Pain, Ethics, and Public Policy

Pain Medicine is a journal that has, perhaps more than any other, affirmed the significance and relevance of ethical principles and analysis to competent and compassionate pain relief in clinical practice. It is the only medical journal with a section specifically devoted to ethical issues in pain management. Consequently, we are pleased to be able to include in this issue of the journal an analysis of preliminary data from “The Pain Action Initiative: A National Strategy (PAINS),” a project undertaken by staff members of the Center for Practical Bioethics with support from the Lance Armstrong Foundation, Rx Action Alliance, and Purdue Pharmaceuticals. The article “Defining the Landscape for Chronic Pain Ethics” is for the most part a comprehensive list of what is wrong with pain care, research, and education. The issues raised are not all normative, but rather encompass political, social, and economic factors that have a negative impact on the quality and accessibility of pain care. Nevertheless, the report does provide the background conditions upon which to ground further development and articulation of the ethical issues. As the authors note, remarkably, despite the pervasive perception among these focus groups that ethical issues permeate the range of concerns on chronic pain relief, there is a dearth of articles in the clinical literature on the ethics of pain management—249 in a recent PubMed search, and only 75 when palliative care and basic neuroscience are excluded. It is even more surprising, but worth noting that until very recently, an absence of discussion and analysis of the ethical implications of undertreated pain characterized not only the medical literature but the field of bioethics as well [1]. A key ethical concern expressed in each of the focus groups the authors suggest can best be framed under the bioethical principle of justice. It is interesting that of the four most widely recognized principles of biomedical ethics—respect for patient autonomy, beneficence, nonmaleficence, and justice—the last, and the one least discussed in the bioethics literature and the media, should be featured so prominently. Only within the last 10–15 years has the failure or refusal to relieve pain come to be recognized as unethical, unprofessional, and indeed substandard medical practice [2]. While it can be argued that all patients are at risk of having their pain undertreated, for reasons further elaborated upon in this commentary and the featured article, certain categories of patients, that is, children, the elderly, the indigent and uninsured, certain racial minorities, and those with major chronic co-morbidities, are much more vulnerable to undertreatment of their pain. These concerns reach beyond the simple fact that recognizing pain in patient populations with major communication problems, for example, infants, the demented, the minimally conscious, foreign language speakers in areas where adequate translation services are not available, is clinically challenging. It extends to the fact that the credibility of reports of pain by certain patient populations appears to be frequently called into question [3]. Furthermore, the very nature of pain, and chronic pain in particular, challenges clinicians to attend much more closely to phenomenological, psychosocial, and cultural dimensions of the pain experience [4]. The enemy of this type of patient-centered care, as the focus group stakeholders noted, is the American system of reimbursement for medical care and cost-control considerations that pressure clinicians to minimize the amount of time spent with each patient and prioritizes interventions and prescriptions over interpersonal engagement. Another important point raised in the article is the apparent conflict between two public health crises: undertreated pain versus prescription opioid abuse, addiction, and diversion. Decades ago, national policy declared a “War on Drugs,” similar to other previously declared wars on cancer, poverty, etc. There was, at the time, no recognition of a public health problem of undertreated pain, so it has only been quite recently that anyone has suggested that a national policy was warranted that recognized the need for a commensurately vigorous “War on Pain”[5]. Recently the “War on Drugs” is being waged on a new front as concerns have shifted from so-called “street drugs,” for example, cocaine and heroin, to prescription drugs, for example, oxycontin, hydrocodone, and methadone. Indeed, some commentators have suggested that the recent exponential increase in the abuse of prescription drugs and in deaths from overdoses of these drugs is directly linked to significant increases in prescriptions for opioid analgesics prompted by a still yet to be officially declared “War on Pain”[6]. Looming over the entire area is a critical lack of concrete evidence concerning the long-term risks and benefits of opioid analgesia for chronic noncancer pain [7]. An interdisciplinary panel convened by the American Pain Society and the American Academy of Pain Medicine revealed a striking lack of evidence upon which to support practice parameters for opioid prescribing in the management of chronic noncancer pain [8]. Elements of the Hatch/Dodd Pain Care Policy Act of 2009 are already being implemented. A milestone has just been reached with the recent publication of the report from the Institute of Medicine titled “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research”[9], which will lead to increased support for research, education, and public awareness. Some candor and perspective is important here, however, since many aspects of the usual custom and practice in patient care and pharmacotherapy are not grounded on a scientifically rigorous foundation, but rather are consensus driven. Two other issues raised by the stakeholders in the PAINS project and discussed by the authors are a purported overemphasis among pain medicine practitioners on pharmacological and procedural measures rather than a more holistic approach, and a failure of collaboration and jointly developed pain policy measures of both a strategic and tactical nature. Fragmentation of pain care and the limited skills of physicians taking care of chronic pain patients are still at the heart of poor health care delivery of pain treatment in the United States. Very few health care professionals see the patient as a whole person with not just a particular diagnosis, but also a unique illness experience. Even when they do, the implementation of an integrated interdisciplinary treatment plan in the present health care system is challenging, if not impossible. For those who have been involved with or concerned about the plight of patients with pain, particularly chronic noncancer pain, there is a certain déjà vu quality to the results of these focus groups [10,11]. Rather than identifying new barriers or suggesting novel approaches to bringing them down, they tend to reaffirm what has been maintained for some time now about the sources of the problems and the changes that are necessary to solve them. Indeed, for those with even a slight tendency toward pessimism, there is little in the article that is likely to undermine that tendency. The increasingly strident calls by some that the pendulum has already swung too far from an epidemic of underprescribing to an epidemic of overprescribing of opioids for chronic pain, and the insistence that a prescribing professional's duty to minimize drug addiction, abuse, and diversion in the larger society is professionally and ethically commensurate with the duty to relieve their patient's pain pose new challenges for those who strive to relieve the suffering of patients associated with persistent pain.