The Bioethics of Pain Management

Beyond Opioids

Daniel S. Goldberg

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317753582
• Edition: 1
• Topic: Philosophy
• Subtopic: Ethics & Moral Philosophy

In this book, public health ethicist Daniel S. Goldberg sets out to characterize the subjective experience of pain and its undertreatment within the US medical establishment, and puts forward public policy recommendations for ameliorating the undertreatment of pain. The book begins from the position that the overwhelming focus on opioid analgesics as a means for improving the undertreatment of pain is flawed, and argues instead that dominant Western models of biomedicine and objectivity delegitimize subjective knowledge of the body and pain in the US. This general intolerance for the subjectivity of pain is part of a specific American culture of pain in which a variety of actors take part, including not only physicians and health care providers, but also pain sufferers, caregivers, and policymakers. Concentrating primarily on bioethics, history, and public policy, the book brings a truly interdisciplinary approach to an urgent practical ethical problem. Taking up the practical challenge, the book culminates in a series of policy recommendations that provide pathways for moral agents to move beyond contests over drug policy to policy arenas that, based on the evidence, hold more promise in their capacity to address the devastating and inequitable undertreatment of pain in the US.

Section IV Towards Ethical, Evidence-Based Pain Policy

DOI: 10.4324/9781315797458-11

In the Introduction, I argued that the Renaissance humanists were early translational researchers. The term “translation” is something of a catchphrase in academic medicine and science these days, emphasizing the need to translate the knowledge produced via scientific and clinical research into practices that will benefit individuals and communities.¹

The translational question lies at the heart of this project. The undertreatment of pain in the U.S. is not a function of insufficient technical knowledge and capacity. If so, it follows that the problem is at its root one of translation. This is one reason why a health humanities approach is particularly well-suited to analysis of the problem. However, mere analysis of the problem is inconsistent with the ethos of practical engagement embodied by the humanists. As worthwhile as it might be to identify some of the primary social and cultural factors in the undertreatment of pain, a health humanities approach demands more. The evidence must be translated into a way that practically engages the nonacademic world. There are many media for doing so; the one I utilize in this final section is public health policy. Why choose policy? Policy by definition affects a multiplicity of communities and persons, and has the potential to change behavior across and within various sectors. For such reasons, policy development is widely regarded as a core function of public health in the U.S.² Under the best of circumstances, policy can have a broad impact on shaping a society’s collective answer to Aristotle’s foundational question, “how shall we live?”

In this chapter and the one that follows, I bring together the various strands of analysis and disciplinary tools I have been working with into a bundle of public health policies that incorporate in their structure key ideas related to the meaning of pain in the U.S. However well-intentioned, currently, dominant policy approaches leave out such an assessment, and as such, are not tailored to the root social and cultural causes that drive the undertreatment of pain. While I have mentioned this problem throughout my analysis, this chapter is devoted to a focused assessment of some of the dominant approaches to ethical pain policy. In highlighting the strengths and weaknesses of these policies, I will contextualize my own pain policy recommendations, which follow in Chapter 8 (this volume).

7 Opioids and Pain Policy

DOI: 10.4324/9781315797458-12

INTRODUCTION

In this chapter, I lay out and criticize what I perceive as the dominant policy approach to pain, which centers on the opioid regulatory scheme. My criticisms do not necessarily arise from a fundamental disagreement with the objectives of this approach, but rather from the evidence that it has had little measurable impact on the undertreatment of pain in the U.S. I then provide a brief analysis, picking up on themes and arguments advanced in the first five chapters, of why the dominant policy approach is deficient.

In thinking about pain and its treatment, we see at least two major public health problems: prescription drug misuse and the undertreatment of pain. While this book has focused largely on the latter, there is no doubt that the former is an enormous problem, and the statistics are in their own way almost as staggering as those regarding the inequitable undertreatment of pain. According to the Center for Disease Control (CDC), drug overdose fatalities have increased annually for the last 11 consecutive years, from 16,849 deaths in 1999 to 38,329 in 2010. Sixty percent of these deaths involved pharmaceutical drugs, with 75 percent of pharmaceutical-related deaths resulting from opioids.

Yet my principal argument in this chapter, and indeed, in this book, is that these are in fact distinct public health problems. In the U.S., well-intentioned stakeholders have proceeded to conflate the problems, apparently believing that if we resolve our difficulties in managing the safe and effective utilization of opioid analgesics, we will substantially resolve our problems in treating pain. This is error. Both of these issues are serious public health problems, but they are not the same problem. We will not resolve the undertreatment of pain in the U.S. by striking the right balance in the management of opioid analgesics, regardless of whether that balance tilts in favor of liberalization or restriction of their availability. This chapter is devoted to explaining why this is so, and hence why I eschew an approach that focuses on opioids. Attention to both problems is certainly justified, but in this book, I am squarely focused on the undertreatment of pain.

At the outset, it is useful to lay out the state-of-the-art regarding the safety and efficacy of opioids for the treatment of pain. As there is reasonable evidence that long-term usage opioids for pain may be only marginally effective for a general population of pain sufferers, this undermines further the notion that liberalizing access to opioids will dramatically improve the undertreatment of pain.

Finally, I end the chapter by surveying some of the issues related to the meaning of opioids in American society. This general lack of an assessment of the meaning of opioids is an additional deficiency in the dominant policy approach. Even if I am mistaken and the opioid regulatory regime is critical to improving the treatment of pain, attempts to reshape and correct the policy scheme are unlikely to have significant impact if they are divorced from a deep understanding of the meaning of opioids. Although I do not provide such an analysis here because I ultimately remain unconvinced that such an approach is central to improving the undertreatment of pain in the U.S., I nevertheless close the chapter by sketching some features of what such an account might look like. This last segment of the chapter addresses some of the furor over the prosecution of opioid prescribers, which far and away generates the lion’s share of the focus on the undertreatment of pain in the U.S. Such focus is unjustified, not because it is irrelevant to the culture of pain, but rather because it is unlikely to improve the undertreatment of pain in the U.S.

THE DOMINANT POLICY APPROACH TO PAIN: BALANCE IN OPIOID REGULATIONS

There is exactly one entity in the U.S. specifically devoted to pain policy that is expressly housed at an academic medical center: the Pain & Policy Studies Group (PPSG), affiliated with the University of Wisconsin Paul B. Carbone Cancer Center. For over 20 years, the PPSG has dominated academic and political discussions of pain policy in the U.S.

Since 1997, the PPSG has produced several editions of two documents whose influence on pain policy can barely be overstated. These documents are the “Achieving Balance” reports, which include a “Progress Report Card” and an “Evaluation Guide” containing profiles of each U.S. state and the federal government. The criteria for evaluation center on the government entity’s compliance with the guiding principle of the PPSG, which is “balance” in regulation of opioid analgesics.³ “Balance” is sought between the legitimate law enforcement aim of preventing the abuse and diversion of powerful narcotics like opioids, and the key role opioid analgesics play in the effective treatment of pain.⁴ As stated in the Introduction (this volume), it is perfectly appropriate to seek balance in public health policy of any kind, and the PPSG documents are valuable tools in this endeavor.

However, there are significant limitations to the PPSG approach. The first major problem is the unstated assumption that achieving balance in opioid policy is the primary means of improving the undertreatment of pain in the U.S. The reason this assumption is problematic is because a focus on opioid policy leaves opaque the role that social and cultural beliefs, attitudes, and practices regarding the meaning of pain play in its undertreatment. The example I provided in the Introduction (this volume) noted the tendency of elderly persons in the U.S. to underreport their pain, which is a significant barrier to effective treatment.⁵ There is little reason to believe that achieving balance in the opioid regulatory scheme will remedy this problem.

Second, a focus on opioid policy inevitably centers on the opioid prescriber, which in the U.S., is exclusively the physician. This is a serious problem because common attitudes, practices, and beliefs about the meaning of pain are part of a cultural frame shared by pain sufferers, caregivers, and nonphysician health care providers (of which elderly populations tending to underreport their pain is an excellent example). Focus simply on the prescribers obscures the larger contexts that deeply influence practices and beliefs towards pain and its treatment. Thus, for example, pain sufferers frequently join physicians in the attempt to objectify their own pain, self-stigmatize, and doubt the pain talk of fellow pain sufferers.

Third, the efforts to achieve balance in the opioid regulatory scheme typically do not explain or account for the reasons why opioid policy has historically been and remains unbalanced in the U.S.⁶ That is, to reconfigure opioid policies in ways that come closer to an ideal state of balance, it seems important to tailor these efforts to address the root causes that have driven the imbalance in opioid policy. Policy that is not so tailored is unlikely to have the practical effect intended or hoped for, and is in my view a central reason why the best efforts of the PPSG and its allies do not seem to have had the expected and hoped-for impact as of the current date. C. Stratton Hill, Jr., a retired cancer physician and pain specialist who has been advocating for improved pain treatment for over three decades, maintains that an approach that focuses almost exclusively on tweaking the regulatory scheme is simply doing what was tried over 30 years ago, with little success.⁷

Why does the PPSG’s approach to pain policy focuses almost exclusively on the opioid regulatory regime? On one level, the answer is obvious: for centuries if not millennia, opioids have been a frontline therapy for the effective treatment of many kinds of pain. Yet other factors likely contribute, and do so in important ways. For example, Richard deGrandpre coined the phrase “behavioral pharmacologism” to refer to the American tendency to see health problems primarily if not exclusively in context of pharmaceuticals.⁸ That this behavior is encouraged by the pharmaceutical industry is also beyond dispute. In context of pain, this operates to shape policy discourse at the highest levels, such that even well-intentioned groups like the PPSG tend to see the problem of and potential solutions to the undertreatment of pain primarily in terms of the availability of pharmaceutical drugs.⁹

There is little question that opioids remain relevant for treating pain today, but an increasing body of evidence suggests that the efficacy of opioid analgesics for different kinds of pain is uncertain at best. If this evidence is legitimate, it obviously suggests a fourth reason for contending that an undue policy focus on opioid regulation is unlikely to substantially improve the undertreatment of pain: opioids themselves, however important, are not even the clinical answer to the undertreatment of pain. Examining this evidence briefly is important to thinking about the strengths and weaknesses of the “balance” approach.

EVIDENCE RELATED TO THE USE OF OPIOIDS IN TREATING PAIN

The present state of the art regarding the use of opioids for treating pain is in flux. There is little question both that opioids remain an important therapy and that the total volume of opioid dispensation has increased dramatically over the last two decades. Such an increase has coincided with a dramatic increase in the total number of fatalities attributed to prescription drugs, and although there are likely myriad reasons for the latter, it strains credulity to deny any causal connection between the liberalization of the opioid regime and the significant increase in deaths and other adverse drug events. Given the significant public health risks, there is reason for demanding significant evidence of clinical benefit for the utilization of such opioids.

Yet Deshpande et al. observe that despite the fact that the use of opioids … remain[s] a controversial issue in the management of chronic non-cancer pain, and chronic [low-back pain] in particular, there is a steadily growing trend toward prescribing opioids for the management of [chronic non-cancer pain]. Market data indicate that since 2000, long- and short-acting opioids experienced a 26.5 percent and 39 percent compounded annual growth rate, respectively.¹⁰

The controversy over the extent of the efficacy of opioids for chronic nonmalignant pain seems to have grown concomitant to its usage.¹¹ In their systematic review of the efficacy of opioids in improving pain or function in persons with chronic low-back pain,...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Table of Contents
• List of Figures
• Acknowledgements
• Preface
• Introduction: The Power of the Visible and the Undertreatment of Pain in the U.S.
• Section I The Lived Experience of Pain
• Section II History, the Power of the Visible, and Pain
• Section III Ethics, Subjectivity, and Pain
• Section IV Towards Ethical, Evidence-Based Pain Policy
• Conclusion
• Afterword
• Index