Ethics Roundtable: Prescribing Controlled Substances in a Terminally Ill Patient With Suspected Substance Abuse Disorder and Opioid Agreement Violations

Webster LR Webster RM . Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Med. 2005;6(6):432-442. doi:10.1111/j.1526-4637.2005.00072.x

Torres-Tenor JL Bruera E Sanchez-Manas I , et al. Frequency and predictors of risk of non-medical opioid use among patients with cancer in a specialized outpatient palliative care clinic. Clin Transl Oncol. 2025;27(10):4051-4057. doi:10.1007/s12094-025-03929-7

21 C.F.R. § 1306.04(a). In Addition, There Is a “Corresponding Responsibility [That] Rests with the Pharmacist Who Fills the Prescription.” Id. See 21 U.S.C. § 829.

United States v. Moore, 423 U.S. 122, 138–43 (1975).

21 C.F.R. § 1306.04(a). The diversion control division of the DEA offers information on its website: https://www.deadiversion.usdoj.gov/ (accessed Dec. 9, 2025).

See 21 U.S.C. § 842; 21 U.S.C. § 841(a); Moore, 423 U.S. at 143.

Centers for Disease Control and Prevention , Clinical Practice Guideline for prescribing opioids for pain — United States. Centers for Disease Control and Prevention, 2022.

See DEA, Practitioner’s manual (2020).

AMA Code of Med. Ethics, op. 2.2.1; op. 2.2.4.

AMA Code of Med. Ethics, Op. 3.2.1. consistent with this, the health insurance portability and accountability act (HIPAA) regulations expressly permit disclosure to law enforcement when a crime is suspected, allowing physicians to report opioid diversion, as outlined more specifically in endnote 16.

45 C.F.R. § 164.512(f). Note that this is a permissive report, but not a mandatory one.

AMA code of medical ethics, Op. 1.1.5.

See generally Am. Coll. of Physicians, Stmt. On opioid misuse and clinician duties (2017).

Emanuel SEJ Ethical issues in palliative care. J Clin Oncol. 2013;21(1):63-78.

45 C.F.R. § 164.502(a).

HIPAA allows disclosure of PHI that the provider believes in good faith constitutes evidence of a crime on the premises of the provider. 45 C.F.R. § 164.512(f)(5). This exception is narrow, typically limited to illegal activity occurring in the clinical setting, such as a hospital. Also, HIPAA permits limited disclosure when the provider has information that “constitutes evidence of criminal conduct.” 45 C.F.R. § 164.512(f)(3). Thus, a provider could report opioid diversion if there is a good-faith belief that criminal diversion exists. In addition, HIPAA allows disclosure when it could prevent a serious and imminent threat to health or safety. 45 C.F.R. § 164.512(j). This provision is very narrow and is not likely to apply in Most patient care contexts. Finally, HIPAA allows disclosure when required by another law, such as a state reporting obligation. 45 C.F.R. § 164.512(a). While It Is Important to Confirm the Jurisdictional Requirements, Generally States Do Not Impose Mandatory Reporting Requirements for Prescription Diversion.

Kwon JH Tanco K Park JC , et al. Frequency, predictors, and medical record documentation of chemical coping among advanced cancer patients. Oncologist. 2015;20(6):692-697.

Maté G . In the Realm of Hungry Ghosts: Close Encounters with Addiction. North Atlantic Books; 2010.

Jairam V Yang DX Verma V Yu JB Park HS . National patterns in prescription opioid use and misuse among cancer survivors in the United States. JAMA Netw Open. 2020;3(8):e2013605. doi:10.1001/jamanetworkopen.2020.13605

Jones KF Osazuwa-Peters OL Des Marais A Merlin JS Check DK . Substance use disorders among US adult cancer survivors. JAMA Oncol. 2024;10(3):384-389. doi:10.1001/jamaoncol.2023.5785

Paice JA Bohlke K Barton D , et al. Use of opioids for adults with pain from cancer or cancer treatment: ASCO guideline. J Clin Oncol. 2023;41(4):914-930. doi:10.1200/JCO.22.02198

Barclay JS Owens JE Blackhall LJ . Screening for substance abuse risk in cancer patients using the opioid risk tool and urine drug screen. Support Care Cancer. 2014;22(7):1883-1888. doi:10.1007/s00520-014-2167-6

Lau J Mazzotta P Fazelzad R , et al. Assessment tools for problematic opioid use in palliative care: a scoping review. Palliat Med. 2021;35(7):1295-1322. doi:10.1177/02692163211015567

Huggins J Ashley J Fasolino T . Substance use disorder, opioid use disorder, and symptom management in palliative care: a rapid review of evidence. J Hospice Palliat Nurs. 2024;26(5):249-256. doi:10.1097/NJH.0000000000001058

McNicol ED Ferguson MC Schumann R . Methadone for neuropathic pain in adults. Cochrane Database Syst Rev. 2017;5(5):CD012499. doi:10.1002/14651858.CD012499.pub2

Jansen LA . Medical beneficence, nonmaleficence, and patients’ well-being. J Clin Ethics. 2022;33(1):23-28.

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Varkey B . Principles of clinical ethics and their application to practice. Med Princ Pract. 2021;30(1):17-28. doi:10.1159/000509119