The Tyranny of "Shoulds": Challenges for the Pain Practitioner

About 10 years ago I wrote a paper with Ken Kirsh and Howard Heit about how every stakeholder from the clinician to the patient, to the media, to law enforcement, regulators, could all work together to improve the state of affairs in pain management and the fate of people with pain. It was Ken Kirsh’s suggestion to use it in the context of a tyranny of shoulds. I think the things that stand out in most practitioners’ mind are always the failures. The people that we couldn’t help; people who passed away; people who overdosed; people who got into trouble. One aspect of this absolutist thinking is there’s been a pushback against the use of opioids in pain management. In the past, the thinking was that if you didn’t get fooled once in a while by a person who came in claiming to have pain, you weren’t treating pain aggressively enough, that you were being too skeptical. Somehow along the way, that turned into, if you ever get duped by somebody who’s actually intentionally trying to dupe you, that you’d lose your license. I’m not trying to minimize the opioid problem, but I think the reaction to what’s happened with opioids has been largely to forget about the people who are being helped. When you get into absolutist types of thinking, and the idea that if opioids don’t work for everybody, then they shouldn’t be used at all, well that just leads to more suffering.

It was a mistake to trivialize the risk of addiction as was typical in the early days of the opioid revolution. And so what we actually need, in Doug Gourlay’s parlance, is more talented amateurs in addiction medicine. As a pain clinician, these are skills that you can acquire. You can get good at them and then apply them as necessary. It is certainly the case that the skills in addiction medicine, knowing how to diagnose it, see it when it starting to happen, knowing how to react, knowing how to be non-punitive, nonjudgmental, knowing how to use the tools of the trade - urine drug testing, prescription monitoring programs, can all be learned. And of course, there are a lot better tools now than the early to mid-90’s.

People with pain have to recognize that they have a responsibility to everyone else with pain. So if you’re a pain patient or a family member, you owe it to the doctor and to everybody in the pain community to be honest about what your risk factors are. Trust them enough to not be punitive if you tell them, and tell them what your recovery efforts are, if you have a history of misuse and so on, and then don’t take liberties that you’re not supposed to take. Recognize that a decision to not take your medicines as prescribed is not only dangerous to you, but perhaps to others with pain as well. I do think it takes a village. We need more collaboration. The media, regulators, law enforcement, pain patients, and practitioners in the field all need to work together, and I think there are signs of progress in every camp.