The Gentle Art of Saying "NO"-How to Establish Appropriate Boundaries With Pain Patients

Author: David Cosio

Boundaries are simply rules or limits that individuals create to identify reasonable, safe, and permissible ways for others to behave around them, and to determine how they’ll respond when someone oversteps these boundaries. It is apparent that pain management, in particular, requires appropriate boundary setting—by the practitioner, for the patient. This is crucial regardless of the treatment plan, in part because providers often find it hard to identify potential ruptures in their relationships with patients. And sometimes, what a patient may want may not be what they need, and the practitioner saying “No” may be the therapy. There is, however, a gentle art to saying “No.”

Since the beginning of the new millennium, the field of pain medicine has witnessed the pendulum of change. At first, national organizations were directing providers towards the use of opioid therapy in pain management. About 5 decades ago, governments around the world adopted the 1961 Single Convention on Narcotic Drugs which, in addition to addressing the control of illicit narcotics, obligated countries to work towards universal access to the narcotic drugs deemed necessary to alleviate pain and suffering. Henceforth, effective pain management was deemed “a right to health” according to international human rights law. As a consequence, patients believed they were entitled to opioids, and providers felt pressured to provide adequate treatment. As a result, this reinforced patient’s beliefs and sole reliance on medications for chronic pain management.

Today, the health community and the general public has witnessed how the sole reliance on narcotic medications has become an opioid epidemic. Politicians have even started acknowledging the need for additional substance use treatment centers in the United States to address the problem. Approximately 80% of opioids are consumed in the US alone, while most other countries do not rely as much on these medications for pain management. This overuse has led to an increase in prescription drug medication deaths, including some high profile individuals, such as Anna Nicole Smith, Heath Ledger, and Prince. In March 2016, the Centers for Disease Control released new guidelines about the use of opioid medications for chronic pain management in response to the crisis. This has caused a lot of frustration among providers, as well as patients who are seeking some relief from their chronic pain.


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