Read the Case-Based Curriculum for Neurology Residents.

"pseudoaddictive"
or distressingly
behaviors. (6) In essence, the problem of functional
impairment reiterates the need for good training in pain management and opioid pharmacology.
Moreover, unnecessary undenreatment of pain by physicians despite available
alterantives, causes identifiable harms. First, undue fear of respiratory depression, addiction,
functional impairment and justice concems that effectively block patient access to needed
treatmentolerates pain in a way that shirks a physician's beneficence-based duty to promote the
well-being of each patient. Honorable individual physicians may disagree about the relative
merits of a "biomedical" approach to opioids in CNP (that extrapolates from the favorable cancer
experience with opioids) and a "biopsychosocial" approach (that favors functional treatment
bolstering individual responsibility and minimizing opioid use), but this does not absolve them of
a duty to secure for the patients some reputable treatment. Second, tbe categorical withholding
of opioids when all other reasonable attempts at analgesia have failed, tolerates and sustains
potentially remediable disability due to pain. It may restrict rhe patent's freedom to pursue the
fullness of life, and to take pleasure in it. Third, deception even with beneficent motives
constitutes unjustifiable patemalism and is morally wrong.
The relevant and legirimate desires of patients with CNP who enter into fiduciary
relationships with physicians are ro obtain relief safely and competently. While a physician may
conscientiously decide that, on balance, the medical literature does not suppon opioids in CNp,
the provides no warant to mislead the padent through silence or excessively negative verba.l
framing of this option. There is, in fact, enough basis in the literature ro ar least discuss it as an
altemative, and to disclose - along with any penonal rcservations - the names of rcputable
physicians who use it. Deliberate withholding of information about opioids for significant
intractable CNP directly violates the patient's autonomy interest in making an informed choice
among clinically relevant and legitimate altemarives. It is every bit as imponant to grant the
patient the opponunity - as a mater of truth-telling and conscnt - to decline opioids for CNP as it
is to accept them. It is unethical for a physician ro withhold this information when doing so
promotes a personal monetary interest in an invasive or neurodestructive procedure-
Fourth, the physician's justice-based duty to take the broader interests of society into
account in decision making does not contradict or trump his or her beneficence-base duty to the
patient with CNP. Bemat defines the physician's duty to society as follows: " The ethical good
that a patient accrues from the patient physician encounter is of paramount imponance, but it.
must also be balanced against the harm other patients may sustain as an inevitable byproduct of
the encounter."(l8) Provided that the conscientious physician concludes that therc is no
reasonable alternative to opioid therapy ofa specific patient's CNP, that therc arc no
countervailing medical or psychosocial risk factors, and provided that thc patient has given valid
informed consent and promised to faithfully adhere to tbe therapeutic contmct, then sciety and
other individuals in it incur no meaningful, dircct or inevitable risk of harm. Physician should
be aware of the porcntial conflict of intercst between their personal aversion to assuming possible
risks in prescribing opioids for CNP, and specific patients' claim for exactly that treatment for
their otherwise-intractable pain.