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By E. Domenik. William Carey International University.
One author has called this neglect of the problem of pain in the bioethics literature ‘a legacy of silence’ proven 120 mg sildalis erectile dysfunction doctor in kuwait. A Common Language The lack of clear definition of many of the terms involved in this contro- versy contributes to the disagreements generic sildalis 120mg mastercard erectile dysfunction medicine reviews. The terms ‘addiction, dependence, toler- ance, and abuse’ have been widely misunderstood and misapplied even among health professionals. The American Academy of Pain Medicine, American Pain Society and American Society of Addiction Medicine produced a consen- sus document containing definitions related to the use of opioids for treating pain. The interpretation of these key terms carries ethical significance. Ethical principles can help frame the clinical import of the key terms employed in scholarly and lay discussions of addiction (table 1). A shared terminology enables all professionals to educate the public about the real nature of addiction and chronic pain diagnoses and their associated pharmacological treatments. The Core Ethical Conflict in Chronic Pain Treatment More than 2000 years ago, Hippocrates succinctly stated the core ethical conflict involved in the treatment of chronic pain in persons with SUD. Ethical acceptability of treating chronic pain Accepted Growing consensus Controversial Malignant pain Chronic nonmalignant pain Chronic nonmalignant pain in addiction use my power to help the sick to the best of my ability and judgment; I will abstain from harming or wronging any man by it’. Ethicists call these two obligations beneficence and nonmaleficence, literally the obligation to do good and not to do harm. Modern codes of ethics continue to regard these ancient principles as two of the physician’s most basic professional obligations. The treatment of chronic pain in any patient accomplishes several recognized goals of medicine: it promotes health and prevents disease; it relieves symptoms of pain and suffering, and it improves functional status or restores previous ability to function. Studies support the contention that treatment of chronic pain with opioids and other psychoactive medications in patients without a history of addiction accomplishes these goals and also may enable patients to return to work and normalize family life [27, 28]. Risk-taking behavior linked to sub- stance abuse as well as the medical complications of addiction may lead to the development of chronic pain conditions necessitating opioid medications for adequate treatment. Between 3 and 16% of chronic pain patients have prob- lems with drug or alcohol abuse [10, 29]. Of 936 patients admitted to a trauma unit in 1988 who had a toxicology screen, 65% were positive for more than one substance. Alcohol-dependent patients are 10 times more likely to become burn victims. Few studies have examined whether the benefits of long-term chronic pain therapy with opioids for chronic pain demonstrated in patients without addiction extend to patients with histories of or active SUD. A 1990 pilot study of methadone maintenance for patients with both chronic pain and substance abuse showed that 3 out of 4 patients remained in treatment for 19–21 months, stopped needle use, and/or markedly decreased substance abuse, and improved functioning despite having a psychopathology serious enough to require psy- chotropic medication. A 2003 study of 44 patients in an integrated 10- week pain management SUD treatment found no difference between patients who continued to take opioids and those who did not during a 12-month follow-up (two thirds of the patients were opioid dependent). Both groups showed reductions in overall medication use while also reporting decreased To Help and Not to Harm 155 pain. Those who continued on opioids were thought to have better functioning, suggesting a potential benefit for chronic pain medication even in patients with SUD. Pain relief may actually reduce the use of alcohol and illicit drugs for self- medication, reduce craving and, thus, avoid relapse, while also increasing the probability that patients will enter or continue in addiction therapy. Dunbar and Katz performed a retrospective study of factors leading to prescription abuse among SUD patients treated for chronic pain for more than 1 year. Patients who were active members of groups like Alcoholics Anonymous (AA), who had a social support system, abused alcohol or had a remote history of SUD were not likely to abuse opioid therapy. Patients with poly-SUD or a prior history of abusing prescription medications were more likely to misuse med- ications. These studies suggest that a SUD may not be an absolute contraindi- cation for opioid treatment for chronic nonmalignant pain. Instead, a continuum of risk must be evaluated for ethical and clinical decision making. Historically, physicians have been apprehensive about prescribing con- trolled substances for patients with a history of addiction or a current SUD because of the medical, legal, and social harms that might result. A study using the critical incident technique identified two common dilemmas regard- ing opioid use in patients with SUD. First, physicians were concerned they would cause abuse and addiction without a proper indication for opioid med- ication. Second, clinicians were concerned about the appropriateness of opioids for particular subtypes of pain.
Asmundson Faculty of Kinesiology and Health Studies and Department of Psychology buy discount sildalis 120 mg on line erectile dysfunction meds, University of Regina Kristi D discount 120mg sildalis with amex neurogenic erectile dysfunction causes. Wright Department of Psychology, University of Regina If we liken models of pain to facial displays of emotion, it becomes readily apparent that many expressions have evolved. Indeed, over the years there have been a large number of models proffered by individuals from varying intellectual traditions. Most of these models can be grouped within one of several general categories—traditional biomedical, psychodynamic, and biopsychosocial. The intent of all models, without exception, has been to address the enduring questions of “What is pain? To date, there have been a number of reviews written on biopsycho- social approaches to pain (e. Nonetheless, the face of pain, or at least the way we as clinical and research psychologists view it, is constantly chang- ing. Indeed, many of the earlier models have proven inadequate for patient care, and more recent research has superseded initial formulations. Take, for example, the advancement of the original conceptualizations of the gate control theory (Melzack & Casey, 1968; Melzack & Wall, 1965, 1982)—the first to integrate physiological and psychological mechanisms of pain—to the current neuromatrix model as described by Melzack and Katz in chapter 1 of this volume. Similar progress has occurred in the context of biopsy- chosocial approaches that have emerged from postulates of the gate con- 35 36 ASMUNDSON AND WRIGHT trol theory, such that our answers to the “what” and “how” questions just posed are, in our opinion, becoming more clear. To this end, the concepts presented herein provide an important piece of the foundation on which the assessment and treatment approaches described in other chapters of this volume are built. Our intent in this chapter is to provide an overview and critical analysis of the traditional biomedical and psychodynamic models, summarize ele- ments of the gate control theory that strongly influenced current conceptu- alizations of pain, and review important details of models that fall under the biopsychosocial rubric. Within the context of the latter, we include discus- sion of some of the most influential behavioral, cognitive, and cognitive- behavioral models and associated empirical findings. We conclude by posit- ing a synthesis of the various iterations of the biopsychosocial approach, place this in the context of a comprehensive diathesis–stress model (i. TRADITIONAL BIOMEDICAL MODEL The traditional biomedical model of pain dates back hundreds of years. Descartes (1596–1650) modernized it in the 17th century (Bonica, 1990; Turk, 1996a), and in that form it held considerable influence through to the mid 20th century. The model holds, in essence, that pain is a sensory experi- ence that results from stimulation of specific noxious receptors, usually from physical damage due to injury or disease (see Fig. Consider the case of Jamie, a middle-aged person with strained muscles in the low back. BIOPSYCHOSOCIAL APPROACHES TO PAIN 37 diagnosing and subsequently treating Jamie should be, for all practical pur- poses (and notwithstanding availability of adequate diagnostic, surgical, and pharmacologic technology), straightforward. Jamie’s physical pathol- ogy would be confirmed by data obtained from objective tests of physical damage and, if thorough, tests of impairment. Medical interventions would then be directed toward rectifying the muscle strain. The impact of the strain on Jamie’s social, psychological, and behavioral functioning would not be given much weight in any intervention. Indeed, other symptoms re- ported by Jamie, such as depressed mood, hypervigilance to somatic sensa- tions, and pain, would not be viewed as significant but, rather, as secondary reactions to (or symptoms of) the muscle strain. In Jamie’s case, intervention was targeted at healing the muscle strain and all symptoms subsided within 5 weeks. But, for every Jamie there is an- other person for whom application of an identical intervention does not re- solve pain and other symptoms, including disability, despite eventual heal- ing of physical pathology. As becomes evident in this chapter, the reductionistic and exclusionary assumptions of the biomedical models have not been upheld. We now know that pain involves more than sensa- tion arising from physical pathology. Indeed, many people with persistent pain, including perhaps the majority with low back pain, will never have had an identifiable medical diagnosis of tissue damage. Most 20th-century models of pain, including amendments to the tradi- tional biomedical model (e.
