Dilemmas Surrounding Opioid Analgesics and the Treatment of Pain

The relationship between opioid analgesics is often complex, frequently debated by some, often contested by others, ultimately resulting in challenging clinical dilemmas with respect to pain treatment with opioid analgesics. When performing an ethical analysis of the risks and benefits of the use of opioids to treat pain, it is important to remember that while opioid analgesics may facilitate rest, ambulation, and participation in rehabilitation, they usually do not have inherent, direct therapeutic effects on the pathophysiologic causes of pain, they do not directly decrease inflammation, do not promote healing, etc. Since 2010, it is virtually impossible for a debate about the utility of opioids in the treatment of pain that does not involve the drug overdose epidemic our nation faces. Between 2000-2010, most would agree that opioids were liberally utilized by clinicians to treat pain. This was likely the result of a combination of factors, including a lack of education about pain and its management, patient advocacy group efforts to improve the quality of life in patients with pain (such as the American Cancer Society), and a lack of substantial scientific evidence basis of the utility of long-term use of opioid analgesics. This has been further complicated by educational deficits in healthcare professional training about aberrant drug-related behaviors which has sometimes led to inconsistent use of nomenclature, and resulted in mixed messaging and misinterpretation of these behaviors, including misuse, abuse, dependence, and addiction. This chapter will explore these issues, and their potential implications on the treatment of patients with pain and resulting clinical dilemmas currently surrounding the use of opioid analgesics. Additionally, this chapter will discuss the ethics of regulatory efforts designed to mitigate the overdose epidemic which in some cases has dissuaded clinicians entirely from including opioids in their pain treatment armamentarium, detailing how the “opioid pendulum” has been real, impactful, and controversial.