Assessment and Management of Pain at the End of Life _ ___________________________________________
The proper storage and disposal of prescription pain medica- tions should also be considered. Taking steps to ensure that medications are stored and destroyed securely and safely can help prevent unintended overdose and substance abuse. In 2010, the U.S. Senate passed the Secure and Responsible Drug Disposal Act, which amended the Controlled Substances Act to permit the take-back disposal of medications by authorized persons (rather than the patient with the prescription) [74]. As such, healthcare professionals may be required to dispose of drugs returned by patients in addition to drug samples that have expired or are not being dispensed. For best practice guide- lines on the disposal of medications by patients or healthcare professionals, please visit the Drug Enforcement Administra- tion Office of Diversion Control at https://www.deadiversion. usdoj.gov/drug_disposal/drug-disposal.html [32].
LEGAL AND ETHICAL ISSUES RELATED TO THE TREATMENT OF PAIN Fear of license suspension for inappropriate prescribing of con- trolled substances is also prevalent, and a better understanding of pain medication will enable physicians to prescribe accu- rately, alleviating concern about regulatory oversight. Physicians must balance a fine line; on one side, strict federal regulations regarding the prescription of schedule II opioids (morphine, oxycodone, methadone, hydromorphone) raise fear of Drug Enforcement Agency investigation, criminal charges, and civil lawsuits [1; 70]. Careful documentation on the patient’s medical record regarding the rationale for opioid treatment is essential [70]. On the other side, clinicians must adhere to the American Medical Association’s Code of Ethics, which states that failure to treat pain is unethical. The code states, in part: “Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care. This includes providing effective palliative treatment even though it may foreseeably hasten death” [71]. In addition, the American Medical Association Statement on End-of-Life Care requires that physicians “reassure the patient and/or surrogate that all other medically appropriate care will be provided, including aggressive palliative care and appropriate symptom management, if that is what the patient wishes”[72]. Physicians should consider the legal ramifications of inad- equate pain management and understand the liability risks associated with both inadequate treatment and treatment in excess. The undertreatment of pain carries a risk of mal- practice liability, and this risk is set to increase as the general population becomes better educated about the availability of effective approaches to pain management at the end of life. Establishing malpractice requires evidence of breach of duty and proof of injury and damages. Before the development of various guidelines for pain management, it was difficult to establish a breach of duty, as this principle is defined by nonad- herence to the standard of care in a designated specialty. With such standards now in existence, expert medical testimony can be used to demonstrate that a practitioner did not meet established standards of care for pain management. Another change in the analysis of malpractice liability involves injury and damages. Because pain management can be considered as separate from disease treatment and because untreated pain can lead to long-term physical and emotional damage, claims can be made for pain and suffering alone, without wrongful death or some other harm to the patient [73].
PATIENTS WITH HISTORY OF SUBSTANCE ABUSE
This population of people with a history of substance abuse presents challenges to the effective use of pain medication, with issues related to trust, the appropriate use of pain medications, interactions between illicit drugs and treatment, and compli- ance with treatment. The issues differ depending on whether substance abuse is a current or past behavior. With active substance abusers, it is difficult to know if patients’ self-reports of pain are valid or are drug-seeking behaviors. It has been recommended that, as with other patients at the end of life, self-reports of pain should be believed [12; 33]. A multidisciplinary approach, involving psychiatric profes- sionals, addiction specialists, and, perhaps, a pain specialist, is necessary. To decrease the potential for the patient to seek illicit drugs for pain, an appropriate pain management plan should be implemented and the patient should be reassured that pain can be managed effectively [12; 33]. When planning treatment, the patient’s tolerance must be considered; higher doses may be needed initially, and doses can be reduced once acute pain is under control. Long-acting pain medications are preferred for active substance abusers, and the use of nonopi- oids and coanalgesics can help minimize the use of opioids. Setting limits as well as realistic goals is essential and requires establishing trust and rapport with the patient and caregivers. Establishing trust is also essential for patients with former substance abuse behavior, who often must be encouraged to adhere to a pain management program because of their fears of addiction. Involving the patient’s drug counselor is beneficial, and other psychological clinicians may be helpful in assur- ing the patient that pain can be relieved without addiction. Recurrence of addiction is low, especially among people with cancer, but monitoring for signs of renewed abuse should be ongoing [12].
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MDNJ1525
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