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 decades by 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.
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.
Keywords: Palliative care, titrate-to-effect principle, Washington v Glucksberg, Vacco v Quill