Managing Chronic Pain Through the Cloud of Doubt

Ethical challenges in the management of chronic nonmalignant pain: Negotiating through the cloud of doubt – The Journal of Pain

Chronic pain is further complicated because it involves suffering and ethics. The anti-opioid crowd would rather not contemplate this uncomfortable reality and treat pain as a “mere symptom” of something else or write it off as “psychogenic”.

Cancer pain treatment is aimed at patient comfort and is validated by objective disease severity. For chronic nonmalignant pain, however, comfort alone is not an adequate treatment goal, [why not?] and pain is not usually proportional to objective disease severity

Therefore, confusion about treatment goals and doubts about the reality of nonmalignant pain entangle therapeutic efforts.

We present a case history to demonstrate that this lack of proportionality fostersfears about malingering, exaggeration, and psychogenic pain among providers. 

Doubt concerning the reality of patients’ unrelieved chronic nonmalignant pain has allowed concerns about addiction to dominate discussions of treatment.

We propose alternate patient-centered principles to guide efforts to relieve chronic nonmalignant pain, including

  1. accept all patient pain reports as valid but negotiate treatment goals early in care,
  2. avoid harming patients, and
  3. incorporate chronic opioids as one part of the treatment plan if they improve the patient’s overall health-related quality of life

Although an outright ban on opioid use in chronic nonmalignant pain is no longer ethically acceptable

Yet such a ban after an arbitrary time period (usually 3 months) is exactly what’s being proposed by some parties, like PROP.

ensuring that opioids provide overall benefit to patients requires significant time and skill.

Patients with chronic nonmalignant pain should be assessed and treated for concurrent psychiatric disorders, but those with disorders are entitled to equivalent efforts at pain relief.

The essentialquestion is not whether chronic nonmalignant pain is real or proportional to objective disease severity, but how it should be managed so that the patient’s overall quality of life is optimized.  

If only our legislators, law enforcement, and doctors would see it this way!


3 thoughts on “Managing Chronic Pain Through the Cloud of Doubt

  1. painkills2

    (2004) “Perspective: The management of chronic nonmalignant pain is moving from specialty settings into primary care. Primary care providers need an ethical framework within which to adopt the principles of palliative care to this population.”

    It’s interesting to see the differences in treating pain patients from 2004 and what it looks like now, 11 years later. In 2004, I guess more primary care providers began trying to treat chronic pain and unfortunately weren’t up to the task.

    Although I find it odd that even in 2004, primary care providers were treating chronic pain — that doesn’t align with my own experiences. If you were diagnosed with chronic pain, it was off to the expensive pain specialist for you. So, how did the majority of chronic pain patients get treated by their GP? Because that’s what all the media reports on the opioid “epidemic” indicate. And I find that really hard to believe, even in 2004.

    And now, primary care providers are forcing pain patients to see pain specialists, an expensive avenue of treatment. And one that has caused more damage (i.e., injections and surgeries galore).

    Instead of pain management through interventional methods, it’s obvious to me that palliative care is what’s needed.

    Liked by 1 person

    1. Zyp Czyk Post author

      I agree that we should be turning to palliative care. The difference between that and hospice is only that palliative care doesn’t have an impending death sentence (though, with access to opioids being cut off, we may wish we did).

      I’ve found a few articles suggesting this kind of care – you can find them with the following search:

      It really seems the most appropriate approach to life long treatment of chronic pain.

      Liked by 1 person

      1. painkills2

        To me, palliative care means treating medical conditions that are intractable. To stop forcing pain patients to have expensive treatments that do more harm than good. To stop expecting some kind of cure or that your pain will get better. This is the reality for many pain patients, yet doctors keep treating them.

        And of course, disability insurance forces pain patients to pay for medical care, because if you’re not seeing a doctor regularly, you’re not disabled. If you’re a chronic pain patient and not taking medications for it, you’re not disabled. And if you haven’t tried every single treatment option, you’re not disabled yet.

        Liked by 1 person


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