Contemplating Fentanyl’s Double Duty

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Sabrina Ford, PhD

In August 2018, Nebraska used fentanyl as part of a lethal cocktail to execute Carey Dean Moore, a prisoner sentenced to the death penalty for committing murder. This action by the state presents an ethical paradox. Tens of thousands of lives are lost to opioid overdose each year and fentanyl now was being used as part of a powerful execution cocktail. How do we comprehend this curious juxtaposition of the use of synthetic opioid drugs, complicated by our understanding of the human condition? To further muddy this absurdity, President Donald Trump suggested that illegal dealers of synthetic opioids, like fentanyl, should be sentenced to death if convicted.

To be clear, this neither is a commentary on the death penalty nor is it intended to be read as a political stance, but instead is an exploration of the phenomenon of dousing physical pain and avenging emotional pain. That is, how do we understand powerful pain-killing prescription medications as a solution to relieve suffering… physical, emotional, societal?

To give further context to this conundrum, the news media seemed equally confused. On August 14, 2018, The Washington Post reported on the fentanyl execution in Nebraska, with minimal mention about the epidemic of deaths by synthetic opioid. In fact, the word “overdose” did not appear in the news article. On August 18, 2018 the Post ran a separate opinion piece on synthetic opioid overdose deaths in the United States, but failed to mention the execution that took place just four days earlier. On August 23, 2018, Bloomberg reported on Trump’s comment about enacting the death penalty for those convicted of illegally dealing fentanyl. Does it stand to reason that a fentanyl dealer would be executed by a fentanyl cocktail? This gives new meaning to “all who draw the sword will die by the sword”.5

Image description: a medical syringe is shown on a flat white surface, with the needle in focus with a drop of liquid hanging from the tip of the needle. The background is not in focus. Image source: Dr. Partha Sarathi Sahana/Flickr Creative Commons

Connecting the Dots

BBC News did attempt to connect the dots between overdose and execution, but only as factual statements placed side by side. The BBC News and other news outlets outlined the combination of drugs used to execute Moore including diazepam, fentanyl, cisatracurium besylate, and potassium chloride. One reason why Nebraska State Penitentiary chose fentanyl was because that drug is obtainable – available in the prison for the medical treatment of pain for inmates. Interestingly, controversy about the use of this drug combination was not because it included fentanyl, with a reputation for ending life, but instead was because it was an untested chemical combination administered by lethal injection to enforce the death penalty.

Pleasure and Pain

Human suffering typically is experienced existentially – mentally and physically. In our daily lives, we often think of suffering as psychological and emotional, and in sickness and death, suffering is associated with a physical state. The philosophical understanding of suffering is grounded in Hedonism. Hedonism is an ethical framework that posits pleasure is good and pain is bad. There is not enough space to explore ethical and epistemological digressions, but let us take a short cut for now.* Pleasure and pain present a long-standing dilemma to the human experience. As hedonistic creatures, we are wired to seek pleasure and longevity, but sometimes our search for pleasure ends in pain, suffering, and even death—the very state we seek to avoid. Akin to searching for the fountain of youth, some opioid users are searching for good in the form of pleasure, an ethereal altered state of consciousness. Too much of a good thing can lead to bad, in the form of death by opioid overdose. How to untangle the conundrum of addiction is something physicians, psychologists, and philosophers have attempted to solve for thousands of years.

Double Duty

Alas, we know that opioid addiction has as one of its greatest risks, titration of just enough of the drug to achieve the ultimate high—just close enough to death to touch heaven. Fentanyl as a prolific painkiller has become America’s death knell. On August 14, 2018, fentanyl also became an elixir to carry out justice and avenge murder. Interestingly, as mentioned above, the pharmaceutical combination was administered by a series of four drugs delivered by intravenous drip: diazepam, to induce sleep; fentanyl, a potent pain medication; cisatracurium besylate, to paralyze and stop breathing; and potassium chloride, to stop the heart; not too different from the process of dying by opioid overdose.

How do we as Americans make sense of this strange state of affairs? We want our suffering to stop, whether it be physical, mental, or even societal. It would seem that fentanyl has become a drug of choice.

*Suggested reading: Epicurus. Epicurus – Stanford Encyclopedia of Philosophy. Metaphysics Research Lab, Stanford University. 2018.

Many thanks to Jamie Alan, RPh, PharmD, PhD and Cara Poland, MD, Med, FACP, DFASAM for technical assistance.

ford-cropSabrina Ford, PhD, is an Assistant Professor in the Department of Obstetrics, Gynecology and Reproductive Biology and the Institute for Health Policy in the Michigan State University College of Human Medicine. Dr. Ford is also adjunct faculty with the Center for Ethics and Humanities in the Life Sciences.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, December 13, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Dr. Stahl presents on physician-assisted suicide, opioid epidemic in November

Devan Stahl photoCenter Assistant Professor Dr. Devan Stahl gave three presentations this month at local and national events.

Dr. Stahl was invited to give a talk at Georgetown University on November 9 as part of their conference on “Physician-Assisted Suicide and Euthanasia: Theological and Ethical Responses.” In her talk, “Understanding the Voices of Disability Advocates in Physician-Assisted Suicide Debates,” she discussed the disability rights perspective on physician-assisted suicide (PAS) and how it relates to Christian ethics. The presentation argued for the importance of faithfully attending to concerns regarding PAS raised by disability advocates, and considered the ways that the Church has historically failed to offer full honor and respect to the lives of people with disabilities. By attentively listening to disability groups who oppose PAS, Christians may come to realize that they too participate in unjust structures and systems that threaten the lives and dignity of disability advocates.

On November 14, Dr. Stahl was the keynote speaker at the annual Ernest F. Krug III Symposium on Biomedical Ethics, presented by Oakland University William Beaumont School of Medicine. Her talk was titled “The Disability Rights Critique of Physician Aid in Dying Legislation.” Dr Stahl spoke to an audience of medical students and faculty about the disability rights perspective on physician aid in dying, and how it differs from the debates happening in mainstream bioethics. Over the past three decades, disability rights advocates have provided clear and consistent opposition to the legalization of physician aid in dying (PAD), which many believe threatens the lives and well-being of persons with disabilities. The presentation reviewed the common objections to PAD from disability advocates and considered what such objections reveal about the systemic failings of our current health care system.

At the American Academy of Religion Annual Meetings in Denver, CO, Dr. Stahl joined a panel of speakers discussing religious responses to the opioid epidemic. She discussed the ethical tensions that physicians experience when managing the opioid crisis, including whether and how to trust patients who request opioids, the validity of opioid contracts and drug screens, as well as the current legislative restricts on opioid prescribing.

Bioethics for Breakfast: Treating Pain Without Feeding Addiction: Is There a Goldilocks Solution?

bioethics-for-breakfastForrest Pasanski, JD, and Steven Roskos, MD, presented at the Bioethics for Breakfast event on April 20, 2017, offering perspective and insight on the topic, “Treating Pain Without Feeding Addiction: Is There a Goldilocks Solution?”

In August 2016 the Michigan Department of Licensing and Regulatory Affairs (LARA) created a permanent Drug Monitoring Section to stem the state’s prescription drug abuse epidemic, tightening its monitoring of physicians’ opioid prescribing. Certainly as the ones who write the prescriptions, physicians should help remedy the prescription opioid epidemic. But they also have a responsibility to effectively manage the pain their patients experience. In striving to meet one of these responsibilities, will they fail to meet the other? Or is there a place in the middle that is ethically “just right?” How might they optimally collaborate with the state to ensure the best interests of its citizens?

Mr. Pasanski discussed the scope of the opioid epidemic in Michigan as well and the state’s response, highlighting efforts to identify, investigate, and take substantial licensing actions against overprescribers. Dr. Roskos offered a physician perspective, touching on trust in the doctor-patient relationship and how state regulations may create tension within that relationship.

Forrest Pasanski, JD
Forrest Pasanski, JD, is Regulation Section Manager, Drug Monitoring Section for State of Michigan, Michigan Department of Licensing and Regulatory Affairs, Bureau of Professional Licensing where he oversees the Michigan Automated Prescription System (MAPS) and staff who identify, investigate, and bring administrative actions against health professionals who overprescribe, overdispense or divert controlled substances. He studied philosophy and political science at Grand Valley State University and graduated from the Michigan State University College of Law.

Steven Roskos, MD
Steven E. Roskos, MD, is an associate professor in the Department of Family Medicine in the Michigan State University College of Human Medicine, where he also serves as associate chair for academic affairs. He received his MD from Temple University School of Medicine, Philadelphia, Pennsylvania and completed a family medicine residency at Lancaster General Hospital, Lancaster, Pennsylvania. Dr. Roskos practiced in southern Appalachia for seven years, then taught at the University of Tennessee before completing a fellowship in academic medicine at Michigan State and then joining the faculty. He has a clinical interest in treating patients with chronic pain and served on the Michigan Advisory Committee on Pain and Symptom Management for five years.

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.

White Horse, White Faces: The Decriminalization of Heroin Addiction

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series

By Karen Kelly-Blake, PhD

The U.S. is in the grips of an opioid addiction crisis. According to the CDC, the rate of opioid (prescription and heroin) overdose deaths has quadrupled since 1999.

Consider the following:

Economic Impact of the Opioid Epidemic:

  • 55 billion in health and social costs related to prescription opioid abuse each year
  • 20 billion in emergency department and inpatient care for opioid poisonings

On an average day in the U.S.:

  • More than 650,000 opioid prescriptions dispensed
  • 3,900 people initiate nonmedical use of prescription opioids
  • 580 people initiate heroin use
  • 78 people die from an opioid-related overdose

There is a strident call for prevention, treatment, research, and effective responses to quell this modern day public health scourge. The Obama administration is calling on Congress to 1) expand access to medication assisted treatment (MAT); 2) improve prescription drug monitoring programs; 3) advance prescriber education; 4) encourage safe pain management; 5) accelerate research on pain and opioid misuse and overdose; 6) expand telemedicine in rural America; 7) safe disposal of unneeded prescription opioids; and 8) improve housing support for those in recovery.

Image description: An individual is shown injecting their arm with a syringe. They are seated and shown from the chest down. Image source: Flickr user Urban Seed Education.

Along with these initiatives, expanded use of naloxone is deemed critical as a lifesaving measure for first responders and others to reverse drug overdose. Injection clinics, where users can inject heroin (illegal drugs) in a safe environment is regarded as a reasonable and appropriate response to the problem.

Undoubtedly, there is a striking difference in tone about this “new” heroin epidemic compared to the old epidemic of crack cocaine, which affected predominately black, poor, and urban communities. The difference is that young white people are addicted and dying, reflecting a shift over the last 50 years in the demographic composition of heroin users. A New York Times analysis found that young white adults are dying at rates not seen since the AIDS epidemic. This new epidemic is predicated on addiction to prescription painkillers and people turning to heroin and fentanyl as cheaper alternatives with no administrative barriers (contracts, doctor visits, prescriptions).

The current narrative goes something like this: “…[B]ut these are people and they have a purpose in life and we can’t as law enforcement look at them any other way. They are committing crimes to feed their addiction, plain and simple. They need help.” So, when young white people become heroin addicts they are “people with a chronic health problem” and thus are deserving of patience, tolerance, and help. Coming from middle-class and suburban environs, they are portrayed as high achievers from exceptional families, and so the addiction is not their fault—it is not a personality flaw or character deficit.

In contrast, at the height of the crack cocaine epidemic in the mid-80s, black people were branded as pathological, unsympathetic “superpredators” and therefore deserved disdain and incarceration. Black crack addicts had several personality flaws—lazy, stupid, it was their fault that they became addicted—their addiction was the result of a moral failure.

Image description: An individual is shown injecting heroin into another individual’s hand with a syringe. Their faces are not shown. Image source: Wikimedia Commons.

Racism is in full effect in this new public health scourge. Of course, addiction requires medical intervention and all the social resources needed to help those afflicted. BUT, let’s not have a conversation about the new heroin epidemic in a vacuum with scant if any attention to the racist underbelly of the discourse. Minority and poor people were junkies and criminals deserving nothing more than a jail cell. Today’s addicts are not even called addicts. The goal is to avoid stigmatizing language and so language conveying a chronic illness is preferred such as substance abuse disorder. Addiction is a serious public health issue and it is encouraging to see the change in strategy to treat those afflicted. We know that mass incarceration is not an effective public health response.

It is problematic that we are having a white washed conversation about opioid addiction. This new conversation is occurring in an ahistorical vacuum. The goal is not to incarcerate young white heroin users, but to help them. However, this new enlightenment is a sting for black and Latino families who suffered the same problems, but they were not deemed “people with futures” or “people who deserved help.” They were junkies and criminals. Ironically, black people are suffering less from this new epidemic because of pervasive racial stereotypes whereby doctors are reluctant to prescribe painkillers to minority patients believing they will sell them or become addicted.

It is disingenuous to frame the conversation ahistorically. The current responses and narratives surrounding the heroin epidemic shows that it indeed matters who is in the grip of addiction: “White heroin addicts get overdose treatment, rehabilitation and reincorporation, a system that will be there for them again and again and again. Black drug users got jail cells and “Just Say No.”

The new white face of heroin addiction has changed the discourse of addiction from criminalization to public health, and the change is welcomed. However, it does give me pause that the white face was necessary to enact humane responses for a health problem that affects us all.

kelly-blake-crop-facKaren Kelly-Blake, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 4, 2016. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Overdosing on Prescription Painkillers: Dying for Pain Relief?

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. For more information, click here.

By Karen Kelly-Blake, Ph.D.

There has been much news coverage in the past few weeks regarding the increasing number of prescription painkiller deaths from opioid and narcotic pain medications such as Vicodin (hydrocodone), OxyContin (oxycodone), Opana (oxymorphone), and methadone (CDC Vital Signs). This trend is especially striking among women (CDC Vital Signs notes a 400% increase since 1999). Non-Hispanic white and American Indian or Alaska Native women have the highest risk of unintentional, suicide, and other deaths from prescription painkiller overdose. The Centers for Disease Control reports that “about 18 women die every day of a prescription painkiller overdose in the US, more than 6,600 deaths in 2010, and for every woman who dies of a prescription painkiller overdose, 30 go to the emergency department for painkiller misuse or abuse” (CDC Vital Signs). While men are still more likely to die of prescription painkiller overdoses (more than 10,000 reported deaths in 2010), women are closing the gap.

Several theories are posited to explain that gap, for example, women are: more likely to suffer from chronic pain than men; more likely to be prescribed higher doses and take painkillers for longer periods of time; and more likely to seek out multiple prescribers, i.e. “doctor shop” to get their prescriptions. Moreover, women typically have smaller body masses than men, and so the gap between a therapeutic dose and a fatal dose is narrower. The overall increase in painkiller deaths does not appear to be linked to a measurable increase in the kind of severe pain that would require prescription painkillers. Rather, the medications may be increasingly used to treat moderate pain (NY Times OP-ED). News coverage has focused on how to curb and monitor the apparent increased prescribing of these medications and how to educate patients about the risks of narcotic painkillers. What’s missing in the news coverage is how to deepen the conversation to speak to the issue of providing effective pain management for chronic pain sufferers.

In light of the new data about the troubling increase in painkiller deaths, how can healthcare providers effectively manage pain and simultaneously avoid under-treatment, misuse, and abuse of prescription painkillers? The CDC offers strategic advice on how to counter this growing problem, including tracking prescription drug overdose trends to better understand the epidemic, using prescription drug monitoring programs to identify patients who may be improperly using prescription painkillers, prescribing only the quantity needed based on the pain diagnosis, and improving access to mental health and substance abuse services through implementation of the Affordable Care Act (CDC Vital Signs). The CDC has spotlighted an important public health issue, and many agree that these strategies are reasonable and will go a long way to curb the epidemic. But one could also argue that in order to curb this newly identified epidemic we have to address another pressing public health issue: under-treatment of chronic pain.

Healthcare providers have failed to provide adequate pain relief. Barriers to providing pain relief include clinician fear (fear of patient abuse and addiction, diversion, and regulatory scrutiny), clinician failure in identifying pain relief as a patient care priority, and a clinician knowledge deficit in the assessment and management of pain (Tomlinson; Rich 2000). Under-treated pain results in a host of physiological, psychological, social and economic consequences ranging from reduced mobility and strength, disrupted sleep, depression and anxiety to difficulty working and lost wages (Brennan et al. 2007). Scholten et al. (2007) assert that 80% of the world’s population fails to receive pain relief when needed. To address this deficit, instead of narrowly focusing on potential abuse, they suggest implementing more balanced policies on opioid use so as to enable access to pain relief that would address human suffering. The optimal way to treat chronic pain is through a multidisciplinary pain clinic, using a team approach offering physical therapy, psychological support, and appropriate pain medications. Such facilities are rare, and not surprisingly, a significant number of chronic pain sufferers are from low-income groups. As such they commonly lack insurance to cover costs for this ideal model for pain treatment.

If we believe that relief of pain is a core ethical duty for medical professionals then in light of the barriers listed we have to find a way to advance that moral imperative. First, clinicians have to trust their patients’ reports of their pain. There is an abundant literature on trust between patients and physicians, focusing largely on whether patients trust their healthcare providers, yet a dearth of literature on the trust physicians have, or don’t have in their patients. To advance this agenda, providers would have to stop viewing their patients as potential drug abusers and dealers, discounting their pain. Second, clinicians would need to appreciate, or be taught to appreciate, pain’s capacity to seriously impair a patient’s quality of life. As Tomlinson suggests about pain, “it is a malignant force in and of itself, a fact clearly evident to most humans who have not had medical training if not to those so trained.” Third, clinicians would need to understand that under-treatment is poor medical practice (Brennan 2007). ’Doing no harm’ does not mean ‘do not treat’ or ‘under-treat because you are scared.’ It requires one to balance the benefits and risks of pain treatment strategies. These strategies would not mean resorting to painkillers first, or to painkillers alone, but instead would involve trying a variety of treatment modalities. Fourth, having balanced the risks and benefits, clinicians should respect patients’ autonomy to choose and reject treatments. This is not to suggest that physicians have to go along with a patient’s choice that is counter to his/her professional rights. What it does mean is that if the clinician has a professional objection, then he/she should provide the patient with information about accessing treatment elsewhere. Lastly, clinicians should demonstrate equal concern for all patients. When a patient presents with a pain complaint and wants help, and the clinician’s response is to be suspicious, to disrespect the pain report, and to underestimate the impact the pain has on the patient’s quality of life, that provider has violated the principle of equal concern. Such violations are more likely when the pain patient is female, African-American, Hispanic, or low socioeconomic status.

So if we are to make any inroads in the epidemic of painkiller deaths, then we have to address the equally compelling public health issue of under-treatment of pain. This would require addressing the barriers outlined here and repackaging the alleviation of pain as a moral imperative in medical practice. Unfortunately, as it currently stands, “the good of relieving pain is far too invisible/too little recognized” (Tomlinson). The absence of pain management as a healthcare priority is seen at every level of health care delivery. This is most evident in the lack of available National Institutes of Health funding for, or focused on, pain relief. Avoiding patient addiction and abuse, diversion tactics, and clinician self-protection are important parts of this conversation to be sure, but these issues cannot dominate the discussion. Understandably, clinicians may feel that they are walking a tightrope when it comes to pain treatment. They may feel they are in a “damned if they do and damned if they don’t” situation when prescribing painkillers, but as Johnson (2007) observes “unrelieved pain blocks enjoyment of all other human goods and values.” Thus the challenge is how to achieve the social and medical change that will make pain management a fundamental component of health care– for that most fundamental physician duty—to care attentively and equally for all patients.


list-cropKaren Kelly-Blake, Ph.D., Dr. Karen Kelly-Blake is a Research Associate whose research interests include health services research, medical shared decision-making, physician training, health disparities, and medical school curriculum development. She is a medical anthropologist and MSU alum. Karen also teaches in the CHM Social Context of Clinical Decisions courses.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Friday, August 9, 2013. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.