What Otolaryngologists Should Consider When Prescribing Opioids

The ethical foundations for patient care rest fundamentally in the four principles of autonomy, beneficence, nonmaleficence, and social justice. It is not always easy to achieve a balance of these principles in medicine, especially when taken in the context of compassion, understanding, honesty, and duty. Often, hard choices must be made, and few clinical situations are more difficult in this regard than pain management.

While it might seem that autonomy (what the patient desires), or even beneficence (doing good), would be the primary ethical principles to follow, in fact, the responsibility for nonmaleficence (do no harm) may well be the best guide. Pain medications in general, but opioids in particular, can lead to misuse, overuse, tolerance, and addiction—hence, the crisis now seen in the U.S. Since it is the physician who can “legally” provide the prescriptions, it is up to us, individually and collectively, to ethically prescribe pain medications for our patients. The key is to appropriately balance the dyad of beneficence and nonmaleficence for each patient, while bearing in mind that patient self-determination and desires (autonomy) will not necessarily be the primary guiding ethical principle in most cases of pain management.

The key is to appropriately balance the dyad of beneficence and nonmaleficence for each patient, while bearing in mind that patient self-determination and desires will not necessarily be the primary guiding ethical principle in most cases of pain management.

Explain Expectations and Limitations

Ideally, in the clinical setting where the level of pain for patients is expected to be high and long-lasting, early discussion of the role of pain medication management in their care is very important. The fear or concern for mitigation of postoperative pain is quite common, and explaining pain management modalities, with their limitations, can be very reassuring for the patient. Educating the patient in the risks, benefits, and goals of pain management is salutary, especially when done with honesty and understanding. Setting boundaries for pain medications initially is much better than trying to work with an unprepared patient in the postoperative setting.

All discussions on pain medication should be well documented in the patient’s health record, along with an outline of the pain management plan preoperatively, all discussions with the patient during the time pain medications are prescribed, and all alternatives that are offered the patient for pain relief. As with all medications, longitudinal reassessment of physical findings and patient complaints/side effects should be performed.