Loyola bioethicist urges doctors to identify their biases in treating opioid-dependent patients

January 2023

By JULIE MINDA

As doctors weigh treatment approaches for patients who are addicted to opioids, Mark Kuczewski thinks it is important that these clinicians acknowledge how their own biases influence care plans.


Kuczewski

Kuczewski directs the Neiswanger Institute for Bioethics and is a professor of medical ethics for the Stritch School of Medicine at Loyola University Chicago. During a CHA webinar titled "Clinical Ethics and Opioid Use Disorders," he said health care providers' views on addiction can have a profound impact on the patients they treat. Misconceptions can lead to poorer outcomes for patients.

Some providers might place great weight on a patient's prognosis for recovering from addiction when making clinical decisions. "Unfortunately, there's no particularly good way to make such a prognostication," Kuczewski explained in an emailed response to follow-up questions. "All a physician can do is assess the patient's expressed willingness to seek treatment and help to arrange the conditions that make recovery more likely, e.g., direct discharge to a treatment facility."

Kuczewski told the webinar audience that it is essential for providers to understand the biological underpinnings of addiction and the implications for treatment of comorbidities. He said that a medical judgment should not be based on whether the clinician concludes a person with late-stage substance dependency has a quality of life worth extending.

Kuczewski told Catholic Health World that as a bioethicist he believes "a clinician should undertake extensive treatments that improve a patient's quality of life and potentially prolong a patient's life, regardless of whether the patient's health ultimately will continue to deteriorate because of an active addiction to alcohol or other drugs.

"That is, medicine does not usually judge treatments as effective only if they are permanently successful and the outcomes for patients with substance use disorders should not be judged differently," he explained.

Worsening epidemic
Opioid misuse and dependency have risen sharply in the U.S. for three decades, spurred on by pharmaceutical companies and pharmacies' malicious marketing of addictive substances to increase sales. The U.S. Department of Health and Human Services estimated 10.1 million people aged 12 or older misused opioids in 2018, with most of them using prescription pain relievers. The agency said emergency department visits for opioid overdoses rose 30% between July 2016 and September 2017.

Overdose deaths involving opioids have increased by more than eight times since 1999, according to the Centers for Disease Control and Prevention. Kuczewski said 75% of the nearly 92,000 drug overdose deaths in the U.S. in 2020 involved an opioid.

Over about the last 10 years, criminals who have been illicitly manufacturing and trafficking drugs have been lacing heroin and other street drugs with synthetic fentanyl, a highly concentrated, powerful opioid. Fentanyl has led to an "explosion" of overdose deaths, said Kuczewski.

The use of medication-assisted therapies to quell drug cravings and access to safe injection facilities are potentially life-saving options for people who are addicted and using street drugs, he said.

Clinical quandaries
Clinicians and ethicists in health care facilities are increasingly deliberating clinical and ethical quandaries related to patients and opioids.

For patients in pain, clinicians must determine to what extent prescription opioid use is appropriate, for what types of pain, in what dose and for how long, given the heightened potential for developing dependency and other harms. Addiction risks are not necessarily relevant when it comes to palliating severe pain in patients at the end of life, Kuczewski said.

He noted that it can be difficult for a clinician to tell the difference between patients who are legitimately seeking prescription opioids to mitigate unresolved physical pain and those who suffer from a substance use disorder and "can easily come to believe they are in pain."

Kuczewski told Catholic Health World that it is essential for prescribing physicians to have a plan for "how the end of the use of the opioids will occur or (for) engaging in alternative modalities of managing the pain."

He said a particular challenge is when providers struggle to keep safe patients who arrive at a hospital seriously ill and actively drug seeking. Patients may try to smuggle in drugs and even attempt to inject their own illicit drugs into a central or peripheral catheter.

Brain rewiring
Kuczewski said an important backdrop to decision-making around patients' safe use of opioids has to do with all patient-facing health care professionals' understanding of the roots of substance use disorders, including opioid addiction.

He said some clinicians believe opioid addiction is the result of people's choices and they bear full responsibility. Others believe opioid addiction is primarily related to genetic predisposition to addiction or untreated underlying mental illness, such as depression.

Kuczewski said research shows that opioid use — especially over time — permanently alters the brain's circuitry, so that the brain is in a continual state of deprivation. This is the root of drug craving and can lead to drug-seeking behavior, said Kuczewski.

According to the CDC, "evidence-based approaches to treating opioid addiction include medications and combining medications with behavioral therapy. ... Medications used in the treatment of opioid addiction support a person's recovery by helping to normalize brain chemistry, relieving cravings, and in some cases preventing withdrawal symptoms."

Defining goals
Kuczewski used a patient case study during the webinar to illustrate how a nuanced consideration of opioid addiction can influence treatment decisions: A 30-year-old man was admitted to a health care facility with severe pain, concentrated on his side, and a fever. He reported he'd recently relapsed and was in opioid withdrawal. The hospital had twice before treated him for endocarditis. The attending physician sought an ethics consult to determine, among other concerns, whether mitral valve replacement was appropriate, given the likelihood that the patient would continue to use opioids and that would render the risky and invasive procedure futile.

Medical providers want to bring about the patient's good, and in questioning the ethics of heart valve surgery the physician is saying that if the procedure has a high risk of failure owing to the use of opioids, perhaps it really isn't something a surgeon should be doing, Kuczewski explained.

In the actual case that is the basis of the case study, the clinician-ethicist team decided that a heart surgeon should replace the heart valve. After surgery, the hospital discharged the patient to inpatient rehab. The patient went two years before again relapsing and seeking care at the hospital for endocarditis that was likely precipitated by the use of injectable drugs.

Kuczewski told Catholic Health World that, generally, physicians decide what procedures or other treatments or medications to offer based on their judgment of what has a reasonable chance of bringing medical benefit.

He explained that patients' and surrogates' rights to make decisions are mostly negative — that is, they can refuse any treatment. But they can't make a physician offer something he or she believes will be ineffective. Kuczewski said in the case examined during the webinar, "two years of recovery and freedom from the endocarditis should probably be seen as a win." If the likelihood of permanent recovery is the benchmark for care decisions, the patient with substance dependence may not be offered lifesaving procedures like valve replacement.

Kuczewski said in treating patients with an opioid addiction, clinicians and patients should work together to realistically define goals. Perhaps, he said, there is success in simply reducing harm to the patient, paving a way for potential addiction recovery and giving the patient better quality of life — even if the person continues using.

"We're saying we don't want you to die," Kuczewski said of approaches that treat the symptoms regardless of the resolution of the addiction.

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