From the Editor
Aug 2020

Ethics, Public Health, and Addressing the Opioid Crisis

Hunter Jackson Smith, MD, MPH, MBE
AMA J Ethics. 2020;22(8):E647-650. doi: 10.1001/amajethics.2020.647.

Magnitude of the Opioid Crisis

The alleviation of pain is one of the oldest and most central duties charged of physicians. Ailing patients seek health care in the hopes that it will ease their suffering, and clinicians often take great satisfaction when they are able to reduce their patients’ discomfort. There is not a single clinician who has not, at some point in their training or practice, been confronted with a patient in pain, prescribed a pain medication, or been touched by a patient whose pain they could not ease. Clinicians wish to ease suffering, but their prescription pads are a source of potentially dangerous and addictive drugs. In the context of the growing opioid crisis, pain management and approaches to opioid prescribing have taken on an entirely new ethical component. Opioid misuse has become one of the gravest and most consequential public health threats facing the United States today.1 Per the National Institutes of Health, the number of US drug overdose deaths has increased markedly over the past 2 decades, primarily due to the role of opioids.2,3 In 2018, there were 67 367 drug overdose deaths in the United States—70% of which involved opioids.4 Between 1999 and 2017, the age-adjusted drug overdose death rate in the United States more than tripled—from 6.1 per 100 000 to 20.7 per 100 000.5

Yet these statistics barely scratch the surface of the negative effects of opioid misuse. The impacts of opioid misuse ripple throughout families and communities and have created a new epidemic of despair. In fact, the opioid crisis has reached such a level of concern that, in 2017, the US Department of Health and Human Services (HHS) declared it a nationwide public health emergency in order to authorize the mobilization of resources, institute public health powers, promote multisector responses, and facilitate innovative strategies to combat it.6 This declaration has been renewed every year since its inception, having most recently been reaffirmed on January 14, 2020.7 This multiyear state of emergency is not the norm, and it highlights our failures to sufficiently control this crisis. As noted on HHS’ public health emergency declarations page, the typical emergency is declared in response to a natural disaster and lasts several months.8 We as a medical community and a society must take this opioid emergency declaration seriously, paying particular attention to multidisciplinary innovative strategies aimed at prevention. Furthermore, there remains a substantial need for ethics involvement in this crisis—something a public health emergency declaration does not address.

Broad Impact and Engaging Stakeholders

One of the central components of a public health emergency is to promote multisectoral engagement. This strategy is of particular importance for addressing the opioid crisis due to its deep, far-reaching impacts across a broad spectrum of medical and social disciplines. As such, this theme issue strives to engage key stakeholders to promote a diversity of ethical perspectives and to generate understanding among communities of professionals. The importance of this topic and the scope of its impact is evident in the diversity of contributors’ perspectives, each of which deserves thoughtful consideration in social, cultural, clinical, and ethical conversations about what we owe individuals, families, and communities affected by pain and our responses to it.

Public Health

Declaring a public health emergency requires that the true urgency underlying the emergency be recognized. It also necessitates that those in health care fields understand the population focus of a public health emergency and engage in population-level thinking. As such, a public health emergency declaration implies an urgent need for clinicians of all kinds to consider their role in responding to the emergency. The declaration should prompt those in health care to answer the call to align their practice with public health strategies and to become more involved in controlling the emergency.

Unfortunately, HHS’ 5-point opioid strategy to address the public health emergency noticeably neglects the need for public health interventions and policy.9 The primary focus remains treatment oriented and responsive. The aggressive marketing strategies of pharmaceutical companies, clinicians’ inadequate training to appropriately manage pain, and a failure to sufficiently treat mental health have been identified as primary causal factors underlying the opioid epidemic.10,11,12 Although these factors are certainly of central importance, they neglect many crucial underlying factors, such as social determinants and policy, that play a role in a person’s health trajectory. Therefore, a central question we must consider is this: What role should the government and society play in combatting the opioid epidemic?13 Public health-focused modalities must be explored and pursued in the context of opioid misuse, and clinicians in all specialties should become more proactive in public health not only in the clinic or hospital but also in their communities.14


Efforts have been made to increase attention to the ethics of the opioid crisis, particularly in the areas of prescription practices, naloxone availability, and clinician regulations.15,16,17 However, the ethics of this crisis still have not been sufficiently addressed. Ethics, both as a guide for what ought to be done and a practice, must be central to any and all strategies we use in combatting this public health emergency. Its importance in this matter cannot be understated. Furthermore, the ethical issues inherent in the opioid crisis extend beyond treatment. Several important ethical questions have been brought to public consciousness: What obligations do pharmaceutical companies have to society due to their role in instigating the crisis? And how do we most appropriately address the underlying factors driving substance misuse and addiction? Yet even these questions require much deeper ethical discussion and are by no means conclusively answered. There are many more questions that remain largely unaddressed: What obligations does the state hold to address opioids, both illicit and prescribed? And how ought we to prioritize funding for opioid prevention and treatment initiatives? These are questions that require our thoughtful attention. It is my sincere hope that you, the reader, will take from this theme issue the need for (1) greater infusion of ethics into our discussions of strategies for addressing opioid misuse and (2) motivating those in health care fields to actively engage in public health regardless of their practicing specialty.


  1. Gostin LO, Hodge JG Jr, Noe SA. Reframing the opioid epidemic as a national emergency. JAMA. 2017;318(16):1539-1540.
  2. Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science. 2018;361(6408):eaau1184.

  3. National Institutes of Health. Overdose death rates. Revised January 29, 2019. Accessed February 7, 2020.

  4. Centers for Disease Control and Prevention. Opioid overdose—understanding the epidemic. Reviewed March 19, 2020. Accessed April 12, 2020.

  5. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999-2018. NCHS data brief 356.,1999%20to%2021.7%20in%202017. Published January 2020. Accessed June 7, 2020.

  6. Hedberg K, Bui LT, Livingston C, Shields LM, Van Otterloo J. Integrating public health and healthcare strategies to address the opioid epidemic: the Oregon Health Authority’s opioid initiative. J Public Health Manag Pract. 2019;25(3):214-220.
  7. Azar A. Renewal of determination that a public health emergency exists. US Department of Health and Human Services. Published January 24, 2020. Accessed February 7, 2020.

  8. US Department of Health and Human Services. Public health emergency declarations. Accessed April 12, 2020.

  9. HHS acting secretary declares public health emergency to address national opioid crisis [press release]. Washington, DC: US Department of Health and Human Services; October 26, 2017. Accessed February 7, 2020.

  10. National Institutes of Health. The drug overdose epidemic affects all communities. Published October 25, 2019. Accessed February 7, 2020.

  11. Van Zee A. The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Am J Public Health. 2009;99(2):221-227.
  12. Wenghofer EF, Wilson L, Kahan M, et al. Survey of Ontario primary care physicians’ experiences with opioid prescribing. Can Fam Physician. 2011;57(3):324-332.
  13. Kolodny A, Frieden TR. Ten steps the federal government should take now to reverse the opioid addiction epidemic. JAMA. 2017;318(16):1537-1538.
  14. Adams JM, Giroir BP. Opioid prescribing trends and the physician’s role in responding to the public health crisis. JAMA Intern Med. 2019;179(4):476-478.
  15. Cohen MJM, Jasser S, Herron PD, et al. Ethical perspectives: opioid treatment of chronic pain in the context of addiction. Clin J Pain. 2002;18(4)(suppl):S99-S107.
  16. Kotalik J. Controlling pain and reducing misuse of opioids: ethical considerations. Can Fam Physician. 2012;58(4):381-385.
  17. Lajam CM, Cenname J, Hutzler LH, et al. Ethics of opioid prescriber regulations: physicians, patients, and pain. J Bone Joint Surg Am. 2019;101(23):e128.


AMA J Ethics. 2020;22(8):E647-650.




The author would like to convey his heartfelt appreciation to his wife, Dr Joy Piotrowski, for her invaluable thoughts and contributions. The author would also like to thank Dr Travis Rieder for his guidance in developing this theme issue and for his mentorship throughout the author’s continuing development as a bioethicist.

Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose. 

The contents, views, or opinions expressed in this publication or presentation are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University, the Department of Defense, or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the US government. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.