Pain, Drugs, and Ethics - A Delicate Balance

Author: Kevin L. Zacharoff

The safe and effective management of chronic pain with prescription pain medications shares both similarities and differences with providing pharmacologic care for patients with other medical conditions. Many forces have recently come together to attempt to reshape the use of prescription pain medications, particularly opioid analgesics, in chronic pain treatment today. Commonly, medication based treatment may be just one component of a chronic pain management treatment plan. Caring for patients suffering from chronic pain, because of its high prevalence, falls largely on the shoulders of frontline healthcare practitioners, many of whom haven't received adequate education in pain management, prescription pain medications, or substance abuse. Competing prescribing guidelines, negative media attention, educational deficits, comorbid medical complexity, and fear of regulatory scrutiny (along with other factors) have increased the burdens, challenges, and anxiety facing clinicians caring for these patients. Unfortunately, not much discussion is taking place regarding the dutiful, thoughtful, and consistent application of ethical principles to treating patients with chronic pain. This article provides a summary of generally accepted principles of medical ethics. It offers a framework for incorporation of these principles into the development of a medication based pain treatment plan for clinicians that can be clinically relevant, reproducible, ethically sound, and above all helpful towards achieving positive patient outcomes.

Chronic pain—how different is it?

Everything is negotiable... maybe more so when healthcare providers are tasked with assessing and treating patients with chronic pain. So closely tied to the negotiation of quality of life and functional capability, chronic pain is one of the few medical conditions where the patient gets to have a significant level of input regarding what determines the success or failure of a treatment plan. The lack of easily available and objective markers for chronic pain contrasts those available for other common diseases such as diabetes and hypertension, where treatment efficacy can be gauged by laboratory results or vital sign assessment like serum hemoglobin A1c or serial blood pressure measurement. Ironically, while shared decision-making is considered to be a hallmark of healthcare today, paternalism continues to play a role in patient care, often confounding key principles of effective pain management. In many cases, patients want to be told what to do, and in many cases, healthcare providers want to tell patients what to do and just be done with it. These sometime hard and fast dynamics can often be difficult to abandon, and may ultimately lead to diminished communication and understanding, and the violation of patient's rights to ethical delivery of care. One could argue that rarely is there more of a need for transparent patient-provider communication than in the case of a patient with chronic pain. If setting goals and expectations of treatment is a foundational step in the assessment process and treatment plan formulation including prescription pain medications, surely there is a need for a high level of dialogue among all stakeholders.

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