You are in your clinic office this morning, reviewing the patients you are scheduled to see today. You note that two of the patients will likely be challenging with respect to pain management, and you begin to consider what options you might have and how to approach the decision-making process with them. Both patients are known to you, and you believe you have a good patient–physician relationship with them.
Explore This IssueApril 2018
Mrs. Smith is a 59-year-old housewife in whom you first diagnosed an invasive squamous cell carcinoma of the right lateral tongue six months ago. After a confirmatory biopsy, you performed a comprehensive evaluation of the patient, which did not reveal suspicious lymphadenopathy or metastatic disease. You offered the patient the options of surgery plus possible neck radiation versus primary chemoradiation, and, after due consideration, she chose the latter. Since completion of therapy three months ago, the patient has complained of intense pain (7/10 analog) in the oral cavity and upper neck, along with right shoulder pain. You have not identified any recurrence or residual tumor in the oral cavity or neck on imaging studies or physical examination. The patient did report a slight diminishment of the pain on the last examination two weeks ago but continues to request opioid prescriptions; however, you are at the point in time when you feel a re-evaluation of the opioid pain management you have prescribed is now in order.
The second patient of concern is a 37-year-old male paralegal who is now six weeks status post open reduction and internal fixation of a LeForte III fracture, including orbital floor fractures. Last month, you removed the maxillary-mandibular fixation, and there was no evidence of any complications from the injuries or surgical reconstruction on examination or repeat CT scan. The patient has been very forceful, however, that he has terrible facial pain and requires more refills of his opioid pain medications. You want to avoid a confrontation with the patient, and you consider the pain management options for his post-trauma pain.
How would you handle these cases?
In the December 2017 issue of ENTtoday, the article “The Opioid Crisis: Five Truths Otolaryngologists Need to Know” discussed the threats of opioid overuse and misuse in the United States for patients, physicians, and society. The article identified five elements to consider when otolaryngologists prescribe opioids:
- Your patients may already be on opioids;
- The number of pills you prescribe matters;
- You can probably decrease the amount of opioids you prescribe;
- Patient education regarding proper use (and disposal) of opioids is necessary; and
- Patients who want refills should be referred to pain management specialists.
These points can help guide the otolaryngologist in managing pain requirements by patients in the clinical setting. But the concerns of the opioid crisis and the responsible management of pain in patients require the otolaryngologist to make the best decisions for patients within the context of clinical and professional ethics.
The ethical foundations for patient care rest fundamentally in the four principles of autonomy, beneficence, nonmaleficence, and social justice. It is not always easy to achieve a balance of these principles in medicine, especially when taken in the context of compassion, understanding, honesty, and duty. Often, hard choices must be made, and few clinical situations are more difficult in this regard than pain management.
While it might seem that autonomy (what the patient desires), or even beneficence (doing good), would be the primary ethical principles to follow, in fact, the responsibility for nonmaleficence (do no harm) may well be the best guide. Pain medications in general, but opioids in particular, can lead to misuse, overuse, tolerance, and addiction—hence, the crisis now seen in the U.S. Since it is the physician who can “legally” provide the prescriptions, it is up to us, individually and collectively, to ethically prescribe pain medications for our patients. The key is to appropriately balance the dyad of beneficence and nonmaleficence for each patient, while bearing in mind that patient self-determination and desires (autonomy) will not necessarily be the primary guiding ethical principle in most cases of pain management.
The key is to appropriately balance the dyad of beneficence and nonmaleficence for each patient, while bearing in mind that patient self-determination and desires will not necessarily be the primary guiding ethical principle in most cases of pain management.
Explain Expectations and Limitations
Ideally, in the clinical setting where the level of pain for patients is expected to be high and long-lasting, early discussion of the role of pain medication management in their care is very important. The fear or concern for mitigation of postoperative pain is quite common, and explaining pain management modalities, with their limitations, can be very reassuring for the patient. Educating the patient in the risks, benefits, and goals of pain management is salutary, especially when done with honesty and understanding. Setting boundaries for pain medications initially is much better than trying to work with an unprepared patient in the postoperative setting.
All discussions on pain medication should be well documented in the patient’s health record, along with an outline of the pain management plan preoperatively, all discussions with the patient during the time pain medications are prescribed, and all alternatives that are offered the patient for pain relief. As with all medications, longitudinal reassessment of physical findings and patient complaints/side effects should be performed.
In keeping with the goal of balancing beneficence with nonmaleficence, the otolaryngologist should pre-emptively assess the patient’s mental capacity and capability, while also evaluating the risk stratification for serious side effects of opioids such as mental disorientation, falls, accidents, and accidental overdose. While shared decision making in patient care is often the norm, in the case of opioid prescribing, there are overriding legal, professional, and ethical considerations that limit the ability of the otolaryngologist to approve the inappropriate and potentially dangerous prescribing of narcotics when not clinically indicated. Here, the otolaryngologist has a higher responsibility to patient safety and well being that may require refusing the patient’s request for more opioid prescribing. The otolaryngologist must often make hard decisions regarding patient requests for narcotic-level pain medications beyond the period of reasonable need. Alternatives such as NSAIDS (if tolerated), massage therapy, physical therapy, other non-narcotic pain medications, biofeedback, and referral to a pain specialist are all potential options. Coordinating pain medications and pain control with the patient’s primary care physician is also a very important responsibility. In the situation of chronic pain in a patient, the otolaryngologist has many resources for assistance in pain management so that full responsibility is not necessarily required.
Other resources for the otolaryngologist can be “best practices,” and “standards of care,” guidelines that are available from many sources, including the Centers for Disease Control and Prevention’s “Guidelines for Prescribing Opioids for Chronic Pain” (MMWR Recomm Rep. 2016;65:1–49). The prescribing of opioids in pediatric patients is undergoing re-evaluation and change, based on new information that there is a risk for significant complications in some patients undergoing tonsillectomy or tonsillectomy-adenoidectomy, especially those with obstructive sleep apnea. Additionally, some children who are rapid metabolizers of codeine to morphine in the liver are at high risk for respiratory depression and death. The alternative use of acetaminophen/ibuprophen is a recommendation that is still under investigation, particularly with respect to a possible increased risk of postoperative hemorrhage. The concerned otolaryngologist has an ethical and professional responsibility to stay informed on current outcomes research and recommended guidelines for pain management in both adult and pediatric patients.
Individualize Your Approach
In consideration of the two patient cases, and with reference to the ethical perspectives noted above, the otolaryngologist will need to individualize the approach to pain management for each patient, as the pain etiologies are different and, therefore, management may not be similar. In general, chronic pain from cancer or cancer treatments is special and is not necessarily approached in the same way as post-trauma pain in developing and maintaining a pain management plan. Cancer pain can arise due to both recurrence/metastasis of the tumor and the resulting treatment (chemoradiation, surgery). Typically, the management of head and neck cancer is a team effort, and it is very common for the otolaryngologist to have access to consultations with a pain specialist who understands the pain associated with cancers in this region. Multi-modality therapy is often recommended—and needed—for cancer-related pain, and such consultations are generally quite beneficial to both the patient and the otolaryngologist. Additionally, discussing pain management goals with the patient’s primary care physician can be quite helpful and appropriate.
On the other hand, post-traumatic pain syndrome may be less easily defined, with litigation and compensation often playing a role in the pain disorder. The otolaryngologist must be open-minded, compassionate, and understanding, yet cognizant of other elements that could be at play. Consultation with a pain management expert is usually very helpful, as is an honest discussion with the patient.
The management of extended acute and chronic pain syndromes in otolaryngology-head and neck surgery can be both challenging and complicated. Balancing ethical principles in providing pain mitigation requires the otolaryngologist to be knowledgeable of current guidelines and best practices, while at the same time relying on a sense of responsibility to the patient and a duty to balance beneficence with nonmaleficence in the best interests and welfare of each patient.
Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.