In this presentation, I ask: what duties do we have to patients with chronic pain? I examine the case of Daniel, a 48-year-old man with chronic back, neck and head pain after a motor vehicle accident 8 years previously. I argue that 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.

1. 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
“I am not seeking out drugs, I am seeking relief.”

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…

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:
205-221;
– “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. Pend
Oreille
WWhhaattccoomm
LLeewwiiss 291
263
MMaassoonn
CCoolulummbbiaia
GGaarrffiieelldd
302
San Juan
207
Kitsap
226
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



Adams
24125
32787
Clallam
Jefferson 231
Grays
Harbor
279
274
Pacific
Skagit 253
Snohomish
251
King
210
Pierce
Cowlitz
273
227
Thurston
Clark
237
Skamania
238
Klickitat
Yakima
Kittitas
218
Chelan
252 Douglas
249
240
Grant
Okanogan
252
Ferry
273
Stevens
Pend
Oreille
268
Spokane289
Lincoln
210
Whitman
Franklin
257
272
Benton
222
Walla Walla
Asotin
227
Wahkiakum
261
284
Island
210
136
282
249
299
227
269
DOH 630-126 May
2017 Statewide tables &
maps
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