How Ethical is Using Opioids in End-of-Life Care?

Written by nityakaza

As people near the end of their lives, they can receive specialized care at a hospice. This type of care is focused on a patient’s quality of life and centers around patients and their families. Many patients who come to a hospice have advanced cancer, which is extremely painful for 65-85% of them. At the same time, a primary goal of end-of-life care is pain control, where the use of opioids is common, most commonly morphine, hydrocodone, and oxycodone, among others. However, when using these types of medications, there is no guarantee that they are secure. Currently, with the urgent issue of the opioid crisis in the US, how ethical is using opioids to relieve such pain? 

Some would argue that there are too many ways that the opioids prescribed for pain can be misused, mainly with drug shortages, missing medication, and opioid diversion. Patients who have opioid use disorder (OUD) and have cancer are at risk for a relapse. In one study, only 23% to 35% of clinicians reported that they had adequate knowledge and experience to care for patients with OUD. In another study, 120 experts in palliative, addiction, or both were asked to give recommendations for giving patients with cancer and advanced OUD methadone (a type of opioid). Perhaps alarmingly, however, there were a variety of opinions about dosage among the experts, indicating that there is no universal way to address the issue of opioid misuse, which can make them more dangerous. 

More studies involving interviewing hospice staff and administrators show increased challenges with understanding and implementing new policies with precautions regarding prescribing and disposing of opioids and a decrease in willingness among hospice staff and patients to work with opioids. Those interviewed expressed: 

“We have a lot of providers that are a bit confused about what they can do, what they can’t do … the new legislation on a state level … and on the federal level, and how does that impact their capacity to prescribe, what kind of limits does it put on them[?]” (Clayton et al. – 2024)

Hospices must not only worry about patient misuse but also about employee misuse of the drug. Drug diversion refers to any transfer of legally prescribed substances (opioids) from the person it was prescribed to another for illegal use. A survey reported that of 371 hospices, the majority (78%) said they screen patients for substance use disorder, but only 43% reported screening caregivers. 42% of hospices reported drug shortages. It has also been observed that many patients and their family members will often refuse pain treatment for fear of developing addiction, especially when the hospice occurs in someone’s home rather than an external facility. 32% of the time, there is the possibility of opioids being left unused in the home after death. With such a low percentage of reporting screening caregivers, there is a possibility for unused opioids to be misused by the staff. We must consider that the use of opioids in hospice care could be contributing to the opioid crisis in America right now. 

However, the core principle of hospice must also be considered: they want to ensure that patients have control over their own treatment. They want the patient and their family to be involved and know all aspects of the patient’s treatment, so if a patient does want pain medication that may involve the use of opioids, naturally, hospice would want to give that treatment. When in the face of serious illness at the end of life, patients often fear pain the most.

As one staff member interviewed explained, “… patients definitely are suffering for those whose family members are reluctant to give that opioid or even for the patients themselves that are reluctant to take it.” (Clayton et al. – 2024)

So then, what about the opioids? Is it right to say that no patient should receive their pain medication if it involves opioids for fear of its misuse? Ultimately, the answer is complex and very nuanced. It is also dependent on conditions such as the patient’s history of substance abuse (OUD), where the hospice is located, local and state legislation related to opioid usage, and many other factors.

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