Treating Patients who have Substance Abuse Disorders and Chronic Pain

As a primary care physician, I see many patients who complain of chronic pain and who want me to prescribe pain medication. Many of these patients also have a history of substance abuse, however, and when I test them for active substance abuse by obtaining urine drug screens, the urine screens often come back positive for cocaine, methadone, fentanyl, marijuana, benzodiazepines, and other street drugs. So I must tell these patients I can't prescribe any opioid medication for their pain, because they're taking street drugs and need to stop taking dangerous, habit-forming drugs.
      Although my initial impulse may sometimes be to feel a little angry or disappointed that patients have tried to deceive me by lying to me about their substance abuse or by asking me for prescriptions for opioids when they knew they already had opioids and other illicit substances in their bloodstream, I think that denial, dissemblance, and concealment of active substance abuse may also be part of the substance abuse disorders that many patients suffer from. 
      I don't think the most caring or tactful way to tell patients I can't prescribe opioids for their pain is to say bluntly, "I can't prescribe opioids for you, because you're a substance abuser." This kind of response is likely to anger them, and seems rather callous, uncaring, and condescending.
      Some of the possible reasons why people might not want to be seen or described as substance abusers are that
      (1) It may hurt their sense of pride.
      (2) It may violate their sense of selfhood and individuality (they may feel they're being seen as just like everyone else who takes street drugs, and that everyone who takes street drugs is being seen as the same by the person who describes them as a substance abuser).
      (3) It may make them feel that the person who sees them as a substance abuser feels that he or she is better than them, and that they are being seen as somehow less worthy of respect (it may make them feel marginalized and disrespected, and it may violate their sense of equal worth and personal dignity).
      (4) They may in fact be in a state of denial that they are habitual substance abusers, and that their habit is in some ways dysfunctional.
      (5) They may be wary of losing various legal and welfare rights to which they are entitled and which they may be in danger of being denied if they're seen merely as substance abusers.
      (6) They may resent being labeled or dismissed as something they don't see themselves as (they may resent being assigned the label of "substance abuser" without their consent).
      (7) It  may make them feel they're being stereotyped, and that the uniqueness of their own life story, personal history, and social situation is being denied.
      (8) It may make them feel they're being told that whatever distress of misfortune they're suffering from is their own fault (they may feel that being told they're substance abusers is an example of "blaming the victim").
      (9) It may seem like an attempt to make them feel guilty about something they may or may not feel guilty about.
      (10) It may seem like an intrusion on their personal or social space (they may not welcome a wake-up call about their substance abuse disorder).
      (11) They may feel they're simply "self-medicating" (a term I think is often mistaken and misplaced. For someone to say "I was self-medicating" may often be a convenient way for them to try to disregard, deny, or justify their substance abuse disorder).

      So physicians must respond compassionately to patients who suffer from substance abuse and chronic pain, not by allowing themselves to be misled into prescribing drugs that such patients will abuse, and not by treating such patients as if they were any less worthy of respect than other patients, but by approaching them as individuals and developing treatment plans with them that will recognize and respond to their personal health care needs.

      The Maryland Board of Physicians guidelines for opioid prescribing include that before opioid prescribing, physicians should consider non-opioid therapies. Physicians should evaluate and inform patients of the risks and benefits of opioid use. They should establish a treatment plan and only continue prescribing opioids if the pain and functionality improvement outweigh the risks. They should screen for substance use disorders. They should consider red flags regarding potential abuse, misuse, and diversion of opioids. They should check the Prescription Drug Monitoring Program (PDMP) to review patient medical history of Controlled Dangerous Substances prescriptions. They should perform patient urine screening to confirm presence of prescribed medication and for undisclosed prescription drug or illicit substance use. And they should schedule a patient follow-up appointment 1-4 weeks after initial prescribing.¹
     The Maryland guidelines also include, regarding dosages and duration of opioids, that physicians should start low and go slow by prescribing the lowest effective dosages for the shortest possible duration. Physicians should avoid prescribing opioids and benzodiazepines concurrently. They should calculate the morphine milligram equivalent (MME) dosages, and if prescribing > 50 MME per day should increase appointment follow-up frequency and offer naloxone for overdose risk, should avoid prescribing > 90 MME per day if possible, carefully consider and justify such doses, and consider referring patients to a pain management specialist.²
     The Maryland guidelines also include, regarding continued treatment with opioids, that physicians should reassess treatment goals and determine if opioids continue to be the best option. Physicians should reassess no less frequently than every three months. They should consider whether there are clinically meaningful improvements in pain and function that outweigh the risks or harms of opioid prescribing. They should consider whether any new red flags of substance abuse disorder or diversion are present. They should perform periodic urine toxicology screenings. If over-sedation or increased overdose risk is present, they should taper opioid prescribing while considering patient psychosocial support. If tapering opioids, they should monitor for withdrawal symptoms.³
      The Maryland guidelines also include that for patients with substance abuse disorders, physicians should refer them for substance abuse treatment, should consider referring them to a pain management specialist, should consider medication-assisted treatment (MAT) such as buprenorphine, methadone, and naltrexone in combination with behavioral therapies, and should consider offering naloxone for those patients with high risk of overdose.⁴

      A complete statement of the Maryland Board of Physicians guidelines can be found at the Maryland.gov website.



FOOTNOTES

¹Maryland.gov Maryland Board of Physicians, "Board Guidance," at https://www.mbp.state.md.us/resource_information/res_con/resource_consumer_od_board_guidance.aspx
²Ibid.
³Ibid.
4Ibid.

Linda Zagzebski's Exemplarist Moral Theory

Linda Zagzebski’s Exemplarist Moral Theory (2017) is a very cogent and persuasive attempt to construct a comprehensive moral theory by directly referring to moral exemplars, of whom she identifies three types: heroes, saints, and sages. Moral exemplars, according to Zagzebski, are people we regard as admirable and may therefore attempt to emulate, because they embody moral virtues, such as love, compassion, wisdom, and courage. Exemplars of non-moral qualities, such as athletically gifted or artistically talented persons, may also be admirable, but they may not be imitable in the same way or to the same extent that we can imitate moral exemplars, unless they have developed their gifts or talents through other qualities that we can imitate, such as determination and hard work. 

      Zagzebski observes that we may sometimes be mistaken in our admiration of people, and we may sometimes envy or resent, rather than admire people for their admirable qualities. We may also disagree about what exactly we admire in some person(s). However, an advantage of exemplarist moral theory is that we may often be more certain that some people, like Confucius, the Dalai Lama, and the Buddha are admirable than we are of what exactly is admirable about them.¹ 

      Zagzebski also notes that we may not always be able to fully imitate the admirable qualities of moral exemplars, unless we completely refocus our lives, which may be very difficult for many of us. Even though such saintly figures as St. Francis of Assisi, St Catherine of Siena, and Mother Theresa may be very admirable for their self-sacrifice and love for strangers, we may not have the moral resources to be able to emulate them in every respect. We may also not always regard moral saintliness as something desirable or something we want to completely devote ourselves to trying to emulate. We may admire some things (such as lives of asceticism and self-sacrifice) without truly desiring them, and we may desire some things (such as lives of comfort and financial security) without truly admiring them. 

      Another point Zagzebski makes is that although the emotion of admiration is assigned a primary function in her moral theory, this fact in no way implies that admiration is necessarily a more trustworthy emotion than other emotions or that we should not attend to moral judgments justified by other emotions.² Admiration shares with other emotions the features of (1) having an intentional object, (2) having an affective component, and (3) having a potentially motivating aspect. However, there may be at least two kinds of admiration: admiration for inborn talent, and admiration for acquired excellence. The latter kind is the more important one for exemplarist theory. 

      Three possible responses to an admirable person may be (1) to feel positively about her, leading to a desire to emulate her, (2) to feel negatively about, or benignly envious of her, but still leading to a desire to emulate her, and (3) to feel negatively about, or malignantly envious toward her, leading to a desire to deprive her of her admirable qualities.³ The third kind of response (malignant or spiteful envy) may arise from a kind of resentment, in which the envious person sees her own lack of, or inability to acquire, the admired good, and thus tries to deprive the admired person of that good, rather than try to acquire it herself.⁴ 

      We may admire some people more than others if they are more consistently admirable or seem to have a deeper disposition to be admirable in a wider range of situations. We may also admire some people more than others if they are admirable in a greater variety of respects (for example, if they are tactful as well as honest, temperate as well as courageous). Moral examplars, according to Zagzebski, tend to be admirable in all or most of their acquired traits, although they don’t have be admirable to the highest degree in all their acquired traits (such a feat would be very difficult or impossible). 

      Zagzebski identifies Leopold Socha (1909-1946), a Polish sewage inspector who at great personal risk sheltered Jews from the Nazis during World War II, as an example of a hero. She identifies Jean Vanier (1928- ), a Canadian philosopher and theologian who founded L’Arche, an international federation of communities for the care of the mentally disabled, as an example of a saint. And she identifies Confucius (551-479 BCE) as an example of a sage. 

      Some of the distinctive qualities possessed by sages include wisdom, insight, understanding, reflectiveness, equanimity, open-mindedness, intellectual humility, fairness, self-discipline, and creativity in problem-solving.⁵ 

      Among the advantages of exemplarist moral theory, according to Zagzebski, are that it may serve as a map, rather than a supposed manual for moral decision-making. 

      Among the purposes of such a theory are (1) to create a comprehensive ethical theory that serves the same purposes as deontological, consequentialist, and virtue theories, (2) to have practical application by structuring moral theory around a motivating emotion—the emotion of admiration, (3) to explain and justify a genealogy of morals, and to track moral development, (4) to link theoretical ethics with empirical research in psychology and neuroscience, and (5) to meet the needs of different communities, and to frame the discussion of moral theory in cross-cultural discourse, by allowing different communities to identify distinct but overlapping sets of moral exemplars.⁶


FOOTNOTES 

¹Linda Trinkaus Zagzebski, Exemplarist Moral Theory (Oxford: Oxford University Press, 2017), p. 10. 

²Ibid., p. 28. 

³Ibid., p. 53. 

⁴Ibid., pp. 55-56. 

⁵Ibid., p. 95. 

⁶Ibid., pp. 3-4.