This chapter discusses opioid therapy for addicted patients based on the three cases studies. Differences in history, culture, healthcare systems, laws, and attitudes have significantly affected perspectives on the ethical management of opioid use between the US and the UK. The present state of affairs is that abuse of prescription opioids is more prevalent in the US than abuse of "street" heroin. Opioid treatment of pain has periodically come under intense scrutiny in the US, resulting in fluctuations between under- and overtreatment of pain. Fears of civil or criminal prosecution may unduly influence physicians in the US, placing self-interest ahead of the traditional prioritization of beneficence and respect for patient autonomy. Differences between the US and UK in healthcare provision additionally influence opioid prescribing. The paternalistic approach more predominant in universal healthcare systems is not appropriate in the US, thus producing ethical dilemmas for the US physicians.

Ethical problems presented by opioid-dependent patients suffering from pain are challenging, but can be guided by simple principles of ethical medical practice. This chapter presents three case studies on opioid therapy for addicted patients. The first is of a 35-year-old woman with chronic leg pain secondary to vascular damage from previous recurrent groin infections associated with intravenous opioid use. The second deals with a 34-year-old man with acute alcohol poisoning. The third focuses on a 40-year-old man with a significant history of drug misuse. The chapter then explains their resolutions from the UK perspective. A major problem with pain management in the patient with opioid dependency is lack of physician knowledge about appropriate prescribing; education of physicians is key to developing reasonable prescribing practices. A principle like that of "double effect" might be useful in defining appropriate physician behavior in relieving pain in the potentially dependent patient.