Negotiate with patients on treatment of pain

Ethics Forum. April 3, 2006.

Scenario: What do you do for a patient who requires chronic pain medication?

What are the professional responsibilities that go along with prescribing powerful pain killers? What is the conversation and possibly the contract the physician has with the patient? How can the physician learn to understand the duties that arise in cases of long-term pain therapy?

Reply:

Pain treatment decisions require an examination of a patient's case history. Molly Thomas (name changed to protect the patient's identity) was diagnosed three years ago with stage II breast cancer. After a mastectomy, she was treated with chemotherapy. During this time, she had moderate auxiliary pain successfully managed with oxycodone. She has no evidence of recurrent cancer but has reported moderate to severe pain for three months. Her pain is multifocal, occurring in her lower back, joints and right lower thorax. Physical examination and diagnostic studies, including a thoracic CT scan, are unremarkable.

Thomas is a divorced woman of 57 with four adult children, including a son with a history of chronic depression and a daughter also recently diagnosed with breast cancer. Thomas' pain has been unsuccessfully treated with nonsteroidal anti-inflammatory drugs and physical therapy. She is requesting oxycodone because this worked so well for her previous pain.

The clinic nurse believes Thomas is not really having severe pain, because she does not appear to be in acute distress. The nurse believes, perhaps, Thomas is anxious about recurrence of her breast cancer, given her daughter's recent diagnosis. The medicine resident also is reluctant to refill the oxycodone, because no cause has been identified for the pain. The previous resident attempted to refer Thomas to the university pain clinic, but her insurance provider denied this request.