1. “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

2. Disclosures
Research grants: Pfizer, Purdue
Consulting: Aetna

3. 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?”

4. 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

5. 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…”

6. 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: ;
Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right. Pain 2004:112:1-4.

7. 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

8. 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: ;
“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

9. 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

10. 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!”

11. 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.

12. 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.

14. 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
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 May 2017
Statewide tables & maps