Category: Medical ethics & standards

I am republishing these “Principles of Opioid Management of Pain“, by Dr. Joel Hochman, et al., because of the explosion of deeply flawed and misguided “Guidelines” for pain management in recent years. This document stands alone in meeting the (textbook, ‘responsible physician’) standard for pain management while not violating core ethical obligations of the doctor-patient relationship and is useful, I think, for comparison when studying promulgated Guidelines. [See also: The Distortion of Medicine and Confusion of Standards]

Excerpt: “Dr. Mangino has been unjustly prosecuted and convicted in Pennsylvania. His case is unusual. He is currently incarcerated at SCI-Cresson… Essentially, in PA and nationwide, if this conviction is allowed to stand on the grounds presented by prosecution, then any single opioid prescription can be deemed illegal.” — Dr. Mangino

“The practice of medicine IS the practice of harm reduction. It is a fundamental principle of medical care that the patient has the right to disagree, to be non-compliant, to choose a path or a goal other than the one we might desire for them. The physician’s job is to do everything possible to help such a patient do the best he can, to minimize harm since, at least temporarily, it cannot be eliminated. Only in addiction medicine is it insisted that patients and staff hew to a ‘philosophy’ of ‘total abstinence’ rather than support appropriately individualized goals.”

In pain medicine we have the deeply disturbing situation that what most doctors do (medical community norm) is at odds with, and clearly below, the medical standard of care. Literally, in the treatment of chronic pain, an ethical physician attempting to practice in good faith, according to the clinical literature, is an outlier deviating from how most reputable physicians would practice.

Many physicians are concerned that prescribing opioid analgesics in chronic pain treatment is accompanied by an unacceptable risk of unwarranted prosecution. The validity of this fear is evaluated by examining the standards through which physicians are targeted and prosecuted. Prohibition law is identified as an error in social policy that distorts medical standards.

Experts: Untreated pain as serious a problem drug abuse. By Tristan Scott of the Missoulian. With the specter of prescription drug abuse looming large, health care workers stressed Friday that untreated pain in Montana is a public health crisis commensurate to that of addiction.

It seems to me an uncivilized and insane notion that just because someone in current moderate to severe pain had a history of an alcohol or drug problem, or even a current substance abuse problem, that you would deny them opioid therapy if that was the best medication to relieve their suffering. But this seems to be a point of confusion that increasingly comes up from patients, doctors, and regulators alike. So, in this post, let me make the medical standard of care in this situation perfectly clear. [...]

Academic quality, fully footnoted, article on why untreated or undertreated chronic pain is a medical emergency.

The nonprofit Pain Relief Network (PRN) says the guidelines for prescribing narcotics, written by the Washington state Department of Health and published in March 2007, have influenced pain treatment across the country and have made doctors afraid to give opiate prescriptions. Siobhan Reynolds, PRN president, says the group decided to target WA because the state has been a leader both in pain treatment and in restricting doctors’ prescriptions of pain relief medication. [...]

Press release from the Competitive Enterprise Institute regarding their Politics of Pain initiative, and video interviews with combat vet chronic pain patient James Fernandez, and with Dr. Alex DeLuca of the Pain Relief Network. CEI Calls for End to DEA Harassment of Pain Doctors.

This Resource Is an article by Dr. Frank Fisher published in the Harvard Medical Alumni Bulletin. He recounts his tale of persecution for practicing excellent pain management – a quintessencial example of the War on Doctors and the Pain Crisis in America.

This Resource Is a peer-reviewed analysis of Gonzalez v Oregon. “If the U.S. Attorney General had won this case, DOJ, through the DEA, would have been given the authority to make decisions about the legality of prescriptions in all situations, not just end-of-life care.” After analyzing the Supreme Court decision, Brushwood reviews DEA identification of physicians and pharmacists despite information obtained from a Freedom of Information Act by Joranson documenting DOJ knowledge of massive theft and loss of controlled substances having nothing to do with the doctor – patient relationship. He also reviews the DEA FAQ debacle, the “Myth of …

Talk given by Frank Fisher, M.D.; Drug Cops and Docs, Cato Institute Conference; 2005-09-09. Introduction — The undertreatment of chronic pain is an ongoing public health disaster. The means to reverse this disaster is a class of medications known as opioid analgesics. The pain crisis exists for just one reason. Physicians don’t prescribe enough of these medications. I’m going to explain why we don’t. — The war on drugs has become a war on legal drugs. This exposes physicians to the risk of unwarranted prosecution. In response to this threat, the academic pain establishment has developed a set of standards …

Excellent article by Dr. Forest Tennant explaining and demystifying chronic opioid therapy for chronic pain.

This Resource Is an article discusses the failure of the ‘barriers to pain care’ literature to analyze those barriers from an ethical POV. The author relates this to ‘the collective failure of the profession to recognize the ethical implications of undertreated pain.’