There are substantial efforts to dampen the pendulum swings in the management of pain; to prevent recent overtreatment from swinging back to undertreatment. In this month’s PediatricsEthics Rounds, commentators discuss the case of a 16-year-old female with progressive, incurable lymphoma and chronic pain (10.1542/peds.2020-046219). Her pain management is complicated by her own addictive behaviors and her caregiver’s diversion of her medication. Her primary oncology and pain teams disagree about using oral or transdermal opioids, or patient-controlled analgesia in a lockbox to help her achieve her goal of dying at home. The commentators emphasize the importance of multimodal analgesia and suggest strategies to achieve appropriate opioid stewardship. These strategies include an accurate assessment of the situation that minimizes bias, written treatment contracts, regular urine drug screens, and supervised visitation by family members with a history of diversion.
As a hospitalist, I greatly value my palliative care and pain management colleagues. Managing chronic pain is an art that entails balancing short- and long-term goals, and potential benefits and risks. It also requires remarkable interpersonal skills to maintain a therapeutic alliance when the desired level of pain control cannot be achieved or achieved quickly. Optimum management is frequently made more difficult by patients’ social vulnerability and the absence of community resources such as substance misuse treatment programs. The commentaries in this article reinforce the importance of developing systems that support providers in doing difficult jobs without burning out, and the need for adequate reimbursement for important systems of care such as home health and hospice. What do you think? We welcome your comments in response to this blog or on our website when you link to the article.
