aggressive opioid prescribing by a clinician.

Some prescribers might feel pressured to taper doses of opioids for such patients, but this article argues that nonconsensual dose reductions for stable opioid therapy patients is impermissible because it both puts a patient at risk and wrongs an individual in a misdirected attempt to ameliorate a systemic wrong.

Although perhaps surprising, this argument is supported by current evidence and recommendations for patient-centered pain care. 

Moral injury and burnout in medicine

Moral injury and burnout in medicine: a year of lessons learned – STAT – By WENDY DEAN and SIMON G. TALBOT – Jul 2019

When we began exploring the concept of moral injury to explain the deep distress that U.S. health care professionals feel today, it was something of a thought experiment aimed at erasing the preconceived notions of what was driving the disillusionment of so many of our colleagues in a field they had worked so hard to join.

As physicians, we suspected that the “burnout” of individual clinicians, though real and epidemic, was actually a symptom of some deeper structural dysfunction in the health care system.  

Delivering Quality Patient Experience without Opioids?

Reconciling the Opioid Crisis with Delivering Quality Patient Experience – Sara Health – Apr 2018

The nationwide opioid crisis has called into question the use of narcotic pain relieving drugs. But as clinicians work to prevent addiction, they face a quality patient experience quandary.

It seems that doctors are now expected to give equal weight to patient pain relief, opioid restrictions, and “customer satisfaction” reviews. The skills, experience, and professionalism of doctors have been devalued to little more than gaming “customer satisfaction” surveys.

Doctors are now just providers of standardized transactional “healthcare services” to customers, who are expected to shop around for the best value, the highest patient-satisfaction scores, and preferably both.  

Health Insurance Industry Interfering with Pain Mgmt

The Role of the Health Insurance Industry in Perpetuating Suboptimal Pain Management – Mar 2011

The author concludes that the outlook for chronic pain sufferers is not particularly bright, until such time that a not-for-profit single-payer system replaces the current treatment/reimbursement paradigm.

Background

Unlike pain practitioners, health care insurers in the United States are not expected to function according to a system of medical ethics.

Rather, they are permitted to function under the business “ethic” of cost-containment and profitability.

This capitalist principle is a problem for all social services because they serve a sector of society that often cannot pay; either their jobs don’t pay enough or they are too disabled to work. 

Corporate Law Creates Sociopaths

The Most Important Problem in the World – Medium – by James Gamble – Mar 2019

The most important problem in the world is a reasonable sounding provision of the corporate law that governs most major U.S. companies.

The rule: corporate management and Boards of directors are obligated by law to make decisions that maximize the economic value of the company.

This is how you end up with absurdities like this: 400% price hike for drugs is ‘moral requirement’. It’s frightening to be at the mercy of such ruthless entities making our health unaffordable, yet this is what corporations were created to do. 

Rein In ‘Sociopaths’ in the Boardroom

Ex-Corporate Lawyer’s Idea: Rein In ‘Sociopaths’ in the Boardroom – NY Times – By Andrew Ross Sorkin – July 2019

This “reformed” lawyer points out a fundamental flaw of our capitalist system that is responsible for increasing income inequality (rich getting richer, poor getting poorer), dysfunctional government (gridlock), and social decay (deaths of despair).

These troubles stem from a particular aspect of corporate law, and he proposes a relatively simple solution to change how corporations operate.

Jamie Gamble, a retired corporate lawyer, has had an epiphany in recent years: The executives who hired him and that his firm sought to protect, he said, “are legally obligated to act like sociopaths.”  

Obscure advisory committees on U.S. drug pricing

The obscure advisory committees at the heart of the U.S. drug pricing debate – Reuters – by Caroline Humer – April 2019

Expectations were high last year for three new migraine drugs hitting the market from Amgen Inc, Eli Lilly and Co and Teva Pharmaceutical Industries.

Priced around $7,000 each, the drugmakers called them “breakthrough” treatments designed to prevent migraines when taken year-round, and estimated that millions of patients could benefit

But a small group of external medical experts who quietly advise U.S. health insurers on new drugs was not impressed, according to a private meeting held at UnitedHealth Group’s OptumRx offices in Chicago that was attended by Reuters.  

Rein In ‘Sociopaths’ in the Boardroom

Ex-Corporate Lawyer’s Idea: Rein In ‘Sociopaths’ in the Boardroom – NY Times – By Andrew Ross Sorkin –  July 2019

Jamie Gamble spent most of his career as a partner at the law firm Simpson Thacher & Bartlett, which counts virtually every major company in the United States — including Facebook, General Motors, Google and JPMorgan Chase — among its clients.

Mr. Gamble has had an epiphany since retiring nearly a decade ago that is so damning of his former life that it is likely to give his ex-partners a case of agita. He has concluded that corporate executives — the people who hired him and that his firm sought to protect — “are legally obligated to act like sociopaths.”

He’s not the only one to notice this: 400% price hike for drugs is ‘moral requirement’

Access to Pain Management as a Human Right

Access to Pain Management as a Human Right – free full-text /PMC6301399/ – Am J Public Health. – Jan 2019

It seems that politicians, government agencies, and law enforcement simply don’t see this, though they’d quickly change their minds if it were their own flesh in agony.

The concept of access to pain management as a human right has gained increasing currency in recent years. Commencing as individual advocacy, it was later embraced by the disciplines of pain medicine and palliative care and by mainstream human rights organizations.

Today, United Nations and regional human rights bodies have accepted the concept and incorporated it into key human rights reports, reviews, and standards.   

Doctors’ duty to relieve suffering

The two PubMed articles in this post are from the early 2000s, over 16 years ago, yet they describe the same situation we’re stuck in today, with doctors being squeezed, harrassed, and sued from both sides of the opioid controversy.

Sometimes they are successfully sued for refusing to administer necessary pain relief when a jury decides that “insufficient pain management in a dying patient constituted abuse by a physician.” (which seems obviously right to me)

Other times they are successfully sued when a doctor who “provided comfort care to terminally ill patients was accused of performing euthanasia.” (luckily, the conviction was later overturned)

I’m very glad I’m not a doctor who has to make such potentially career-ending decisions these days.