All of us have heard the phrase "between a rock and a hard place," and many of us have been in the situation that the idiom describes. However, few of us (other than English professors) likely know the origin of the saying and even fewer of us know how it applies to clinical psychiatry. Delving into these seemingly unrelated queries will be the subject of this month's column.
Between a rock and hard place refers to a quandary or dilemma in which one must choose between two equally difficult, unpleasant, or unacceptable options. Most lexicographers trace the phrase back to Homer's Odyssey, which portrays Odysseus attempting to sail through a narrow passage in the Strait of Messina with a 6-headed monster on a rock (Scylla) on one side of the strait and another whirlpool-causing sea monster (Charybdis) on the other.1 Hence the more cultured version of our saying, "caught between Scylla and Charybdis."2 The ancient expression, even more than the modern, captures the feeling experienced by many psychiatrists and other physicians struggling to treat chronic pain and prevent addiction in the midst of a flood of mixed messages from government, professional organizations, and the media. In this essay, I will use the metaphor of Scylla, the dog-headed beast, to represent the problem of chronic pain which "devours lives" and Charybdis, the sea-spouting mouth, to symbolize addiction that "sucks humans down," to explore this ever more pressing ethical conflict.
Case 1: Scylla
Ms L is a former practical nurse who has chronic low back pain with radiculopathy—the result of motor vehicle and work-related accidents. Her pain has been relatively well controlled on moderately high doses of sustained-release oxycodone (OxyContin) for maintenance, short-acting oxycodone for breakthrough pain, and periodic corticosteroid injections during pain flares. Psychiatrically, Ms L has chronic posttraumatic stress disorder and associated depression from childhood sexual abuse. Ms L manages all her own activities of daily living, makes jewelry to supplement her pension, and volunteers for several organizations. She has no history of substance abuse and there is no documentation of aberrant behavior, such as early refills or visits to the emergency department on weekends. Ms L regularly attends physical therapy, pain group, individual counseling, and medical and psychiatric appointments. Recently, Ms L attempted to obtain her routine refill of narcotics. She was told by nursing staff that her primary care provider had changed and the new physician indicated he "would not prescribe such high doses of opioids and would begin tapering her immediately." While distraught over being forced into withdrawal, Ms L was even more indignant over feeling she was being labeled as a "drug addict."
In 2001, the Joint Commission on Accreditation of Healthcare Organizations implemented pain treatment standards that hospitals must meet for accreditation. A Veterans Health Administration directive, issued in 2003, described the assessment of pain as the "5th vital sign."3 Yet cases such as Ms L's are more the expectation in general medical and psychiatric care than the exception. An extensive survey, Chronic Pain in America: Roadblocks to Relief,4 reported that 9% of the US population suffers from moderate to severe chronic pain, a third of whom said that their pain is the "worst imaginable." Over two thirds have lived with this pain for more than 5 years and just over half—mostly those with moderate pain—feel their pain is under control. Many of these patients could not find a physician willing or able to manage their pain, with one fourth having changed physicians 3 times since onset of pain. The major reasons for switching doctors underscore aspects of the dilemma: the physician failed to take pain seriously, was unwilling to treat aggressively or lacked knowledge about pain, and most importantly, the pain was not sufficiently relieved.4 There is considerable evidence that women, minorities, and patients with mental illness, particularly those with substance abuse and co-occurring chronic pain, receive even poorer quality of care.5
Many factors, including lack of education and confidence, problems with health care access, pharmacy regulations, and cultural views, among others, contribute to the undertreatment of chronic pain, but it is the internal dispositions that underlie physician diffidence or refusal to treat chronic pain, at least with opioids, that are of most interest and least discussed.6 Some of these are relatively noble and clearly fall under the fundamental ethic to "do no harm," such as the genuine desire not to be responsible for iatrogenic addiction, reawakening a sleeping giant of past dependence, or facilitating illness behavior. Other motivations also appear to be realistic, such as the fear of professional censure or criminal action; certainly, some recent government actions and sensational press coverage promote these apprehensions.7
1. Homer. The Odyssey. Cook A, trans-ed. New York: Norton; 1967.
2. Radice B. Who's Who in the Ancient World. Baltimore: Stein and Day; 1971.
3. Pain Management. Washington, DC: Department of Veterans Affairs, Veterans Health Administration; 2003. VHA Directive 2003-021.
4. Chronic Pain in America: Roadblocks to Relief. American Pain Society Web site. Available at: http://www. ampainsoc.org/links/roadblocks/. Accessed May 21, 2007.
5. Breitbart W, Rosenfeld BD, Passik SD, et al. The undertreatment of pain in ambulatory AIDS patients. Pain. 1996;65:243-249.
6. Stannard C, Johnson M. Chronic pain management—can we do better? An interview-based survey in primary care. Curr Med Res Opin. 2003;19:703-706.
7. Jung B, Reidenberg MM. The risk of action by the Drug Enforcement Administration against physicians prescribing opioids for pain. Pain Med. 2006;7:353-357.
8. Cheng GS. Regulatory Scrutiny Cited in Pain Undertreatment. Fam Pract News. 2000.
9. Rich BA. The doctor as double agent. Pain Med. 2005; 6:393-396.
10. Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health: National Findings. Rockville, Md: Department of Health and Human Services; 2006.
11. Nicholson B. Responsible prescribing of opioids for the management of chronic pain. Drugs. 2003;63:17-32.
12. Roosevelt M. Why is the DEA hounding this doctor? TIME magazineWeb site. July 18, 2005. Available at: http://www.time.com/time/magazine/article/0,9171,1083911,00.html. Accessed May 21, 2007.
13. Satel S. Doctors behind bars: treating pain is now risky business. New York Times. October 19, 2004. Available at: http://www.nytimes.com/2004/10/19/health/policy/19essa.html?pagewanted=2&ei=5070&en=c74f21fab1015f3f&ex=1179892800. Accessed May 21, 2007.
14. Robeznieks A. Removal of FAQs about prescriptions on DEA Web site causes turmoil. American Medical News. December 20, 2004. Available at: http://www.ama-assn.org/amednews/2004/12/20/prse1220.htm. Accessed May 21, 2007.
15. Savage SR. Assessment for addiction in pain-treatment settings. Clin J Pain. 2002;18(4 suppl):S28-S38.