Each year, millions of individuals in the United States are treated for a variety of serious medical conditions with prescription drugs whose therapeutic benefits are well known. The vast majority of these medications are used to treat medical and psychiatric illnesses. Generally, they are used as prescribed, and contribute to a better quality of life for persons suffering from debilitating or life-threatening disorders.

The fact that a small portion of these medications is diverted by those who seek their psychoactive effects raises the important policy issue: how to make drugs easily available for medical use while limiting access for purposes of abuse.

Such a responsibility poses challenges very different from those of the so-called “war” on illicit drugs, because this control must be achieved without impeding patients’ access to medical care. A rational public policy would attempt to achieve a balance between the need to minimize abuse and the need to provide relief.

“It was the best of times. It was the worst of times.” Charles Dickens easily could have been describing our time and the dilemma in which victims of nonmalignant chronic pain find themselves.

I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life.

The morning of February 1983 severed my life into “before” and “after,” as clearly as if it has been cut by a sharp knife. The “before” included my career as an oncology nurse, a college nursing professor, and a writer; but that was abruptly ended by the catastrophic rupture of a deep cerebral aneurysm. Surgery saved my life, but something unforeseen occurred during the procedure; and so, in the “after,” I have had to live with a serious seizure disorder and memory loss.

We can think about the use of controlled substances in the treatment of anxiety disorders in two simple but diametrically opposed ways. First, we can say that anxiety disorders are trivial and require only acts of willpower, or, if anxiety disorders do require treatment, they are better treated without the use of benzodiazepines (BZs). When BZs are used to treat anxiety, they pose grave risks of addiction to the patients to whom these medicines are prescribed; they relieve patients’ symptoms, but are the equivalent of a pharmacological “roach motel,” a haven into which many unsuspecting patients enter, but from which few emerge without becoming addicted. Patients must then face terrible struggles to free themselves of dependence on BZs, and this compounds the problem for which they sought treatment. Furthermore, the large number of prescriptions for BZs are a threat to the public health because these drugs are widely abused by alcoholics and drug addicts.

A great deal has been learned in the past fifteen years from the study of pain mechanisms. More recently, the relief of pain has begun to receive much needed attention as well. Although most, if not all, acute and cancer pain can be relieved, recent evidence shows that inadequate treatment of pain is still common among the general population—even for pain due to cancer. Inadequate treatment of cancer pain is even more likely if the patient is a member of an ethnic minority, female, elderly, or a child. Evidence also suggests that substance abusers are at risk for poor pain treatment.

A number of barriers which involve problems of knowledge, attitudes, and laws and regulations affect health care professionals, patients, and the health care system; collectively, they contribute to the inadequate treatment of pain.

George Will, the well-known pundit, once observed: “A society's recreation is charged with moral significance. Sport—and a society that takes it seriously—would be debased if it did not strictly forbid things that blur the distinction between the triumph of character and the triumph of chemistry.” In opposition, Dan Duchaine, the highly publicized “steroid guru” and counter-culture columnist, declared: “There comes a time for many in competitive athletics where winning is more important than those initial goals of health, recreation, and relaxation.” The parallels of these two philosophies to life in general are patent simply by substituting “sports” and “winning” for “career” and “success,” respectively.

This paper will review the basis for banning anabolic steroids in athletics, and consider especially the recent medical findings that support this prohibition. This survey leads into a discussion of the available deterrents, and the secondary, but essential, role of random drug testing as a final safeguard.

The regulation of narcotic medications used in narcotic addiction treatment is unique in medical therapeutics. Physicians who want to use narcotics for this indication must obtain a separate annual registration from the Drug Enforcement Administration (DEA). Annual registration is contingent on compliance with both the DEA's security regulations (inventory, record-keeping, and physical security) as well as treatment regulations jointly promulgated by the Food and Drug Administration (FDA) and the National Institute on Drug Abuse (NIDA).

During the last decade, a number of events have occurred that persuaded NIDA that it is time to reevaluate the current method by which the Department of Health and Human Services (HHS) regulates methadone treatment. As a result of research during the past twenty years, we have learned about the effective components of methadone treatment. In comparison to other available treatment modalities for opioid addiction, methadone treatment is uniquely effective when administered by well-trained medical staffs.

In the United States, screening the urine of employees or job applicants for the presence of drugs has become commonplace. A survey of 794 large- and mediumsized companies, conducted by the American Management Association in January 1994, found that 87 percent of them now test job applicants for drug use. In 1987, a similar survey found that 22 percent screened job applicants. Federally mandated drug testing programs with random testing requirements affect millions of workers in the transportation industry, the nuclear power industry, and the United States civil and military services.

As some of these programs pass their fifth anniversary since being instituted, it is important to assess the forces that led to their creation. Whether or not these programs are considered successful depends on what one expects to achieve by such widespread testing.

A relatively healthy forty-six-year-old woman with mild hypertension receives a prescription for an antihypertensive medication. One of the medication's adverse effects is its potential to cause severe depression. Four months later, she is diagnosed with anxiety, an early manifestation of depression. An antianxiety drug is prescribed, but her anxiety worsens. Her physician then diagnoses her as having a depressive disorder, and prescribes a new antidepressant medication. She is still on the same antihypertensive.

A seventy-two-year-old man is given furosemide and digoxin to control a mild case of congestive heart failure and hypertension. Because furosemide deletes potassium from the body, his physician also places him on a potassium supplement. Six months later, the physician tells the patient to stop taking the furosemide and prescribes an angiotensin converting enzyme (ACE) inhibitor. An effect of ACE inhibitors is to reduce the body's excretion of potassium thereby reducing the digoxin's effectiveness.

Pain is one of the most frequent presenting symptoms for patients who come to a physician's office. Despite the frequency of this presentation, little consistent, systematic information is provided to medical students or physicians about the treatment of pain. In addition, relatively little information is given about the recognition and prevention of drug abuse and about how to prescribe analgesics rationally to minimize the chances for abuse. This lack of educational preparation for both pain and addiction contributes to significant fear and inability on the part of health professionals to diagnose and treat both conditions. It creates a barrier of fear to prescribe adequate doses of pain medications for patients who present with both acute and chronic pain problems. Inadequate medicating can be caused by the physician's overriding worry about creating addiction in a patient. Morgan has called this problem “opiophobia.”

Nurses in all practice roles and settings need to understand the therapeutic use and potential for abuse of prescription drugs. Nursing roles, which include the administration and prescription of medication, health teaching and the implications of application, and the detection of drug-related problems, require that such education be timely and comprehensive. This paper discusses the state of knowledge dissemination about prescription drugs within the general context of nursing education. It highlights educational needs and explores the attitudinal factors and knowledge deficits that influence the nursing practices of prescribing, pain management, nursing assessment, and care of persons with drug problems.

Standard educational requirements in all nursing curricula undergird teaching about licit and illicit drugs and medication, as well as their therapeutic use, misuse, and abuse. It has been recognized widely since the early 1980s, however, that clinical experiences and didactic content on licit and illicit drugs presented in nursing programs is inadequate.

During the past decade, a new term has entered the medical/legal lexicon : maternal-fetal conflict. Implicit in the terminology is the assumption that a pregnant woman and her fetus have separate and competing rights. This concept has stimulated extensive legal and ethical debate, primarily in the context of medical interventions (cesarean sections and blood transfusions) forced on unwilling pregnant women, and in corporate efforts to bar fertile women from hazardous jobs. On one side of the debate are the proponents of the future child's right to be born of sound mind and body, and society's interest in the delivery of healthy newborns. On the other side, are advocates of a woman's right to reproductive autonomy, bodily integrity, due process, confidential medical treatment, and freedom from gender discrimination. Neither side has challenged the formulation of the problem, or has examined its permeation into public health policy.

Access to abortion is becoming increasingly restricted for many women in the United States. Besides the longstanding financial barriers facing low-income women in most states, a newer source of scarcity has emerged. The relatively small number of physicians willing to perform the procedure is compromising the ability of women in certain parts of the country to obtain an abortion.

Do physicians have a duty to respond to this situation? Do they have a professional responsibility to ensure that abortions are reasonably available to the women who want to terminate their pregnancies? Or, is abortion so morally and socially controversial as to remove any professional obligation to provide reasonable access?

Both law and medical ethics have traditionally protected physicians’ freedom to refuse to perform any procedure, including abortion, that conflicts with their religious or other moral beliefs.