Investigators explored concerns with regard to opioid prescribing in compliance with new regulations in a commentary piece published in the AMA Journal of Ethics. Referring to a case study of a patient requesting an opioid refill, authors explored how physicians may address patient pain in the increasingly complex landscape of opioid legislation.
Prior to prescribing opioids, physicians are now required to provide patients with information regarding opioid dependence, the legal consequences of opioid distribution or diversion, and the proper means of opioid disposal. Physicians must document the contents of this conversation in patient medical records and complete the Opioid Start Talking consent form, which requires the patient’s signature. These laws, while an essential component in the fight against the opioid crisis, may undermine patient autonomy and negatively affect the patient-provider relationship. Patients may be guided away from receiving opioids and may feel offended when asked to sign the Opioid Start Talking form, which explains that dealing opioids is illegal.
Authors described the case study of LJ, a 64-year-old woman who has been taking oxycodone following surgery for a fractured tibia and fibula. She requests additional oxycodone at her follow-up visit, citing that she takes 2 pills at night. Although radiographs show inadequate healing postsurgery, her surgeon, Dr M, is concerned that she may be developing opioid dependence. Dr M would typically comply with LJ’s request, but new Michigan Public Acts have made the process of prescribing additional opioid medication less feasible. In a busy outpatient practice, Dr M struggles to balance “her obligation to…new legal requirements with her obligation to take a patient’s claim of pain seriously.”
Authors agreed that prescribing more opioids may be the best course of action for Dr M. However, it remains important to guard against potential opioid dependence and emphasize the gravity of opioid abuse to LJ. Citing decision science literature, authors advocated for shared decision making, a clinical model in which patients are presented with all options and supported in their decisions. Authors also described “nudging,” a technique that frames certain decisions without removing patient autonomy. Dr M may “nudge” LJ, for example, by supporting her request for opioids while also citing statistics on dependence (i.e. “prescription has a change of leading to…dependence in 15% of cases”). Nudging, however, must be used carefully so as not to undermine patient autonomy. The Opioid Start Talking form must also be introduced with care, such that it does not signal “distrust or suspicion” toward the patient.
Ultimately, authors suggested that physicians should use shared decision making in addressing patient pain. Patients should be presented with an array of options for pain management; however, these options must be framed in a way that respects the gravity of opioid dependence. Framing techniques remain a useful tool in navigating the physician-patience alliance, while also respecting patient autonomy.
Hjelmaas AJ, Vercler CJ. How should a physician respond to a patient’s pain when new opioid prescribing laws limit shared decision making? AMA J Ethics. 2019;21(10):E838-E843.