Read the Case-Based Curriculum for Neurology Residents.

wayward practitioners (including inappropriate prescriptive practices). Srate govemors appoint
board members, whose qualifications vary considerably from state to state- There is considerable
diversity in the language of different states'HPAS, each requiring inrerpretarion, ranging from
encouraging to threatening. No systematic analysis exists srare-by-srate; the individual physician
is responsible for understanding the applicable regulations in his or her own jurisdiction. It rs
therefore at the state ievel that physician uncertainty is most intense conceming the boundaries of
permissible opioid prescribing practices. one "chilling effect" is physician uncenainty over whar
indications, duration, and overall volume of opioid prescription will create a "high profile" for
state (and federal) regularors, triggering a license-threatening and potentially criminal
rnvestigadon.
Some states have recently adopted detailed guidelines for ongoing prescription controlled
substances for chronic nonmalignant pain. A few all but prohibit it (20). Most arc in the middle,
limidng dosing beyond "usual and recommended" dose ranges and durations, imposing
restricrions on dose unirs unrelared to indication (e.g., to 120 pills irrespective ofpotency),
restrict opioids ro specific indications, limiting phone refills to emergencies, restricting who may
pick up prescriptions, impose onerous records keeping rules, and establishing multipte-copy
prescription programs (MCPP, "triplicate forms"). ln the ten srares currently with MCpp laws,
one copy goes ro the srare police or drug enforcemenr agency. The tighrer the rcstdctions, the
harder a time patients have in locating pharmacies (operating under their own regulations) rhat
stock strong narcot.icsuch as hydromorphone, oral morphine, or methadone-class drugs. (21)
B. Identification of the Ethical problem(s)
7- what are the ethicar probrems in this case? (rfappropriate, rank by magnitude)
A well-documented feature of contemporary medical practice is the widispread
undenrearment by physicians of moderate ro severe pain, through underdosing or outrighi
w.ithholding. Panicularly vulnerable populations include women, the elderly, and minorities. To
withhold or fail to refer for the sole rcmaining class of analgesics that mighi relieve a patient's
refractory CNP for no rcason other than undue fear of causing iatrogenic addiction abiicates the
physician's traditional role in rclieving suffering and effectively tolerares avoidable disability.
It must be noted that opponents of opioids for cNp argue for a less biomedical and more
biopsychosocial model of pain managcment, that shifts the locus of responsibility for cNp
control from physician prcscribing to parient responsibility for modifiable factors, especially
habitual and psychologic or behaviora.l (here weight reduction, smoking cessation, and perhaps
biofeedback or other nonpharmacologic modalities of treatment), where the explicit goal is to
minimize the amounr of opioids acnrally prcscribed. (22,23)
The ER physician's well-meaning recommendation to vcrify compliance by entering the
patient's name on a metro-wide computer database for the use of affiliated hospitals carries heavy
risks of breach of confidentiality of highly sensitive informadon withour the patient's knowledge
or consenr by employers, and by third parties with no compelling need to know. A much better
strategy is to enter into a formal "conrracr" with the patient, specifying that therc will bejust one
prescribing physician, specified amounts for well-documented indications, the possibilitv of