Ethical challenges in the management of chronic nonmalignant pain: Negotiating through the cloud of doubt

After successful cancer pain initiatives, efforts have been recently made to liberalize the use of opioids for the treatment of chronic nonmalignant pain. However, the goals for this treatment and its place among other available treatments are still unclear. Cancer pain treatment is aimed at patient comfort and is validated by objective disease severity. For chronic nonmalignant pain, however, comfort alone is not an adequate treatment goal, and pain is not usually proportional to objective disease severity. Therefore, confusion about treatment goals and doubts about the reality of nonmalignant pain entangle therapeutic efforts. We present a case history to demonstrate that this lack of proportionality fosters fears about malingering, exaggeration, and psychogenic pain among providers. Doubt concerning the reality of patients' unrelieved chronic nonmalignant pain has allowed concerns about addiction to dominate discussions of treatment. We propose alternate patient-centered principles to guide efforts to relieve chronic nonmalignant pain, including accept all patient pain reports as valid but negotiate treatment goals early in care, avoid harming patients, and incorporate chronic opioids as one part of the treatment plan if they improve the patient's overall health-related quality of life. Although an outright ban on opioid use in chronic nonmalignant pain is no longer ethically acceptable, ensuring that opioids provide overall benefit to patients requires significant time and skill. Patients with chronic nonmalignant pain should be assessed and treated for concurrent psychiatric disorders, but those with disorders are entitled to equivalent efforts at pain relief. The essential question is not whether chronic nonmalignant pain is real or proportional to objective disease severity, but how it should be managed so that the patient's overall quality of life is optimized. The management of chronic nonmalignant pain is moving from specialty settings into primary care. Primary care providers need an ethical framework within which to adopt the principles of palliative care to this population.