Can New Guidelines Keep Docs From Undertreating Pain?

Arthur L. Caplan, PhD


January 04, 2023

This transcript has been edited for clarity.

Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at New York University, Grossman School of Medicine, in New York City.

I have a colleague who has a terrible problem with a bad back. She has had it for a long time, probably involving a slipped disc and maybe other issues. She is in chronic pain all the time, and she often says to me, "I'm really worried that I can't get adequate pain treatment for my bad back."

She knows, I know, and you know that we have had a horrible epidemic of drug deaths, overuse of drugs, and overprescription of addictive drugs in this country for many years.

We all know about the huge fines levied against companies that make OxyContin, distributors of those drugs, and drugstore chains saying nobody stepped in and did anything about this gigantic abuse of addictive painkillers in our society.

Still, there are people out there with real pain. There are people out there, some of whom are terminally ill, who really need their pain addressed because fears of addiction for them, when you've got that terminal illness, I would argue, are basically irrelevant. You want to make sure their pain is controlled and do whatever it takes to control it as they die.

Even without getting into the terminally ill, there are plenty of people like my colleague who suffer from serious pain; incapacitating pain; and pain that doesn't let them work, conduct housekeeping, or engage in family activities. It causes their quality of life to blow up.

We did a poll at Medscape in November. It showed that 17% of doctors who answered the poll would not treat or would undertreat pain because they were worried about being accused by the DEA or other government agencies of misprescribing medicines. Notably, only 10% said that 10 years ago. There's clearly fear on the part of some doctors that trying to control pain is going to get them in trouble and they're going to undertreat.

There are certainly many who would say that yoga, mindfulness, and other types of nonpill treatment of pain are the way to go. I have no problem with that as a first step, but I have a problem with that as a last step if people still can't function or are in terrible pain.

One bit of good news is that the CDC recently issued some guidelines on pain control, saying you have to be flexible. They didn't set any limits on doses. They left that up to the discretion of the physician.

That guideline will help, and I think it ought to keep those who are worried about being charged with misprescribing drugs a little safer because the guideline says to treat pain seriously and gives information and a standard that would hold up in court as a guideline to what standard of care ought to be. There is reassurance from the federal government that pain control still has to be taken seriously.

What do we do? First, we have to realize that there is a population out there that needs pain control. Second, start slowly and sometimes use behavioral interventions, stress control, changing the environment, looking for chairs and equipment for the workplace that reduces pain, whatever the cause might be: carpal tunnel, bad back. Sure, let's do that.

Gradually increasing doses to make sure that we don't addict anyone who shouldn't be addicted? Absolutely.

Let's make sure that we control pain. It really is a serious inhibition to quality of life and function for many people. We have to find a medium with it. Just undertreating it or ignoring it is not the answer.

Hopefully, we'll get more guidelines from professional societies and the federal government about the steps that can be taken by doctors who really want to help their patients get through pain but don't want to be misheard or misunderstood as trying to do things that are cavalier or irresponsible in the treatment of pain.

No one wants poor pain treatment, but there is such a thing as excellent pain treatment.

I'm Art Caplan, at the Division of Medical Ethics at NYU's Grossman School of Medicine. Thank you for watching.

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