The Ethics of Patient Selection for Opioid Management for Pain

Moral change in social behavior only comes when we are able to see the ethical implications of the behavior in a new light and as a consequence we are moved to act differently. This general statement seems especially true when the ethical implications of a social behavior have been heretofore under-appreciated. In such situations, a change in ethics requires that we first raise awareness of the implications of our behavior. In so doing, we foster an understanding that our behavior has ethical consequences when, perhaps, we had previously thought that our behavior had no such ethical implications at all.

A recent example in our everyday life is the movement to ‘go green.’ We now have the opportunity to make a variety of choices about home goods, office products, the cars and food we buy, and even our choice of office buildings to lease. We may or may not make such ‘green’ choices, depending on different circumstances, but we do so in the knowledge that our choices make some difference to our environment and climate, whether for good or ill. Few among us had previously considered the ethical dimensions of such goods and services, but we do now because we have come to see the ethical implications of our consumer choices in a new light. In other words, once we have come to understand the ethical implications of our previous consumer choices, we now have the opportunity to change our behavior and foster positive ethical change.

For those of us who are either providers or patients in the field of chronic pain management, we face a similar newfound appreciation of the ethical implications of long-term opioid management, one which leads us to an opportunity for positive ethical change. We might safely assume that for many years the field considered the alleviation of pain and suffering as a social good and by extension had considered the practice of long-term opioid management as something that brings about this social good. Indeed, it has been commonplace to consider the practice of long-term opioid management for chronic pain as unquestionably the ethically right thing to do. This understanding is now, however, giving way to a re-conceptualization of the practice, particularly in light of the present epidemics of prescription opioid addiction and overdose (Compton & Volkow, 2006; Sullivan & Howe, 2013).

The last decade and a half of research on the practice of long-term opioid management has shed light on how the epidemics of addiction and overdose has arisen. What the research shows is that we have not been providing long-term opioid management to all patients with chronic pain, but only to a select few, and these few, as it turns out, are the most vulnerable to the adverse consequences of addiction and overdose. Dubbed “adverse selection” (Sullivan & Howe, 2013), long-term opioid management has settled into a practice of providing the most addictive medications to those who are most vulnerable to addiction and emotional distress: those patients with chronic pain who also have had past or present histories of either mental health problems or substance dependence or both.

This finding brings with it the opportunity to raise our consciousness about the ethical implications of this practice: in our intentions to bring about a social good – the alleviation of pain and suffering, we have in fact brought about an altogether different form of pain and suffering in the form of addiction and overdose. We must therefore re-evaluate the practice of long-term opioid management.

This realization will no doubt be difficult to achieve on a wide-scale basis. The practice of long-term opioid management has for so long been unquestionably assumed to be a social good. It continues to have many proponents to this day. Let us therefore review the research in some detail to determine for ourselves how we might arrive at a newfound appreciation of its adverse ethical implications.

Who receives long-term opioid management for chronic pain?

Providers and patients who advocate for the practice of long-term opioid management are often surprised to learn that most people with chronic pain do not manage their pain with opioid medications. Breivek, et al, (2006) found in an epidemiological study of European countries that 19% of the general population had chronic pain. In further follow-up interviews of those with chronic pain, they found that 5% take long-acting opioids and 23% take short-acting opioids. In a later study, Fredheim, et al., (2014) found that only 15% of people with chronic pain used opioids to manage their pain. Among those reporting their pain as severe or very severe, 11% used opioids. In the United States, the rate of opioid use among patients with chronic pain is similar. Toblin, et al., (2011) found that a quarter of the population has chronic pain. Among people with chronic pain, they found only 15% using prescription opioids to manage their pain. Importantly, a very large majority of all those with chronic pain, even the 85% of them who were not taking opioids, were satisfied with the way they were managing their pain (Toblin, et al., 2011).

Even among patients who are readily offered opioid management on a long-term basis, most of them will voluntarily stop using opioids even though they remain in pain (Fredheim, et al., 2013; Gustavsson, et al., 2012).

What these studies show is that the vast majority of people with chronic pain do not take opioid medications to manage their pain.

Numerous studies consistently show that patients who remain on long-term opioid management are those who, on average, have significantly higher rates of mental health and substance abuse problems (Breckenridge & Clark, 2003; Hojsted, et al., 2013; Jensen, Thomsen, & Hojsted, 2006; Mallen, et al., 2007; Sullivan, et al., 2006; Thomas, et al., 1999). As the data above suggests, this subset of people with chronic pain is small and is not representative of all people with chronic pain. Their co-occurrence of chronic pain with mental health or substance dependence problems suggests that they have struggled to cope with different aspects of life prior to or concurrent with the onset of pain. As such, they now struggle to cope with the additional problem of chronic pain and come to rely on opioids at a much higher rate than those people with chronic pain who do not have such additional problems.

The co-occurrence between chronic pain and mental health or substance dependence problems are highly associated with addiction to prescription opioids (Ives, et al., 2006; Turk, Swanson, & Gatchel, 2008; Wasan, et al., 2007). With an empathetic view, we can see why: the field of chronic pain management has settled into a pattern of providing the most addictive medications to the most vulnerable subset of people with chronic pain – those who also have mental health and/or substance dependence problems.

(Now, to be sure, any aggregate data admits of counter examples. So, the reader, here, might readily be able to acknowledge someone in their life, either personally or professionally, who may have chronic pain, take opioids on a long-term basis, and have no history of a mental health or substance dependence problem. However, the occurrence of a counter-example does not disprove the more general finding that, on average, those who come to rely on the long-term use of opioids to manage chronic pain have higher rates of mental health and/or substance dependence problems than the majority of people with chronic pain who cope with their pain well and without opioids.)

The field has thus fallen into a pattern of providing long-term opioid management to only a select minority of people with chronic pain. This select minority are those people with chronic pain who are most susceptible to addiction and emotional distress. Meanwhile, we are witnessing epidemics of prescription opioid addiction and overdose. While correlation, of course, does not prove causality, it seems against any reasonable odds that the addiction and overdose epidemics are coincidental to the rise of long-term opioid management as it is practiced today.

A false dilemma

In the debate over the practice of long-term opioid management for chronic pain, many commonly assume that large-scale pain and suffering will result if the field curtails the practice. The assumption leads to a seemingly impassable dilemma: with the practice of long-term opioid management, we have epidemic levels of prescription opioid addiction and overdose; without the practice of opioid management, we will have large-scale pain and suffering.

Here is where the epidemiological data cited above is so important. The data shows that the majority of people with chronic pain, even moderate to severe chronic pain, do not use opioids to manage their pain. We know that they are not suffering because the vast majority of these people report that they are satisfied with the ways they are managing pain. In other words, the norm for those with chronic pain is not one of wide-scale suffering. The norm is that people with chronic pain cope well without long-term opioid management. Thus, the dilemma is really a false dilemma.

The ethics of long-term opioid management in a new light

We might therefore assert that it’s unethical that we relegate long-term opioid management to the most vulnerable subset of those with chronic pain – those people with chronic pain who have comorbid mental health and substance abuse problems. These patients are the most susceptible to prescription opioid addiction and overdose. We do not alleviate their pain and suffering through the use of long-term opioid management. Indeed, we may just be adding to their pain and suffering.

Our field of chronic pain management thus needs a new moral calling for the alleviation of pain and suffering (at least as it regards what is truly incurable, chronic pain). We must recognize that the majority of people with chronic pain do not manage their pain with opioid medications on a long-term basis. They are not suffering, for they cope well with their pain and are satisfied with their pain management. This recognition puts into a new light the nature of the problem of those who are suffering. They are the people with chronic pain and co-occurring mental health and substance dependence problems. They are the people with chronic pain who have struggled to cope and as a result have come to be reliant on the long-term use of opioids as a substitute for effective coping. Our new moral calling should be to help them learn how to cope well with chronic pain – in the ways that those who self-manage pain already do. This therapeutic goal – what is essentially a rehabilitation goal – is the ethically right thing to do. What’s not the right thing to do is to continue the widespread practice of maintaining the most vulnerable subset of people with chronic pain on a poor substitute for good coping -- the most addictive pain medications available.

Author

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain. The Institute for Chronic Pain is an educational and public policy think tank. Its purpose is to bring together thought leaders from around the world in the field of chronic pain rehabilitation and provide academic-quality information that is approachable to all the stakeholders in the field: patients, their families, generalist healthcare providers, third party payers, and public policy analysts. Its aim is to change the culture of how chronic pain is managed through education and consultation efforts that advocate for the use of empirically supported conceptualizations and treatments of chronic pain. Dr. McAllister also blogs at the Institute for Chronic Pain Blog.

References

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