Balancing patient pain with ethical treatment: a doctor’s dilemma

The medical profession has gone back and forth in its approach to pain treatment. Alcohol and opioids, once seen as miraculous and valid ways to assuage pain from injury or chronic disability, are now viewed—and used—differently. Dean Robert J. Alpern, M.D., discusses what has changed since he was trained as a physician—and what that bodes for the future.

Has the landscape changed in terms of how the medical community discusses individuals with substance use disorder challenges?
Many years ago the treatment of pain was dominated by the traditional philosophy of “do no harm.” We as physicians undertreated pain due to the fear of causing addiction and overdoses. Then there was a period when medical professionals saw undertreatment of pain as a kind of harm, and we went through a period of increasingly aggressive pain treatment, which led to the development and expansion of pain as a specialty. Medical schools and health systems began developing and expanding pain programs, because as it turns out, it’s very difficult to treat pain effectively.

Most recently, we’ve seen that pain treatment that frequently relies on opioids has secondary and even tertiary consequences, causing an epidemic of addiction and overdoses. Now the medical profession is pulling back, trying to find the right balance.

Do you feel that part of the issue with substance use disorder surrounding pain medication involves the idea that one should not have to feel any pain?
No, I don’t think so. Medically, you were always balancing the patient’s comfort with risk to the patient’s health. The ideal would be to treat pain in ways that don’t involve opiates. Steve Waxman’s research into blocking specific sodium channels that affect the sensation of pain is extremely promising. But there’s a danger, too. If you block all pain sensation, a patient could burn themselves and not know it. There’s a reason we feel pain.

What’s the School of Medicine’s role in the substance use disorder epidemic?
Yale is very strong in substance use disorder research. Our faculty in psychiatry, general internal medicine, and emergency medicine are world-class experts on the subject. Substance use disorder spans many variables so, while many of them work in opioid addiction, others focus on tobacco, alcohol, food, and other things. In every case, Yale should be among the first to take the most effective practices to the bedside. I hope that in the near future, someone suffering pain will be able to receive treatment specific to their ailment that isn’t addictive.