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LAS VEGAS -- Four commonly accepted principles of medical ethics can guide chronic pain management decisions, a prominent expert said here.

"Forces are being applied to healthcare providers about how they prescribe opioids," Kevin Zacharoff, MD, of SUNY Stony Brook School of Medicine, told a capacity crowd at the PAINWeek 2018 conference.

There's a "swirl" surrounding opioid prescribing, including state mandates, conflicting guidance, media attention, and new drugs, he said. "Fentanyl being added to heroin has changed the game. Even though often it's an illicit substance when it's obtained 99% of the time, healthcare providers are still in the crosshairs.

"Fear of regulatory scrutiny is motivating a lot of healthcare providers. And that is dynamic, not static." In this environment, clinicians need "some set of reproducible ideas to plug patients into" and process them the same way.

"That's where ethics come in. We've been teaching people for years to do an assessment, identify what's going on, determine risk, formulate a treatment plan, implement the plan, reassess the patient, and you'll be good to go. The ethical principles turn that all around."

Four principles to guide chronic pain management decisions are:

• Patient autonomy: Make sure you convey the risks to the patient and the patient gets to decide what happens to them, as long as they're competent and capable of making a decision.
• Justice: Pay attention to the law. "Justice is a two-way street," Zacharoff observed. "It doesn't only mean that people have to worry about the legal ramifications of what they do. It also means that everybody has a right, a justice-based right, to be treated fairly and equitably regardless of the variables they bring to the table."
• Nonmaleficence: Known as "do no harm," nonmaleficence has changed over time, Zacharoff explained. "In 2018, you not only have to consider patient harm. You have to consider household harm, community harm, and societal harm."
• Beneficence: Determine what will benefit the patient most.

"These principles can be applied to any medical condition and any patient regardless of age, gender, or anything else," Zacharoff added. "They're not going to change, regardless of whatever else is changing."

Some clinicians believe "do no harm" is the highest standard, but Zacharoff disagreed in an interview with MedPage Today. "As far as I'm concerned, autonomy is the number one rule of all the ethical principles: that a patient has the right to make decisions about themselves," he said. "We all think about it in simple terms: you can't operate on someone unless you have their consent, and it is considered battery if you do.

"If you can't get the patient to understand what the risks of opioids are, what your responsibilities are, what their responsibilities are, they can't make an autonomous decision," he pointed out. "That should then get you to the point where you say, 'I don't think opioids are the right solution for you.' And that has nothing to do with politicians. It has nothing to do with regulatory agencies. It has to do with the ability of the patient to digest the risks and benefits."

While clinicians have a moral mandate to not let people suffer, "opioids are not the only solution, and sometimes the answer is no," Zacharoff said. "But it's not always supposed to be no. The decision has to be based on applying ethical principles and capturing information that falls outside what a standard history and physical captures."

The "swirl" has led to clinicians to drawing conclusions, sometimes before they have met the patient, he added. "We try to plug patients into clinical pathways. As it turns out, in this case, you really can't do that, especially if you want to mitigate risk.

"We're definitely guilty if we don't query someone about the likelihood of a substance abuser in the family who might abuse medication that's put in the household," he said. "That has to be part of the nonmaleficence discussion; it has to be part of the beneficence discussion. We have to probe for those kinds of things. If we don't, we're not doing no harm."

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