Excerpt From Medical Ethics: Real-World Application By Afshin Nasser

Prescribing Opiates, or Not

A physician must be able to justify prescribing decisions with documentary evidence of a patient’s initial assessment and reassessments as required, including when accepting the transfer of care of a patient from another healthcare provider.

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A physician must be able to justify prescribing decisions with documentary evidence of a patient’s initial assessment and reassessments as required, including when accepting the transfer of care of a patient from another healthcare provider.

CDC Guidelines (March 2016)
Nonpharmacologic therapy should be attempted as the primary treatment
Opioids should be continued only if improvement in pain and function outweighs risk.
Clinicians should discuss known risks and realistic benefits of opioid therapy and managing therapy with patients
Start with immediate-release opioids, and use the lowest effective dosage
Limit quantities for short term therapy and assess efficacy of opioids regularly. If no benefit is perceived, taper or stop.
Evaluate for risk factors.
Access prescription drug monitoring programs for refills
Use urine drug testing.
Avoid concurrent use of opiates and benzodiazepines


Use buprenorphine or methadone in combination with behavioral therapies for patients with opioid-use disorder.
At the time of initial assessment, a physician must discuss and determine with the patient the best medication choice considering the:
(a)  efficacy of other pharmacological and non-pharmacological treatment options.
(b)  common and potentially serious side effects of the medication; and
(c)  probability the medication will improve the patient’s health and function.


The physician must review the patient’s medication history from PMP, before initiating and renewing a prescription, at minimum every month when the prescription is for the long-term treatment of a patient. In the event of inaccessible PMP or lack of a patient’s medication history, physicians should prescribe the minimum amount of medication required until more information can be obtained.

A physician who prescribes long-term opioid treatment for a patient with chronic pain, or as exclusive treatment for active cancer, palliative or end-of-life care, must also have a pain management contract signed by the patient and the physician, and this contract must be fully explained to the patient, with an executed copy provided. A violation of the pain management contract is grounds for dismissal from a pain management agreement, i.e. any further opiate prescription. Furthermore, a spot urine toxicology screen, serves as a tool for patient compliance.


It is important to:
(a) Establish and measure goals for function and pain for the patient, (b) Evaluate and document risk factors for opioid-related harms,
(c) Prescribe the lowest effective dose and, doses that exceed the opioid prescribing guidelines should be carefully justified and clearly documented in patient’s chart,
(d) Reassess the patient within four weeks of initiating opiates and every four weeks thereafter,
(e) Document the status of the patient’s function and pain at each reassessment; and
(f) Renew opiates only if there is a measurable clinical improvement in function and pain that justifies the risks of continued opioid treatment

Patient Drug Abuse warning signs:
1.Declines a physical exam and diagnostic tests, and won’t allow the physician to obtain past records

  1. Travels an exceedingly long distance or out of state for the visit without explanation
  2. Seeks medications from emergency rooms, urgent care facilities or walk-in clinics
  3. Has prescriptions from multiple providers without the physician’s knowledge (Access available via Prescription Drug Monitoring Programs)
  4. Resists changes in the treatment plan despite evidence of adverse effects. 6. Repeated claims of lost prescription or medication.
  5. Declines non-pharmacologic therapies
  6. Attempts to change, forge, or rewrite prescriptions.
  7. Diverts or sells medication or borrows drugs from others 10. Requests prescriptions written in the names of other people

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State Medical Boards

The medical board’s duty is to protect the public, not the physician. State medical boards today focus on licensed physicians who violate professional ethics, and their mandate has significantly evolved to focus on disciplining physicians.

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Boundary Violation

Boundaries create a therapeutic distance between physician and patient and clarify their respective roles and expectations. Boundaries define limits of the therapeutic relationship.

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Medical Ethics: Real-World Application By Afshin Nasser

You may have acquired this book as a result of conflicts with peers, administrators, patients, or State Medical Boards, where the outcomes of those interactions have left you wondering, “…what if I had done things differently?”

In that case, I hope that this book answers some of your questions and guides you with regards to any future quandaries you may encounter.


If you are a healthcare worker seeking to understand the subject of medical ethics, then I hope this book helps you acquire the clarity you seek.
If you are an individual simply curious about medical ethics, then I raise my hat to you for your pursuit of knowledge.