Our Ethical Duty Is to Relieve Pain and Suffering // American College of Emergency Physicians | September 2007 | Andrew Luke Aswegan, MD
This seems so obvious, yet 8 years later, the problem of undertreatment is getting far worse, especially with PROP’s influence in the upcoming CDC opioid prescribing guidelines.
Pain as a presenting complaint accounts for up to 70% of emergency department visits, making it the most common reason to seek health care. Often, it is the only reason patients seek care.
Despite a heightened awareness in recent years, health care providers still fail to treat pain consistently and adequately.
Patients don’t get analgesics early enough, often enough, or in correct dosages. When they are discharged, patients leave with inadequate prescriptions to treat their pain while at home.
This failure to properly alleviate pain stems from clinician barriers such as a lack of knowledge and a reluctance to give analgesics under certain medical conditions or in specific patient populations.
It is the duty of health care providers to relieve pain and suffering.
Therefore, all physicians must overcome their personal barriers to proper analgesic administration.
One of our ethical obligations as physicians is beneficence – “doing good,” or maximizing the best interests of patients. When applied to a specific clinical situation, these benefits are weighed against any risks, which involves the ethical concept of nonmaleficence, or “do no harm.”
By knowing the benefits and risks of medical interventions and treatments, we can provide our patients with pertinent information to maximize their autonomy in making decisions about diagnostic and treatment modalities
The decision to administer pain medications ought to be analyzed by comparing the benefits and risks involved. The obvious benefit of administering analgesics is the relief of suffering. In fact, many believe that the “obligation of clinicians to tend to patients’ suffering is the essence of the medical profession.”
Another benefit is that patients can often give a more accurate and detailed history when their pain is lessened.
Without the negative influence of pain, patients’ capacity for making medical decisions also improves. And, although it was once widely taught that pain control would cloud physical findings, it actually facilitates a more accurate assessment and diagnosis.
Unfortunately, the risks of analgesics are often overestimated.
Regarding opioids, respiratory depression is a concern. Studies, however, have shown that the incidence of serious respiratory depression in these patients is no more than 1%, and that any ensuing respiratory insufficiency may be quickly reversed by naloxone
A bigger concern among physicians is narcotic addiction and dependence.
It is important to realize the difference between the tolerance and physical dependency that develop with chronic opioid use and the development of psychological addiction. Addiction in this sense is uncommon, even in patients treated for chronic pain disorders.
More common and often misunderstood is pseudoaddiction, a term used to describe the iatrogenic syndrome of abnormal behavior that develops as a direct consequence of inadequate pain management.
When pain is consistently undertreated, many patients begin to distrust medical providers and resort to symptom exaggeration and manipulation of the health care system in order to obtain enough analgesics to control their pain. The term pseudoaddiction arose to differentiate these patients from those who display similar behaviors for secondary gains or because of psychological addiction.
So, why aren’t patients receiving adequate pain relief in the ED? One reason is simply lack of knowledge. For instance, the overstated risks of analgesics prevent many physicians from using them in the appropriate circumstances. One study found that over a third of medical personnel believe that patients should experience discomfort prior to receiving the next dose of pain medicine.
Other physicians may not understand the severity of their patients’ pain, whether because of cultural differences, lack of empathy, or simply not believing some patients’ pain reports. These factors have led to a higher incidence of unrelieved pain in minority groups and the elderly.
Also undertreated are patients who abuse street drugs. They inevitably present to the emergency department with painful conditions more often than their healthier counterparts. Because of tolerance, they require higher doses of narcotics to achieve pain relief. Frequently, however, they may receive no narcotic analgesia at all, as the physician may be intent on not getting “duped” into giving opioids to someone who may be trying to supply his/her addiction.
Unfortunately, the prevalence of illegitimate drug-seeking patients presenting to emergency departments is unknown. Without these data, health personnel tend to overdiagnose illegitimate drug-seeking behavior and addiction, especially in patients who frequent the emergency department with exacerbations of chronic pain.
Often, it is simply impossible to make that distinction, and the alternative to unknowingly giving analgesics to some drug seekers is to allow many innocent patients to suffer needlessly.
It needs to be accepted, both on a personal level and by society at large, that we will inadvertently give opioids to some drug seekers with deviant motives as we attempt to treat patients honestly and compassionately.
At this point, some physicians simply refuse to give the patient any narcotics for fear of adding to an addiction or perpetuating the cycle of visits.
Some patients, however, require narcotics for adequate relief of their pain. By not treating them, we jeopardize their autonomy and increase their distrust of the health care system.
As physicians, we need to be strong advocates for our patients, and pain relief is no exception.
For emergency physicians, this is even more pertinent, as most of our patients come to us in their most desperate hour.
When we question whether to give a patient analgesics, it is important to revisit the risks and benefits, keeping in mind that the best predictor of continued patient pain is patients’ verbalization that they are having pain.
Patients should be allowed to make autonomous decisions when appropriate, and the principle of justice guides us to evaluate and alleviate pain in a nonprejudicial and nonjudgmental manner.
Our ethical duty to relieve suffering is clear. If we don’t provide adequate pain relief, we risk losing our patients’ trust, and, ultimately, our patients.