This post is a part of our Bioethics in the News series. For more information, click here.

By Karen Kelly-Blake, Ph.D.

There has been much news coverage in the past few weeks regarding the increasing number of prescription painkiller deaths from opioid and narcotic pain medications such as Vicodin (hydrocodone), OxyContin (oxycodone), Opana (oxymorphone), and methadone (CDC Vital Signs). This trend is especially striking among women (CDC Vital Signs notes a 400% increase since 1999). Non-Hispanic white and American Indian or Alaska Native women have the highest risk of unintentional, suicide, and other deaths from prescription painkiller overdose. The Centers for Disease Control reports that “about 18 women die every day of a prescription painkiller overdose in the US, more than 6,600 deaths in 2010, and for every woman who dies of a prescription painkiller overdose, 30 go to the emergency department for painkiller misuse or abuse” (CDC Vital Signs). While men are still more likely to die of prescription painkiller overdoses (more than 10,000 reported deaths in 2010), women are closing the gap.

Several theories are posited to explain that gap, for example, women are: more likely to suffer from chronic pain than men; more likely to be prescribed higher doses and take painkillers for longer periods of time; and more likely to seek out multiple prescribers, i.e. “doctor shop” to get their prescriptions. Moreover, women typically have smaller body masses than men, and so the gap between a therapeutic dose and a fatal dose is narrower. The overall increase in painkiller deaths does not appear to be linked to a measurable increase in the kind of severe pain that would require prescription painkillers. Rather, the medications may be increasingly used to treat moderate pain (NY Times OP-ED). News coverage has focused on how to curb and monitor the apparent increased prescribing of these medications and how to educate patients about the risks of narcotic painkillers. What’s missing in the news coverage is how to deepen the conversation to speak to the issue of providing effective pain management for chronic pain sufferers.

In light of the new data about the troubling increase in painkiller deaths, how can healthcare providers effectively manage pain and simultaneously avoid under-treatment, misuse, and abuse of prescription painkillers? The CDC offers strategic advice on how to counter this growing problem, including tracking prescription drug overdose trends to better understand the epidemic, using prescription drug monitoring programs to identify patients who may be improperly using prescription painkillers, prescribing only the quantity needed based on the pain diagnosis, and improving access to mental health and substance abuse services through implementation of the Affordable Care Act (CDC Vital Signs). The CDC has spotlighted an important public health issue, and many agree that these strategies are reasonable and will go a long way to curb the epidemic. But one could also argue that in order to curb this newly identified epidemic we have to address another pressing public health issue: under-treatment of chronic pain.

Healthcare providers have failed to provide adequate pain relief. Barriers to providing pain relief include clinician fear (fear of patient abuse and addiction, diversion, and regulatory scrutiny), clinician failure in identifying pain relief as a patient care priority, and a clinician knowledge deficit in the assessment and management of pain (Tomlinson; Rich 2000). Under-treated pain results in a host of physiological, psychological, social and economic consequences ranging from reduced mobility and strength, disrupted sleep, depression and anxiety to difficulty working and lost wages (Brennan et al. 2007). Scholten et al. (2007) assert that 80% of the world’s population fails to receive pain relief when needed. To address this deficit, instead of narrowly focusing on potential abuse, they suggest implementing more balanced policies on opioid use so as to enable access to pain relief that would address human suffering. The optimal way to treat chronic pain is through a multidisciplinary pain clinic, using a team approach offering physical therapy, psychological support, and appropriate pain medications. Such facilities are rare, and not surprisingly, a significant number of chronic pain sufferers are from low-income groups. As such they commonly lack insurance to cover costs for this ideal model for pain treatment.

If we believe that relief of pain is a core ethical duty for medical professionals then in light of the barriers listed we have to find a way to advance that moral imperative. First, clinicians have to trust their patients’ reports of their pain. There is an abundant literature on trust between patients and physicians, focusing largely on whether patients trust their healthcare providers, yet a dearth of literature on the trust physicians have, or don’t have in their patients. To advance this agenda, providers would have to stop viewing their patients as potential drug abusers and dealers, discounting their pain. Second, clinicians would need to appreciate, or be taught to appreciate, pain’s capacity to seriously impair a patient’s quality of life. As Tomlinson suggests about pain, “it is a malignant force in and of itself, a fact clearly evident to most humans who have not had medical training if not to those so trained.” Third, clinicians would need to understand that under-treatment is poor medical practice (Brennan 2007). ’Doing no harm’ does not mean ‘do not treat’ or ‘under-treat because you are scared.’ It requires one to balance the benefits and risks of pain treatment strategies. These strategies would not mean resorting to painkillers first, or to painkillers alone, but instead would involve trying a variety of treatment modalities. Fourth, having balanced the risks and benefits, clinicians should respect patients’ autonomy to choose and reject treatments. This is not to suggest that physicians have to go along with a patient’s choice that is counter to his/her professional rights. What it does mean is that if the clinician has a professional objection, then he/she should provide the patient with information about accessing treatment elsewhere. Lastly, clinicians should demonstrate equal concern for all patients. When a patient presents with a pain complaint and wants help, and the clinician’s response is to be suspicious, to disrespect the pain report, and to underestimate the impact the pain has on the patient’s quality of life, that provider has violated the principle of equal concern. Such violations are more likely when the pain patient is female, African-American, Hispanic, or low socioeconomic status.

So if we are to make any inroads in the epidemic of painkiller deaths, then we have to address the equally compelling public health issue of under-treatment of pain. This would require addressing the barriers outlined here and repackaging the alleviation of pain as a moral imperative in medical practice. Unfortunately, as it currently stands, “the good of relieving pain is far too invisible/too little recognized” (Tomlinson). The absence of pain management as a healthcare priority is seen at every level of health care delivery. This is most evident in the lack of available National Institutes of Health funding for, or focused on, pain relief. Avoiding patient addiction and abuse, diversion tactics, and clinician self-protection are important parts of this conversation to be sure, but these issues cannot dominate the discussion. Understandably, clinicians may feel that they are walking a tightrope when it comes to pain treatment. They may feel they are in a “damned if they do and damned if they don’t” situation when prescribing painkillers, but as Johnson (2007) observes “unrelieved pain blocks enjoyment of all other human goods and values.” Thus the challenge is how to achieve the social and medical change that will make pain management a fundamental component of health care– for that most fundamental physician duty—to care attentively and equally for all patients.

References:

• Brennan F, Carr DB, Cousins M. Pain Management: A Fundamental Human Right. Anesthesia & Analgesia 2007, ;105(1):205-221. doi: 10.1213/01.ane.0000268145.52345.55.
  http://www.anesthesia-analgesia.org/content/105/1/205.long
• Brody H, Hooked: Ethics, Medicine, and Pharma. Painful to Report: ProPublica Skewers American Pain Foundation. Updated Friday, December 23, 2011. Accessed July 22, 2013. http://brodyhooked.blogspot.com/2011/12/painful-to-report-propublica-skewers.html
• Carrollo K, Deaths from Painkiller Overdose on the Rise, says CDC. ABC News Website Updated November 1, 2011. Accessed July 22, 2013.
  http://abcnews.go.com/Health/prescription-painkiller-overdose-deaths-rise/story?id=14858375#.UdrgU6zNnnE
• Centers for Disease Control & Prevention Website. Injury Prevention & Control – Policy Impact: Prescription Painkillers Overdoses. Accessed July 22, 2013.
  http://www.cdc.gov/homeandrecreationalsafety/rxbrief/
• CDC Vital Signs – Prescription Painkiller Overdoses. Updated July 2013. Accessed July 22, 2013. http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/index.html
• Fishman SM. Recognizing Pain Management as a Human Right: A First Step. Anesthesia & Analgesia 2007;105(1):8-9. doi: 10.1213/01.ane.0000267526.37663.41.http://www.anesthesia-analgesia.org/content/105/1/8.full.pdf+html
• Johnson SH. Legal and Ethical Perspectives on Pain Management. Anesthesia & Analgesia 2007;105(1):5-7. doi: 10.1213/01.ane.0000268148.38688.e7.
  http://www.anesthesia-analgesia.org/content/105/1/5.full.pdf+html
• Rich BA. An Ethical Analysis of the Barriers to Effective Pain Management. Cambridge Quarterly of Healthcare Ethics Published online September 8, 2000. Accessed July 22, 2013. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=46021
• The New York Times Editorial Board, The Opinion Pages – Painkiller Overdoses in Women. The New York Times website. Published July 7, 2013. Accessed July 22, 2013.
  http://www.nytimes.com/2013/07/08/opinion/painkiller-overdoses-in-women.html?_r=0
• Scholten W, Nygren-Krug H, Zucker HA. The World Health Organization Paves the Way for Action to Free People from the Shackles of Pain.Anesthesia & Analgesia 2007;105(1):1-4. doi: 10.1213/01.ane.0000267542.72315.34.
  http://www.anesthesia-analgesia.org/content/105/1/1.full.pdf+html
• Tomlinson, T. Constraints on the Quality of Mercy: Using Opioids to Alleviate Pain. (Personal communication from an unpublished manuscript).

Karen Kelly-Blake, Ph.D., Dr. Karen Kelly-Blake is a Research Associate whose research interests include health services research, medical shared decision-making, physician training, health disparities, and medical school curriculum development. She is a medical anthropologist and MSU alum. Karen also teaches in the CHM Social Context of Clinical Decisions courses.

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