Sullivan MD, Ballantyne JC. The Right to Pain Relief: Its Origins in End-of-life Care and Extension to Chronic Pain Care. Clin J Pain. 2021 Oct 26;38(1):58-63. doi: 10.1097/AJP.0000000000001000. PMID: 34699404.
Objectives: The claim of a right to pain relief was made in recent decadesby pain professionals, courts, and patient advocacy groups and likely contributed to increased opioid prescribing, overdose deaths, and addictions, but the origins and nature of this right have not been investigated.
Materials and Methods: Relevant clinical, ethical, and legal literature concerning patient rights to pain care was reviewed.
Results: The record describes the effort to improve end-of-life and cancer pain care in the 1980s and 1990s, which simultaneously legitimated pain relief as an independent goal of medical care and opioids as a safe and effective means to achieve this relief. In 1997, the US Supreme Court denied the right to assisted suicide but affirmed a right to palliative care to prevent dying in overwhelming pain. Other guidelines and regulations extended this right to pain relief from end-of-life care to chronic pain care, along with the titrate-to-effect principle, which specified that the correct opioid dose was the dose that relieved pain.
Discussion: The most important consequence of combining the right to pain relief with the titrate-to-effect principle was the idea that a high pain score must not be ignored. This extension of the right to pain relief neglected important differences between end-of-life care and chronic pain care including: time frame, clinical setting and context, target of titration, and nature of iatrogenic harms. To help end our current opioid epidemic and prevent a future epidemic, we need to demedicalize pain and reintegrate it with the rest of human suffering as an experience connected to other personal behaviors and meanings.
Key Words: palliative care, titrate-to-effect principle, Washington v Glucksberg, Vacco v Quill
Ballantyne JC, Sullivan MD. Is Chronic Pain a Disease? J Pain. 2022 Oct;23(10):1651-1665. doi: 10.1016/j.jpain.2022.05.001. Epub 2022 May 13. PMID: 35577236.
It was not until the twentieth century that pain was considered a disease. Before that it was managed medically as a symptom. The motivations for declaring chronic pain a disease, whether of the body or of the brain, include increasing its legitimacy as clinical problem and research focus worthy of attention from healthcare and research organizations alike. But one problem with disease concepts is that having a disease favors medical solutions and tends to reduce patient participation. We argue that chronic pain, particularly chronic primary pain (recently designated a first tier pain diagnosis in ICD 11), is a learned state that is not intransigent even if it has biological correlates. Chronic pain is sometimes a symptom, and may sometimes be its own disease. But here we question the value of a disease focus for much of chronic pain for which patient involvement is essential, and which may need a much broader societal approach than is suggested by the disease designation.
Perspective: This article examines whether designating chronic pain a disease of the body or brain is helpful or harmful to patients. Can the disease designation help advance treatment, and is it needed to achieve future therapeutic breakthrough? Or does it make patients over-reliant on medical intervention and reduce their engagement in the process of recovery?
Sullivan MD, Sturgeon JA, Lumley MA, Ballantyne JC. Reconsidering Fordyce’s classic article, “Pain and suffering: what is the unit?” to help make our model of chronic pain truly biopsychosocial. Pain. 2023 Feb 1;164(2):271-279. doi: 10.1097/j.pain.0000000000002748. Epub 2022 Aug 15. PMID: 35972469; PMCID: PMC9840653.
The biopsychosocial model (BPS) of chronic pain aspires to be comprehensive, incorporating psychological and social factors omitted from biomedical models. Although psychosocial factors are viewed as highly influential in understanding behavioral and psychological responses to pain, these factors are usually viewed as modifiers of biological causes of the experience of pain itself, rather than as equal contributors to pain. To further advance the BPS model, we re-examine a classic 1994 paper by Wilbert “Bill” Fordyce, “Pain and suffering: what is the unit?” In this paper, Fordyce suggested that pain-related disability and suffering should be viewed as “transdermal”, as having causes both inside and outside the body. We consider Fordyce’s paper theoretically important because this concept allows us to more fully break free of the medical model of chronic pain than customary formulations of the BPS model. It makes it possible to place psychological and social factors on an equal footing with biological ones in explaining pain itself and to remove distinctions between pain mechanisms and pain meanings. The brain’s salience network now offers a platform on which diverse influences on pain experience—from nociception to multisensory indicators of safety or danger—can be integrated, bridging the gap between impersonal nociceptive mechanisms and personal meanings. We also argue that Fordyce’s article is practically important because this concept expands the BPS model beyond the bounds of the clinical encounter, opening the door to the full range of social, psychological, and biological interventions, empowering patients and non-medical providers to tackle chronic pain.
Sullivan MD, Ballantyne JC. Understanding the Risks of Long-Term Opioid Therapy for Chronic Pain. Am J Psychiatry. 2022 Oct;179(10):696-698. doi: 10.1176/appi.ajp.20220592. PMID: 36181333.
What is our final lesson about prescription opioid use, misuse and POUD risk? Opioid misuse and POUD risks do not only arise from patient misbehavior or improper intentions. They are intrinsic to opioids and the roles they play in the human brain. We learned this lesson about opioid overdose risk a decade ago. While initial studies of opioid overdoses in West Virginia pointed toward drug diversion and doctor shopping as the causes of opioid overdose(26), subsequent studies showed that opioid overdose risk was strongly related to the prescribed dose of opioids.(27) This showed that overdose was an inherent risk of opioids and not simply related to patient misbehavior. Now we must learn a similar lesson about opioid misuse. Endogenous opioids evolved to modulate both physical pain and social pain to promote human survival.(28) It is not possible for laws or diagnostic criteria to pull these apart into entirely separate categories of legitimate opioid use for pain relief and illegitimate opioid misuse for mood relief.
Sullivan MD, Ballantyne JC, Questioning the right to pain relief and its role in the opioid epidemic, Mayo Clin Proc, in press
The new discipline of palliative care helped to establish the right to pain relief at the end of life and the necessity of using opioids to achieve that goal. Professional pain organizations followed the United Nations’ model for universal human rights in their declaration of a universal right to pain management. Both palliative care and pain medicine worked to establish pain as a legitimate focus of medical treatment separate from its association with disease. Pain intensity became the metric used to determine the need for treatment and the success of that treatment. Opioids were favored as the most reliable and feasible means to reduced pain intensity. The Harrison Act of 1914 restricted legitimate opioid use to that prescribed by medical professionals as analgesics. This helped establish opioids as specific painkillers that had a distinct capacity to induce addiction. This understanding of opioids as having distinct and separable analgesic and addictive potential was challenged by the 1970s discovery of an endogenous opioid system, which integrates pain and reward functions to support survival. Our modern pain neurophysiology still follows Descartes in separating a passive impersonal receptive phase of nociception from a more active personal interpretive phase of pain perception. This places the patient with pain in a passive position from which it make sense to assert a right to pain relief. To prevent future opioid epidemics we need to: abandon clinical outpatient use of pain intensity scores and redefine the medical necessity of pain treatment as less about the reduction of pain intensity with opioids and more about the capacity to pursue personally valued activities.