Defining Addicts and Pain Patients as One and the Same, A Moral and Ethical Failure in Policy

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By R Carter

“The enemy of society is not error but indifference. Unfortunately bad societies can live on bad morals just as well as good societies can live on good ones.”

Lord Devlin, The Enforcement of Morals

Morals and Ethics

Morals and ethics are often used interchangeably, but there are small differences. Ethics refers to rules provided by an external source, e.g., codes of conduct in workplaces or principles in religions. Morals refer to an individual’s own principles regarding right and wrong. And when the collected moral beliefs of a society are acknowledged, morals through ethical principles become laws, governing our behavior with each other and between groups. So out of what society believes is moral, ethical rules of conduct are devised.

There are two great arbitrators of morality devised by mankind, the State and Religion. Each has a power they use to enforce ethical standards.

Religion’s power is derived by virtue of its monopoly to include or exclude individual’s membership in a group and by its power to define the afterlife, whether a person goes to heaven or hell.

The State’s power is derived by virtue of its monopoly to impose monetary fines, take away freedoms but more importantly, it’s exclusive right over life and death. This sets government apart from all other moral institutions, regardless of whether or not you believe in a heaven or hell.

Religion’s greatest power is future tense, by virtue of the fact that its greatest rewards or punishments occur in the afterlife, limiting its effectiveness in the present.

The State’s greatest power is present tense and is limited only by elaborate rules which define an ever increasing level of punishment or reward based crimes or compliance.

Morals, Ethics and Law

This post will look at the methods by which the State defines morality and enforces ethics on the subject of opiates used in medical care. For our examples, I looked at Ohio codes which were in effect prior to 3/20/2019 compared to revised codes which went into effect after 3/22/2019.

Note; based on data collected by the State of Ohio up through 2017 and beyond, Ohio continues to revise its laws and regulations to make a distinction between opiate abuse and the legitimate use of opiates in treating chronic pain. This makes Ohio a progressive leader in establishing balance and equity between these two issues. Protecting the rights of its citizens to unobstructed and equal access to medical care while fighting a continued blight on society through illicit drug abuse.

Ohio’s Title 37 governs Health, Safety and Morals. Chapter 3719 Section 011 defines a controlled substance as:

  1. Before 03/22/2019
    1. “Drugs of abuse”, are further defined in section 3719.01 with opiates defined as:
      1. (R) “Opiate” means any substance having an addiction-forming or addiction-sustaining liability similar to morphine or being capable of conversion into a drug having addiction-forming or addiction-sustaining liability.
  2. After 03/22/2019
    1. Drugs of abuse”, and are further defined in section 3719.01 with opiates defined as:
      1. (BB) “Opioid analgesic” means a controlled substance that has analgesic pharmacologic activity at the opioid receptors of the central nervous system, including the following drugs and their varying salt forms or chemical congeners: buprenorphine, butorphanol, codeine (including acetaminophen and other combination products), dihydrocodeine, fentanyl, hydrocodone (including acetaminophen combination products), hydromorphone, meperidine, methadone, morphine sulfate, oxycodone (including acetaminophen, aspirin, and other combination products), oxymorphone, tapentadol, and tramadol.[1]
    2. “Drug dependent person” means any person who, by reason of the use of any drug of abuse, is physically, psychologically, or physically and psychologically dependent upon the use of such drug, to the detriment of the person’s health or welfare.[2]
    3. “Person in danger of becoming a drug dependent person” means any person who, by reason of the person’s habitual or incontinent use of any drug of abuse, is in imminent danger of becoming a drug dependent person.[3]

I want to clarify these points:

  • While after 03/22/2019 paragraph (II)(i) is a step forward in creating a separation of concerns between illicit opiate abuse and the use of opiates in treating pain, paragraphs (II)(ii) and (II)(iii) fail to make this distinction.
  • Therefore by law, chronic pain patients treated with opiates remain defined as addicted, lacking self-control and or being uncontrolled.

This loop hole will no doubt result in continued exploitation by anti-opiate zealots who wish to wage an ideological war on chronic pain patients. The CPP community in Ohio and other states with similar language should continue their efforts to have the definitions changed to accurately reflect the differences between patients medically treated with opiates and those who use them illicitly.

Actual law governing the prescribing of opiates for acute and chronic pain is both general and indirect, as it should be. They are limited to those actions which can be taken by a licensed physician. This fact indirectly acknowledges that as a legislative body, legislators are not qualified to diagnose and prescribe medical treatments requiring opiates.

The specific details for diagnosis and treatment are legislatively delegated to State Medical Boards as is common across all states and recognized under Title 21 (USC) Controlled Substance Act.

Specific recommendations and guidelines governing standards of care for chronic pain, how a primary care provider should treat and prescribe for chronic pain, are recent developments which have come about since 2016. Prior that, few if any states had written standards of care for both primary care providers as well as pain specialist. Such guidelines were often left to non-government private interest groups representing medical specialties. The entry of the Federal Government into this space through the CDC is both unprecedented and alarming, many calling it overstepping and government interference.

By implementing these recommended guidelines through the CDC and through State Medical Boards, government is now making unilateral decisions which affects hundreds of millions, avoiding the possibility of a hotly contested ethical debate and political fight, by keeping it from coming to a vote of the general public.

[1] It’s important to note that the new definition as of 3/22/2019 removes the language “addiction-forming or addiction-sustaining”. It’s believed this is done based on the growing evidence that there is a distinct difference between the use of opiates for abuse and the use of opiates in the treatment of pain. Further evidence of Ohio’s progressive efforts to identify the treatment of acute and chronic pain as medical conditions rather than illicit drug abuse.

[2] Paragraph (II)(ii) still equates drug abuse with physical and or psychological dependence. Further reinforcing the concept that the uses of opiates in treating pain have a risk, yet making no distinction between managed risks under the care of a physician and unbridled risks associated with illicit opiate abuse.

[3] Habitual or incontinent use is defined as: lacking self-restraint; uncontrolled.

More Federal Overstepping

Under Title 21 (USC) Controlled Substance Act, the DEA is empowered to issue certificates granting doctors the right to prescribe federally regulated controlled substances, as well as investigate violations of the same. The recent trend of prosecuting and imprisoning physicians for violations, seizing property and assets, is an abuse of those powers as they were written and intended for use against drug traffickers importing these substances into the U.S. across borders, not in prescribing for patients.

Societal Morals and Ethics

A person who knows the difference between right and wrong and chooses right is moral. A person whose morality is reflected in his willingness to do the right thing, even if it is hard or dangerous, is ethical. Ethics are moral values in action.

Ethics are the moral principles which govern a person’s behavior or the conducting of an activity. Morals are concerned with the principles of right and wrong behavior and the goodness or badness of human character. Law is the system of rules that a particular country or community recognizes as regulating the actions of its members and are enforced by levying fines, imprisonment or death.

If you are ethical you can abide the law. If you are moral you can be ethical. Also, if you are moral you can abide the law, but you can never be all three at the same time.

So it follows that any individual or group, even when acting on their moral convictions, who acts unethically, i.e. against the written law, are individuals and groups who are now morally corrupt. Another way to say it is, until a majority of society supports a change in ethics to reflect its new moral perspective, disobedience against laws is an ethical violation which is morally corrupt.

Our system accomplishes this through its elected officials. But we also have ethical rules our elected officials are sworn to follow, which ensure a fair hearing from all concerned parties before enacting new laws. All of this was working as it should up until 2015, when the process was hijacked, the rules violated in secret and the CDC published it guidelines on chronic pain.  

Since then there’s been mass confusion and a blatant disregard for the welfare of a minority group. Resulting in suffering for tens of thousands, death for others and imprisonment for physicians sometimes irresponsibly so. A failure of law enforcement and government to enforce existing laws, an unchecked profit motive in healthcare, the unchecked growth of the illegal drug trade and unchecked political influence on our democratic process has all come together like a perfect storm.

Intertwined within this moral confusion are more changes, allowing the use of cannabis in treating medical conditions as well as allowing it as an opiate replacement therapy or augmentation. This progressive change only feeds the fire of those morally opposed to psychoactive substances used in medicine. And while such opposition is irrational from a medical perspective, it remains moral for some.

For some, the need to rapidly enact new laws which reflect their moral convictions resulted in unforeseen consequences to a silent minority. As of 2017 estimates are 100 million or 40.8% of the population claim to have daily pain of some type, half of which is managed with non-opiate treatments. 50 million or  20.4% of the population are chronic pain patients, many of which have taken opiates for decades. While 80% of the non-opiate treated population rushed to curtail its use, little regard was given to the consequence it would have. Now that nearsightedness is reflected in a growing number of suicide deaths from individuals who have been forced to taper or terminate.

Some people talk about their personal ethics, others talk about a set of morals and everyone in a society is governed by the same set of laws. If the law conflicts with our personal values or a moral system, we have to act, but to do so we need to be able to tell the difference between morals vs ethics and count the cost before doing so.

Ethics and morals relate to “right” and “wrong” conduct, so I ask these questions.

Is it right or wrong to deny chronic pain patients medication when most have used it without incident, simply for the possibility of curtailing illicit drug use and overdose deaths? Or is it possible to do both, fight drug abuse while protecting individuals who use opiates as medication and do so without the tragic consequences we see in drug abuse?

Law cannot change morals. Enacting laws without hearing from those substantively impacted by them, is nothing short of a moral and ethical failure of government. What was done in error can be undone, but for those who have suffered needlessly and for those who have died, government has a responsibility to own this failure and take corrective action.

To date, these issues and questions have gone unacknowledged by our elected officials. So when they fail to practice their due diligence, hearing their constituents, establishing fair and equitable laws, it’s time to replace them with those who will.

Morality demands that men should act from a sense of ethical duty. Morality has no such enforcing authority on the state. The state remains autonomous (coming from the inner life of men) and governs the inner life of men. So when we see unethical acts by the State, we must conclude, those elected to power must be immoral men, indifferent to those they represent and apathetic in their efforts to take actions demanded by their position.

If the promise of government is to act in an equitable manner, to create balance between individuals and groups, then the legal duty of government becomes a moral duty. But since a moral duty is not enforceable before a court of law, it is left to the society to make that problem correspondingly right when they go to the voting booth.

Reference:

Moral Values

Declining Moral Standards and The Role of Law, by Sue H. Mialon

Is There a Universally Valid Moral Standard? By Frank Chapman Sharp

Lord Devlin and the Enforcement of Morals, By Ronald M. Dworkin

Social Solidarity and the Enforcement of Morality, by H. L. A. Hart

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1 thought on “Defining Addicts and Pain Patients as One and the Same, A Moral and Ethical Failure in Policy

  1. Can you explain how NarxCare is supposed to work? I see at least 5 doctors a year, due to mutiple diseases and am also a PM patient. I have used the same pharmacy for years, with no intention of changing/using another. I see 1) a neurologist, 2) a GP, 3) a PMP who just this year started having 4) a NP see his pts (and he did an ablation in February – but that is 2 providers in the same clinic for this year), 5) an allergist, and 6) a GI doctor or rheumatologist. By this summer, I will be up to 5 doctors. I need my hip and knees replaced in the near future. Do I forgo the GI doctor for Crohn’s disease and the orthopedic doctor for Ankylosing Spondylitis this year to keep my NarxCare score down? My pharmacist stated the PMDP tracks >5 doctors in a month, but NarxCare states >5 providers/physicians in a year! They also tallying patient’s use of antidepressants as part of their “score”. Last year, I had an additional physician for an intestinal parasite due to a suppressed immune system. Do you know if we can obtain these scores ourselves?

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