We Need to Help, Not Hurt, Patients
Doctors often wrestle with dilemmas. The profession has tried to establish ethical guidelines for resuscitation and end-of-life care following the desire of the patient.
But when it comes to treating chronic pain, it is even stickier. The patient may want relief of pain with opiates while the doctor feels that these drugs should be withheld or tapered, but then the patient is left in misery and pain. There is a clash between the wish of the patient, our desire to relieve suffering, and our duty to do no harm. In this article, I want to suggest some ways to tease out this conflict and help both the patient and the doctor feel better about doing the right thing, even when that is hard.
Pain is such a powerful behavioral motivator, and everything is tuned towards its alleviation. The stress hormone system is put on alert and manifests as anxiety and insomnia. Attention is tuned toward the pain, with brain and spinal cord components contributing to obsessions, hypersensitivity, and inability to focus on other life goals. Anything analgesic or distracting from pain becomes experienced as reward, sought out, and repeated, so that opiates are intensely reinforced while other reinforcers, such as relationships and family, can pale. Such is the experience of the chronic-pain patient.
As doctors, we want to help. How can we refuse patients the medicines that they feel relieves their suffering? We now know that opiates have limited analgesic role in chronic pain and that overusing opiates can increase disability, decrease functioning, and contribute to another terrible disease — addiction.
It’s important to understand that the drugs of abuse are in this class because they have special qualities. They invoke tolerance, which means the body mounts compensatory responses to their presence that oppose their action. For example, opiates first suppress the stress response, which then rebounds back. On the behavioral level, people can temporarily avoid distress, but there is a rebound, demanding a predictable relief. It’s like throwing a shovel to a man stuck in a pit. They feel helped and can be distracted. The doctor can feel she or he has done something, but really, to what end? At what point, and for whom, will they be the shovel that only helps that patient in the hole dig himself deeper?
Several scales try to estimate risk of losing control of opiates, and doctors must attempt to categorize risk level considering past or present history of addiction (because it is too easy to reawaken a long-dormant beast), family history (because genetics make drugs more compelling and reinforcing), psychiatric history (because emotional pain is also profoundly, and temporarily, relieved by opiates, making them more reinforcing), and disability claims (because we all need incentives to keep us on the track of functioning, especially when that path can brings pain). We can be wrong, because both the question and the answers can be inexact, and because anyone can lose control.
Conversely, many can erect sufficient safeguards and external contingencies to limit drift towards the abyss. But doctors need to see this ongoing assessment as crucial in the process of helping a patient. Is our goal to provide mere instant relief or the overall, long-term well-being of the patient? For that matter, what is our responsibility to public health, to limit the enormous leakage of opiates onto the street, which has contributed to the alarming rise of opiate-related morbidity and mortality?
This is my mentality when I’m with a patient: I am keeping in mind the harm that I could do by prescribing, and trying to act on behalf of the patient. I hear a request for opiates as the conscious tip of the iceberg, and try to dive down to see the motivational forces beneath. It always amazes me that patients welcome this deeper level of concern and caring for their well-being.
Many have already noticed that escalating doses of opiates have not brought satisfaction. They can see they are in a hole and need help to escape. I don’t offer them nothing: there are so many non-opioid approaches to chronic pain, including medications and physical and psychological interventions. We can work together toward meeting deeper recovery goals.
It’s at this point that some patients declare themselves. They are not interested in recovery, but in getting drugs. That is an important diagnosis, with a quite different treatment plan. I will not be facilitating their demise. To me, this is the essence of being a physician: collaborating with the totality of the patient, believing in health and doing no harm.
Dr. Mark Green is a board-certified addiction psychiatrist and founder and principal of the Psych Garden (www.psychgarden.com), an addiction-psychiatry practice providing a variety of consultative and treatment services. This article first appeared in Vital Signs, a publication of the Mass. Medical Society.
