Assume that you are a physician, treating a patient who is terminally ill with cancer. As the cancer progresses, and as neuroadaptation to the narcotic analgesic develops, you have increased the patient's daily medication dose to the point where you are starting to worry about causing the person to become addicted to these medications. This patient has no prior history of alcohol or drug addiction, although many members of the patient's family have substance use disorders. You have the choice to order dosage increases as warranted, or hold the patient at the present level to avoid the danger of iatrogenic addiction. A moral question is whether the physician should worry about inducing an addiction in a patient who will soon expire from a disease process such as cancer.

Questions

1. What would you do in this situation? Why?
2. What are the various factors that need to be taken into account in this case? What does your answer to question 1 imply about which of these factors is the most important?
3. Now imagine that the patient has a prior history of a substance use disorder and of poor compliance with treatment. Should you refuse to administer narcotic analgesics for such a patient who is living at home? What would be the reasoning behind either choice?
4. How can the physician identify legitimate pain from addictive behaviors? Should the doctor rely on the patient's word, or should the physician order urine toxicology testing to confirm the presence of prescribed medications?