AMA Journal of Ethics^®

In the residents’ lounge at the University of Kentucky, there is a scrap of paper posted on the wall with a haiku scribbled on it: “Drug-seeking patients / You will get NONE of your candy / When I am on call.” It’s unknown how long the sign has been up, but concerns about pain and pain relief have a long standing in medicine. Evidence of fossilized opium has been found in the remains of our earliest hominid ancestors, and narcotics are mentioned liberally throughout the Homeric epics. In our own day and age, more than 100 million Americans experience the debilitations of chronic pain. So, when confronted with such a massive problem, why all the cynicism?

Part of this lies in the mysterious and ambiguous nature of pain. We inherit the word “pain” from the Romans, who viewed it as a punishment for moral failure. Over the years, we have deemphasized that aspect in favor of more scientific explanations. In 1975, the International Association for the Study of Pain finally defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” [1]. Despite this consensus, the biology of pain remains poorly understood, and options for the treatment of pain remain frustratingly inadequate.

This issue of Virtual Mentor highlights the ethical dilemmas that clinicians face when treating patients who experience significant pain. Our authors hail from diverse professional backgrounds; they are legal experts, psychiatrists, family medicine practitioners, and hospital administrators. They bring their individual perspectives to explore and help resolve ethical dilemmas in pain management.

Broadly speaking, the issue is dominated by three themes: (1) the differing perceptions of pain, (2) the inadequacy of current management strategies, and (3) the societal need for responsible pain management.

The first theme explores the subjective nature of pain. Three authors write principally from the perspective of the patient. In our medical humanities section, Fernando Antelo, MD, shares the experiences of the renowned Mexican painter Frida Kahlo, whose works illustrate the profound physical and emotional pains that dominated her life. Likewise, Gillian Bendelow, PhD, speaks in her medicine and society article about the need to humanize pain and think of it as more than just the result of altered neurophysiological processes. This emphasis on incorporating biopsychosocial approaches is also highlighted in the policy forum section by Ronald Wyatt, MD, where he notes how culture and ethnicity influence the perception of pain.

Other authors suggest ways to reduce discord between patients and physicians over perceptions of pain. In the journal discussion section, Robert Learch, DO, and Jeremy Cumberledge, MD, systematically examine the roots of inequity in pain management and advocate for individualized approaches. David Borsook, MD, PhD, calls for more objective measurements of pain in the state of the art and science section. And in the medical education feature, Nalini Vadivelu, MD, Sukanya Mitra, MD, and Roberta Hines, MD, emphasize the importance of incorporating pain management into undergraduate medical education.

A large portion of this issue is devoted to ethical dilemmas in pain management. The inadequacies of current treatment are the focus of three articles. Craig T. Hartrick, MD, overviews the profile of opioids in the treatment of chronic pain in his state of the art and science piece. In the first of three case commentaries, Jack M. Berger, MS, MD, PhD, and Nalini Vadivelu, MD, provide a framework for negotiating tough situations in which pain relief may inadvertently shorten a patient’s life. And Igor Grant, MD, makes his case for the legalization of marijuana for the relief of chronic pain in an op-ed.

Finally, this issue concerns itself with larger societal concerns about pain and pain management. Since at least the nineteenth century, the widespread use and abuse of opiates has been identified as a public health problem. In the health law section, Valarie Blake, JD, MA, provides updates on federal and state legislation designed to curtail prescription drug abuse and diversion. Kristy Deep, MD, MA, also writes about the diversion and misuse of opioids from her perspective as a physician who employs narcotic contracts. And Pamela L. Pentin, JD, MD, explains the difficulties emergency department physicians face in distinguishing pain crises from drug-seeking behavior.

Pain is a perplexing symptom that physicians have difficulty addressing and treating, in both its acute and chronic forms. Sadly, its nebulous nature lends itself to either underestimation or overtreatment, both of which pose significant ethical dilemmas. It is unlikely that we find an ideal solution in the near future, but perhaps through introspection and reflection in forums such as Virtual Mentor we will discover insights that help us better serve our patients.