WMA Statement on the Responsibilities of Physicians in Preventing and Treating Opiate and Psychotropic Drug Abuse
Adopted by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 67th WMA General Assembly, Taipei, Taiwan, October 2016
PREAMBLE
Opiate and psychotropic drugs are valuable therapeutic tools when used as medically indicated for a variety of symptoms and conditions. Indeed, the WMA has called for the greater provision of pain management treatment in its Resolution on the Access to Adequate Pain Treatment (Montevideo, Uruguay, October 2011). Unfortunately, non-clinical misuse of these addictive substances is an enormous problem worldwide. Drug addiction is a complex social, economic and legal issue as well as a threat to public health and safety globally. It affects people from all demographic and social groups and economic spheres. In addition to exposing themselves to the direct health risks related to the inappropriate use of these substances, persons addicted to drugs may engage in high risk behaviour, such as needle-sharing and unprotected sex, and many resort to criminal activity to finance their expensive addiction. These factors increase transmission of viral infections, such as Hepatitis B and C and HIV/AIDS, among both users and non-users alike. Other results of addiction include failure to maintain employment or to function in social and family life.
The legal ramifications of non-medical drug use, which is illegal in most countries, generally do little to assist users in breaking free from their addiction. Despite the presence of drug programs in many correctional facilities, illegal substances are very often available to inmates and, in fact, some users begin their addiction in these institutions. Addressing addiction therefore falls largely to society and the health profession.
The World Medical Association, concerned by the widespread misuse of psychotropic and opiate drugs, urges physicians to prioritize this problem in the practice of medicine and to adhere to the following guidelines.
PRINCIPLES
Responsible prescribing practices
Physicians should be aware of the addictive properties of certain psychotropic and opiate drugs. Such drugs should be prescribed with the greatest restraint, observing the strictest possible generally accepted medical indications. Physicians must take all necessary measures to ensure that they are fully informed of the effects of these drugs. This includes reviewing up-to-date research regarding dosage, potential effectiveness for the specific condition, potential side effects and pharmacological interactions and prevalence of misuse.
When such drugs are medically indicated, their use must be carefully monitored to ensure that the patient is following strict dosage instructions, timing and any other factors associated with the safe use of the particular drug. All appropriate measures must be taken to prevent the stockpiling, resale or other illicit usage of the drug.
Patients must be fully informed of all potential therapeutic and non-therapeutic effects of psychotropic and opiate drugs, including potential for addiction, and be fully involved in the decision to take them. No competent patient should be forced to take any psychotropic drug against his or her will.
Physicians should be aware of non-medical factors that may predispose patients to addiction. These may include, among others, family history, past addiction, emotional trauma, depression or other mental health conditions and peer pressure, especially among young persons.
Physicians should learn to recognize ‘drug seekers’, addicted patients who attempt to obtain psychotropic and opiate drugs under false medical pretenses. Drug seekers often consult more than one physician in an effort to obtain multiple prescriptions. In extreme cases, drug seekers may harm themselves to create symptoms to obtain a prescription. All patient conditions and symptoms should be clinically verified, to the extent possible, and meticulous records maintained regarding the patient’s drug history. If databases containing patient drug records and prescribing histories are available, they should be consulted.
When prescribing any psychotropic or opiate substance to minors, physicians must ensure that the parents or guardians of the patient are fully informed of the potential misuse of the drug and encouraged to monitor the child carefully to ensure adherence to the physician’s instructions. Parents or guardians should be informed that, in some countries, it is increasingly common for children to sell prescription drugs to their peers.
Non-drug therapy for addicts to opiate and psychotropic drugs
Physicians should be aware of all non-drug treatment options for addicts to opiate and psychotropic drugs, including inpatient and outpatient programs and therapeutic communities, in which recovering addicts live in a supportive, drug-free environment. Most treatment programs are focused on breaking the cycle of drug dependence through detoxification, counselling – including ongoing peer support – and permanent abstinence from the use of any addictive opiate or psychotropic substance, including alcohol. Some offer educational and/or vocational programs to facilitate successful reintegration into community life.
Physicians should encourage their patients to participate in drug treatment programs at the earliest possible stage of addiction.
All efforts should be made to respect the dignity and autonomy of addicted patients. Involuntary inpatient treatment of addicted persons should be a last resort, according to established guidelines and, where applicable, legal requirements.
Drug therapy for addicts to opiate drugs
In some cases, persons addicted to opiate drugs may be treated using medications that relieve withdrawal symptoms and cravings for the addictive substance without producing the ‘high’ associated with opiates. These medications also provide cross tolerance to other opioids. The objective of drug treatment is the immediate cessation of the use of opiate drugs.
Drug therapy can assist the opiate-dependent patient to function in his or her normal environment and activities while working to overcome the opiate addiction. However, it should always be part of a multi-disciplinary approach that includes proven non-drug treatment elements, such as counselling and peer support.
Drug therapy should be administered according to established evidence-based guidelines and supervised by specially trained physicians with an appropriate support team.
Awareness raising and policy development
National Medical Associations (NMAs) should engage in cross-sectoral national efforts to raise awareness of the risks associated with the abuse of opiate and psychotropic drugs and to ensure the availability of appropriate treatment options for addicted persons. NMAs should encourage their members to participate in similar programs at the community level.
NMAs should promote appropriate drug prevention programming at all levels of the educational system, recognizing that experimentation with drugs is increasingly prevalent among younger age groups.
NMAs and physicians should participate in the development of evidence-based guidelines that support a multi-disciplinary approach to the treatment of drug addiction, including harm reduction strategies such as needle exchange programmes.
NMAs should participate in the development of legal procedures relating to illegal drug use to ensure that addicted persons are recognized as entitled to receive appropriate medical and rehabilitative care, including in correctional institutions.
CONCLUSION
Physicians have an important role to play in the treatment of drug addiction, both as clinicians and as advocates for the treatment, rights and dignity of persons addicted to these harmful substances. Treatment of addiction, like treatment for any disease or condition, should be undertaken in the best interests of the patient and according to established principles of medical ethics.