by Myra J. Christopher, Kathleen M. Foley Chair in Pain and Palliative Care and Director of PAINS at the Center for Practical Bioethics
I recently received a brochure marketing the Journal of Opioid Management, which according to their website, is “a peer-reviewed, professional journal that addresses all aspects of the safe use and management of opioids. The Journal provides guidance to physicians and healthcare professionals on how to safely prescribe and responsibly manage these important drugs.”
I have been seething ever since.
I have received this journal for some time and am acquainted with several people who serve on its editorial board. I do believe it fills a gap in this era of “opiophobia.” However, I feel that I must comment on the brochure, which I found completely inappropriate, and suggest a more positive approach.
The brochure has a single message on the cover, “The Seven Deadly Sins of Opioid Prescribing.” It is printed on a background that has been designed to look like ancient parchment and even has a small illuminated design at the bottom. The background of the last page is very faint Latin script. The header on the inside cover is “Seven Sins Physicians Commit when Prescribing Opioids.”
One (again beautifully illuminated): Prescribing Too Many Medications…
And it continues:
- Providing medications in a rush
- Failing to detect addiction
- Skipping the examination
- Ignoring legal aspects
- Misunderstanding opioid pharmacology
- Failing to improve quality of life and efficiency
I refer to myself as a philosophical Christian and am a regular churchgoer; I am certainly no biblical scholar. However, I find this “Christian” framework offensive and am stunned that the Journal succumbed to the pervasive stereotypes about those who live with chronic pain (“drug seekers”) and those who care for them (sinners). Particularly, in that in Matthew 4:23-24 (NASB), the New Testament says, “Jesus went throughout Galilee, teaching in their synagogues, proclaiming the good news of the kingdom, and healing every disease and sickness among the people. News about Him spread all over Syria, and people brought to Him all who were ill with various diseases, those suffering severe pain, the demon-possessed, those having seizures, and the paralyzed; and He healed them.”
I would like to propose to Paul Alexander Sloan, the Journal’s Editor, and its Editorial Board that a translation could be helpful and not unintentionally further harm those struggling to live with high-impact chronic pain. If the Christian framework is advantageous from a marketing perspective, let me propose:
The Seven Heavenly Virtues of Caring for Those in Pain (Please skip the illumination)
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- Prescribe only the amount of medication that you believe your patient will need. Encourage them to keep them in a safe place, and tell them about prescription take-back programs in your community.
- Take time to listen to your patient before prescribing anything. Ask if they have seen other physicians for their pain and if so, if other pain medications been prescribed to them. What was prescribed and what were the outcomes?
- If you prescribe opioids or benzodiazepines, assess your patients’ risk of addiction. Use SOAP or one of the other validated assessment tools and tell your patient why you are doing so. Inform them about risks associated with these medications.
- Always do a physical examination. A trusting relationship is critical to a successful interaction between chronic pain patients and their physicians. Human touch can be as effective as a prescription.
- Be confident that you are practicing within guidelines for best practice and are aware of statutes and regulations in your state. Document the conversation with your patient and give a justification for the decision you make.
- Keep current on pharmacology. As with many medications, opioids vary from one medication to another, which has been well-documented, e.g., that many unintended deaths have been associated with physicians not understanding the translation of MME from an opioid to methadone as well as with co-prescribing opioids and benzodiazepines.
- Establish goals of care that focus on improving functionality and quality of life. Knowing your patients’ goals and values are critical.
The brochure I received concludes with “LET’S HEAR FROM YOU” and invites recipients to share a story regarding opioids at email@example.com. A few years ago, there was a popular bumper sticker that asked, “WWJD – What would Jesus do?” I’m not sure, but I am forwarding a copy of my comments to the Journal of Opioid Management and encourage all those who read PAINS Update to also respond by sending them a “story” about your personal experience.
The Pain Action Alliance to Implement a National Strategy (PAINS) is a consortium of leaders working in professional societies, patient advocacy organizations, policy groups, consumers, payers and the private sector working together toward a common vision and mission. For more information, visit PAINSProject.org.