“I am not seeking out drugs, I am seeking relief.” 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

Disclosures Research grants: Pfizer, Purdue Consulting: Aetna

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?”

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

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…”

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… Brennan F, Carr DB, Cousins M, Pain Management: a fundamental human right, Anesth Analg, 2007; 105: 205-221; Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right. Pain 2004:112:1-4.

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

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

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

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!”

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.

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.

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   227 WWhhaattccoomm  San Juan 207 Pend Pend Okanogan 252 Ferry 273 Oreille Oreille Skagit 253 282 Island 210 299 Clallam Stevens 261 Snohomish 251 Chelan 252 Jefferson 231 Douglas 249 268 Spokane Kitsap 226 289 Lincoln 263 MMaassoonn King 210 Grays Harbor 279 240 Grant 249 Kittitas 218 227 Thurston Pierce Adams 24125 210 Whitman 274 Pacific LLeewwiiss 291 Franklin 257 GGaarrffiieelldd 302 Yakima 227 Wahkiakum CCoolulummbbiaia 32787 Cowlitz 273 269 272 Benton 222 Walla Walla Skamania 238 284 Asotin 136 Clark 237 Klickitat DOH 630-126 May 2017 Statewide tables & maps