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  • Writer's pictureSociety of Bioethics and Medicine

The Silent Sufferers: Underprescribing, Stigmatism, and the Ethical Quandary in Pain Management

Written by Amanda Pisciotta

Edited by Jonathan Gao

Across the vast spectrum of human experience, pain is a universal communicator, signaling potential threats through whispers and roars alike[1]. In this, a complex challenge persists, exacerbated by the use of prescription opioids such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, and morphine[2]. Family physicians often find themselves standing at a crossroads, balancing the imperative to provide optimal pain relief with the responsibility to shield patients from the risks of addiction[3]. This delicate dance raises a crucial question: How can physicians avoid the pitfalls of underprescribing opioids to their patients while also safeguarding them against opioid misuse? 


Chronic pain is a pervasive challenge affecting 20% of the U.S. population and presents unique difficulties for vulnerable groups including the elderly, racial and ethnic minorities, women, and socioeconomically challenged individuals[4]. Unfortunately, such groups experience more severe pain that remains untreated due to long-held stigmas and biases within the healthcare system. This discrepancy is particularly evident in the case of women, who are all too often dismissed by doctors as overly sensitive or emotional, attributed to differing hormones or biology. As a consequence, doctors are more likely to recommend psychological treatment to women and analgesics to men, although a staggering 70% of individuals enduring chronic pain are women[12,14]. Physicians are thus confronted with an ethical dilemma: in their efforts to prevent opioid misuse and safeguard vulnerable populations, they inadvertently underprescribe, potentially compromising the well-being of those in need due to societal biases.


The once-held belief in the safety and efficacy of opioids for chronic pain faces a harsh reality check: challenging the medical community to reassess its approach. The opioid epidemic, casting a dark shadow across the globe, affects millions, with over 100,000 deaths annually attributed to opioid misuse[5]. Historical roots in pain management trace back to the 1800s, driven by war injuries and advancements in pain physiology[3]. However, the evolving landscape reveals a critical flaw in long-term opioid use: ineffectiveness, diminishing returns, and escalating risks of addiction and overdose[6]. 


The Hippocratic Oath is a formidable challenge to physicians when patients, especially those within vulnerable groups, are left with inadequately treated or untreated pain. Pushback against opioid prescriptions, while well-intentioned, may inadvertently neglect patients' legitimate medical needs, leading to accusations of negligence. Critics, like non-doctors or even the DEA, advocating for avoiding opioids fail to recognize their essential role in managing conditions such as acute and chronic pain, active-phase cancer treatment, and palliative and end-of-life care[7,13]. Countless individuals, guided by their physicians, rely on opioids for effective pain management. Dismissing the necessity to prescribe medications, such as oxycodone, hydrocodone, codeine, and morphine, and instead recommending patients with severe pain to address their symptoms with Tylenol and meditation is not merely just a failure to address the legitimate needs of those depending on them, but it is also a departure from the physician’s responsibility to “do no harm”[2,13]. In navigating this balance, physicians must champion a nuanced approach, acknowledging opioid necessity in specific contexts while diligently addressing potential harms.


Addressing the opioid epidemic necessitates a multifaceted approach, with physicians playing a crucial role. However, this involvement must be accompanied by an introspection into prescribing practices and recognizing the potential necessity of opioids for optimal pain treatment. Striking a balance is imperative because the failure to control pain adequately in situations where opioids may be necessary can lead to profound consequences, impacting the quality of life and resulting in physical, psychological, social, and economic repercussions[7]. Inappropriately managed acute pain can lead to immunological and neural changes and further progress to chronic pain if left untreated[7]. Although physicians have the ethical responsibility to prevent addiction, drug diversion, and trafficking, the opioid epidemic must not be addressed with a solution that uses the treatment of chronic pain as a weapon to further oppress already marginalized groups.


Confronting the opioid epidemic demands a critical examination of pervasive stigmas within the medical field that obstruct proper treatment for all groups. Relying solely on doctors' judgments proves insufficient as they are also prone to influence by stigmas, resulting in the undertreatment of vulnerable groups. Shockingly, disparities persist, with white patients receiving significantly more opioid prescriptions than their racial/ethnic minority counterparts, while women and those facing lower income often lack adequate pain management[8,9,10].


In addressing the intricate interplay of pain, opioids, and ethical complexities, physicians grapple with the potential justification of undertreatment based on perceived patterns linking certain groups to opioid overdoses. Nevertheless, it is paramount to acknowledge the reality that all pain is valid and stems from the brain, imposing on physicians the obligation to uphold the fundamental human right for patients to be free of unnecessary pain. While doctors are not mandated to prescribe opioids, the presence of stigma should not impede necessary treatment. Instead, a proactive approach is urged, with physicians advocating for positive intervention protocols that include screening for opioid use disorder and enhancing education and treatment accessibility[11]. This compassionate advocacy positions physicians as pivotal players in the fight against the opioid epidemic without perpetuating societal inequalities. 


As the focus shifts to the unseen toll of untreated pain on vulnerable populations, the underprescribing dilemma, entrenched in stigmatism and biases, emerges as a formidable barrier to effective pain management; this subjects these groups to profound and often overlooked consequences. 


This calls for physicians to rise above the shadows of the opioid epidemic, weaving a narrative that ensures equitable access to pain treatment while upholding the sacred oath to "do no harm" and recognizing the urgency of addressing untreated pain in vulnerable populations. Justice demands a departure from stereotypes, fostering fair and equitable treatment and emphasizing the universal human right to be free of unnecessary pain.


References:

  1. Santiago, Vivian. “The Functional Role of Pain: JPR.” Journal of Pain Research, Dove Press, 16 Feb. 2022, www.dovepress.com/painful-truth-the-need-to-re-center-chronic-pain-on-the-functional-rol-peer-reviewed-fulltext-article-.  

  2. “Opioid Use Disorder.” Psychiatry.Org - Opioid Use Disorder, www.psychiatry.org/patients-families/opioid-use-disorder#. Accessed 18 Dec. 2023. 

  3. “Chronic Pain Management and Opioid Misuse: A Public Health Concern (Position Paper).” AAFP, 12 Dec. 2019, www.aafp.org/about/policies/all/chronic-pain-management-opiod-misuse.html

  4. Dillinger, Katherine. “Chronic Pain Is Substantially More Common in the US than Diabetes, Depression and High Blood Pressure, Study Finds.” CNN, Cable News Network, 16 May 2023, www.cnn.com/2023/05/16/health/chronic-pain-study/index.html.   

  5. Mann, Brian. “U.S. Drug Overdose Deaths Hit a Record in 2022 as Some States See a Big Surge.” NPR, NPR, 18 May 2023, www.npr.org/2023/05/18/1176830906/overdose-death-2022-record. 

  6. Opioid Use Disorder - Statpearls - NCBI Bookshelf, www.ncbi.nlm.nih.gov/books/NBK553166/. Accessed 18 Dec. 2023. 

  7. King, Nicholas B, and Veronique Fraser. “Untreated Pain, Narcotics Regulation, and Global Health Ideologies.” PLoS Medicine, U.S. National Library of Medicine, www.ncbi.nlm.nih.gov/pmc/articles/PMC3614505/. Accessed 18 Dec. 2023. 

  8. Flores, Michael William, et al. “Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System.” Journal of Racial and Ethnic Health Disparities, U.S. National Library of Medicine, 9 Mar. 2023, www.ncbi.nlm.nih.gov/pmc/articles/PMC9997438/

  9. “Department of Health.” Laws and Regulations, www.health.ny.gov/professionals/narcotic/laws_and_regulations/. Accessed 18 Dec. 2023. 

  10. Joseph Friedman, MPH. “Assessment of Racial/Ethnic and Income Disparities in the Prescription of Controlled Medications in California.” JAMA Internal Medicine, JAMA Network, 1 Apr. 2019, jamanetwork.com/journals/jamainternalmedicine/fullarticle/2723625

  11. “How Physicians Can Combat the Opioid Epidemic.” Home, www.cerner.com/perspectives/how-physicians-can-combat-opioid-epidemic. Accessed 18 Dec. 2023.  

  12. Clouser, Gillian. “Oh, the Aches and Pains.” Yale School of Medicine, Yale School of Medicine, 2022, medicine.yale.edu/news-article/oh-the-aches-and-pains/#:~:text=According%20to%20the%20U.S.%20Centers,chronic%20pain%20sufferers%20are%20women.   

  13. “Doctor Convicted of Illegally Prescribing Opioids to Patients.” DEA, www.dea.gov/press-releases/2021/11/19/doctor-convicted-illegally-prescribing-opioids-patients. Accessed 19 Dec. 2023. 

  14. The Gender Pain Gap: Why Men Get Better Pain Treatment than Women, www.goodhousekeeping.com/health/a39763690/gender-pain-gap-explained/. Accessed 19 Dec. 2023.

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