By: Joel Reynolds
In states like Oregon, opioid crackdowns have also landed on physicians. Once the medical board issues an Interim Stipulated Order (ISO), in some cases a practitioner must either revoke their license immediately or agree to have their practice limited until the board completes its investigation. These limitations can be such that by the time the investigation is complete and the case decided, the practitioner has lost many of their patients. Regardless of the outcome of the investigation, their reputation is tarnished because the ISO automatically becomes a public document. It is not just chronic pain patients who are suffering from the misguided approaches and methods variously employed by federal and state agencies. It is also health care practitioners.
As Dr. Leipzig points out in the article above, “there is no maximum dose for narcotics.” But what then is a practitioner or a pharmacist to do in the current anti-opioid, criminality-complex climate? A dosage that might kill someone who has never had it before might barely get a chronic pain sufferer of twenty years out of bed. There are doctors who claim that, regardless of the DEA’s interference in treatment, lessening the use of narcotics is preferable given potential damage to the liver and other side effects. It is indeed preferable, but that is a therapeutic decision that should be made at the level of an individual patient, not at the level of a federal or state mandate. If someone has exhausted other treatment options and cannot even get out of bed due to immobilizing pain without a dosage at level X, then keeping them at a lower dosage for fear of potential future damage, not to mention the practitioner’s fear of litigation, is ethically suspect. Some would argue it qualifies as maleficence. Perhaps physicians and pharmacists working with chronic pain patients ought to seriously consider whether or not this is a situation where medical ethics opposes the letter of the law. However one adjudicates that tension, while opioid manufacturers reap in profits—often through misinformation and now also thanks to maintenance drugs—it is clear that research should be focused on non-opioid solutions to the treatment of chronic pain.
The Hippocratic oath is ultimately a list of do’s and don’ts. Although doctors still commonly take it, the oath curiously lacks a central and necessary component of medical ethics. It fails to define the ethics of the interpersonal relation between patient and practitioner. The oath of Maimonides, on the other hand, offers a clear guideline: “May I never see in the patient anything but a fellow creature in pain.” This ethical maxim should cause particular concern for practitioners working with chronic pain patients today. How can one see in the patient anything but a fellow creature in pain if one is actively forced to consider the patient as a deceptive creature of addiction? How could a medical practitioner be ethical in such a situation? With respect to the treatment of chronic pain, perhaps the current legal climate is in conflict with the ethical principles upon which medical practice is based.
 See also http://www.wweek.com/portland/article-22735-harry_rineharts_house_of_pain.html.
 ORS 677.410 allows the Oregon Medical Board to attach conditions to the license of the Licensee to practice medicine before the investigation is complete.
 Pursuant to ORS 677.425.
 Daniel S. Goldberg, The Bioethics Of Pain Management: Beyond Opioids, Routledge Annals of Bioethics (New York: Routledge, Taylor & Francis Group, 2014).
 Diane E. Hoffmann, "Physicians who break the law," Saint Louis University Law Journal 53, no. 4 (2009). Freely available at http://digitalcommons.law.umaryland.edu/cgi/viewcontent.cgi?article=1896&context=fac_pubs.
 Louis Lasagna’s 1964 updated version includes a similar line: “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being.” The full version is freely available online.