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Ethics of Pain Care: what duties do we have to patients with chronic pain?

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In this presentation, I ask: what duties do we have to patients with chronic pain? I examine the case of Daniel, a 48-year-old man with chronic back, neck and head pain after a motor vehicle accident 8 years previously. I argue that our foremost duty to patients with chronic pain is not to reduce their pain intensity but to improve their health. Titrating opioid doses to a pain level may reduce pain and at the same time make it harder for a patient to live his or her life.

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Ethics of Pain Care: what duties do we have to patients with chronic pain?

  1. 1. Ethics of Pain Care: what duties do we have to patients with chronic pain? Mark Sullivan, MD, PhD Psychiatry and Behavioral Sciences Anesthesiology and Pain Medicine Bioethics and Humanities University of Washington “I am not seeking out drugs, I am seeking relief.”
  2. 2. Disclosures • Research grants: Pfizer, Purdue • Consulting: Aetna
  3. 3. Daniel, 48 y/o male • New to Seattle • Back, neck and head pain since MVA 8 y ago • Spine MRI: DJD, DDD • Has failed PT, ADs • Constant 10/10 pain • Sober for 10 years • Seeks restart of oxycodone ER 40mg BID “Don’t you believe I am in pain? Don’t you think I deserve relief?”
  4. 4. What do you owe to Daniel? • A cure, a diagnosis • Pain relief, no pain, less pain • Pain management, what tools, what goals • Improved function, what kind, what goals • Improved quality of life, as defined by, according to what standard
  5. 5. Historical duty to relieve pain • Hippocratic Oath: – “I will keep them from harm…” • Declaration of Geneva (1948) – “The health of my patient will be my first consideration…” • American Medical Association (1992) – “physicians have an obligation to relieve pain and suffering.” • American Nurses Association (2001) – “nursing encompasses… the alleviation of suffering…”
  6. 6. IASP Declaration of Montreal 2010 • Pain management is inadequate in most of the world because: • …chronic pain is a serious chronic health problem requiring access to management akin to other chronic diseases such as diabetes or chronic heart disease. • There are major deficits in knowledge of health care professionals regarding the mechanisms and management of pain. • Chronic pain with or without diagnosis is highly stigmatized. • Most countries have no national policy at all or very inadequate policies regarding the management of pain as a health problem…
  7. 7. IASP Declaration of Montreal 2010 • Recognizing the intrinsic dignity of all persons and that withholding of pain treatment is profoundly wrong, leading to unnecessary suffering which is harmful; we declare that the following human rights must be recognized throughout the world: • Article 1. The right of all people to have access to pain management without discrimination • Article 2. The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed • Article 3. The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health care professionals
  8. 8. Evolution of right to pain relief • Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right. Pain 2004:112:1-4. • Brennan F, Carr DB, Cousins M, Pain Management: a fundamental human right, Anesth Analg, 2007; 105: 205-221; – “to listen to a patients’ complaint of pain, to make a reasonable effort to provide pain relief” – Focus has shifted from a measure of outcome “pain relief” to a measure of process: “pain management” – Not possible to guarantee outcome, so shifted to process
  9. 9. A thought experiment • Think of Daniel’s demand in different terms: – “Do you not believe I am suffering? Do you not believe that I deserve relief?” • This shifts the kind of moral claim made of us: – Less medical, less like acute pain – More personal, more individualized – Less innocent, focuses more on Daniel’s role – Calls less for medication, more for engagement
  10. 10. Innocent suffering • We privilege pain as a form of physical suffering • Like acute pain and disease , we consider this pain to be innocent suffering – “You did nothing to bring this on yourself.” • Parallel and corollary to this innocent suffering is a form of pain-specific relief, opioids. – We prescribe opioids to “kill” the pain and leave the person alone. – As our patients say to us, “don’t give me any of your mind-altering drugs, just take away my pain!”
  11. 11. • We must ask: why do we speak of a right to pain relief but not a right to depression or anxiety or suffering relief? – But in fact depression and post-traumatic stress disorder are associated with alterations in the endogenous opioid system and both strongly promote long-term and high-dose opioid medication use.
  12. 12. • Our foremost duty to patients with chronic pain is not to reduce their pain intensity, but to improve their health. • Titrating opioid doses to a pain level may reduce pain and at the same time make it harder for a patient to live his or her life. • TJC hospital standards: Adequacy of pain relief should be in terms of adequacy of function. For chronic pain, function is focus not only because payors are interested in this, but because functional improvement may precede pain improvement.
  13. 13. Pend Oreille WWhhaattccoomm LLeewwiiss 291 263 MMaassoonn CCoolulummbbiaia GGaarrffiieelldd 302 San Juan 207 Kitsap 226 Figure 2: All Opioids by County, 2014: Recipients per 1,000 Residents (Age-Gender adjusted) Statewide Rate = 232  274–302 252–273 227–252 136–227    Adams 24125 32787 Clallam Jefferson 231 Grays Harbor 279 274 Pacific Skagit 253 Snohomish 251 King 210 Pierce Cowlitz 273 227 Thurston Clark 237 Skamania 238 Klickitat Yakima Kittitas 218 Chelan 252 Douglas 249 240 Grant Okanogan 252 Ferry 273 Stevens Pend Oreille 268 Spokane289 Lincoln 210 Whitman Franklin 257 272 Benton 222 Walla Walla Asotin 227 Wahkiakum 261 284 Island 210 136 282 249 299 227 269 DOH 630-126 May 2017 Statewide tables & maps - 14 -

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