Ethical duties when patients make suspicious narcotic requests

Practicing dentists are likely to be familiar with the prospect of patients who request controlled substances for doubtful indications. Torn between ethical obligations of beneficence and nonmaleficence, the dentist may be uncertain whether to prescribe a medication with the intention of alleviating pain or to refuse the prescription due to concerns related to chemical dependency, underlying emotional illness, or ulterior motives on the part of the patient. Pharmaceutical choices often do not provide a mechanism for sidestepping this dilemma as chemically dependent patients may be quite sophisticated in their knowledge of drugs and the ways in which to couch their requests. Dentists have an ethical obligation to move beyond simply refusing prescriptions for patients suspected to be chemically dependent; they should sensitively discuss the issue with these patients and be prepared to offer referral for intervention. However, dentists must always be open to the possibility that a particular patient's assertion of chronic physical pain may be of complex origin. When this is the case, appropriate treatment is essential and may involve referring the patient to others with specialized skills. Dentists should not withhold pain medication from patients with uncontrolled pain in the final stages of life.