The Static Pendulum

There has been a significant amount of reactivity in the pain management world since pain was designated the 5th vital sign in 2000. The relationship between pain and the most common approach to treating it, opioid analgesics, has been a pendulum in seemingly constant motion. As mentioned in the previous chapter, the “opioid pendulum” swung towards decreased and more discriminative opioid prescribing to prevent them from being “over-utilized.” Additionally, the overdose epidemic plaguing the United States has continued to grow, with record numbers of drug overdose fatalities each year. The relationship between these two phenomena has created several dilemmas for clinicians, including fear of regulatory scrutiny for “inappropriate” or “excessive” opioid prescribing, potential stigmatization regarding concerns about being labeled as a “high prescriber”, confusion with respect to educational initiatives and regulatory guidelines or recommendations about opioid prescribing, and a lack of consensus about how pain should best be managed, particularly if opioids are considered as a component of the pain treatment plan. Regulatory efforts attempting to mitigate the overdose epidemic have included several “silver-bullet” approaches including requiring states to develop and support Prescription Drug Monitoring Program databases, limiting the quantity of opioids that could be manufactured each year as a way to curb prescribing, and recommending “ceiling doses” of opioid prescribing. Many have voiced concern that these and other similar efforts have created a state of “paralysis” with respect to how pain is treated, which in turn has had significant negative impact on people suffering with pain, particularly those already being treated with opioid analgesics. This chapter explores the reactivity of past and present efforts, and the potential role that ethical analysis can play in helping to provide safer, reproducible, effective, and consistent pain care, helping to facilitate the determination of who might benefit most from the utilization of opioids when appropriate, and who might not.