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Evolving Role of the Neurologist in the Diagnosis and Treatment of Chronic Noncancer Pain

      The neurologist has become increasingly involved in the multidisciplinary treatment of patients with chronic noncancer pain (CNP). Chronic noncancer pain affects a diverse patient population with multiple underlying diagnoses and associated therapies. Following the model of the American Board of Anesthesiology and the American Society of Anesthesiologists for practice guidelines and subspecialty requirements, neurologic pain management is now recognized as a subspecialty of neurology by the American Academy of Neurology and the American Board of Psychiatry and Neurology. Current basic and clinical research into the neuropathology, neurophysiology, neurochemistry, and neuropharmacology of chronic pain continues to expand diagnostic and therapeutic options. Informed regulatory agencies and professional organizations such as the American Academy of Neurology recognize the undertreatment of patients with CNP and provide clear recommendations to help neurologists in the ethical and effective treatment of patients with pain. Improved education of neurologists, other health care professionals, patients, and the media about evolving standards of pain care and therapy will produce a more supportive environment for the compassionate and ethical treatment of patients with CNP.
      AAN (American Academy of Neurology), CNP (chronic noncancer pain), DEA (Drug Enforcement Administration)
      The treatment of chronic noncancer pain (CNP) is a practical and ethical issue for neurologists. In current practice, patients with CNP are referred to neurology offices and clinics in increasing numbers,
      • American Academy of Neurology Practice Characteristics Subcommittee
      and daily documentation of pain control for all hospitalized patients, including those with neurologic disease, has become a requirement of the Joint Commission on Accreditation of Healthcare Organizations.
      • Joint Commission on Accreditation of Healthcare Organizations
      In a recent special article, the American Academy of Neurology Ethics, Law and Humanities Committee outlined the ethical issues for neurologists who treat patients with CNP, including its recommendations for current multidisciplinary treatment and future approaches to research, education, and therapy.
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      Unfortunately, multiple barriers (Table 1
      • Doubell TP
      • Mannion RJ
      • Woolf CJ
      The dorsal horn: state-dependent sensory processing, plasticity and the generation of pain.
      • Petrovic P
      • Ingvar M
      • Stone-Elander S
      • Petersson KM
      • Hansson P
      A PET activation study of dynamic mechanical allodynia in patients with mononeuropathy.
      • Urban MO
      • Gebhart GF
      Central mechanisms in pain.
      • Carver A
      • Foley K
      Facts and an open mind should guide clinical practice.
      • Cassel EJ
      The nature of suffering and the goals of medicine.
      • Weinstein SM
      • Laux LF
      • Thornby JI
      • et al.
      Physicians' attitudes toward pain and the use of opioid analgesics: results of a survey from the Texas Cancer Pain Initiative.
      • Weinstein SM
      • Laux LF
      • Thornby JI
      • et al.
      Medical students' attitudes toward pain and the use of opioid analgesics: implications for changing medical school curriculum.
      • Marks RM
      • Sachar EJ
      Undertreatment of medical inpatients with narcotic analgesics.
      • Pilowsky I
      An outline curriculum on pain for medical schools [editorial].
      • Wilson JF
      • Brockopp GW
      • Kryst S
      • Steger H
      • Witt WO
      Medical students' attitudes toward pain before and after a brief course on pain.
      • Galer BS
      • Keran C
      • Frisinger M
      Pain medicine education among American neurologists: a need for improvement.
      • Fishbain DA
      Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient.
      • Hill Jr, CS
      Government regulatory influences on opioid prescribing and their impact on the treatment of pain of nonmalignant origin.
      • Portenoy RK
      Opioid therapy for chronic nonmalignant pain: a review of the critical issues.
      • MacLeod DB
      • Swanson R
      A new approach to chronic pain in the ED.
      ) impede the treatment of CNP by neurologists. Nonetheless, these concerns, problems, and myths are changing through multilevel medical education, ongoing research, and better informed regulatory agencies.
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      Table 1Barriers to Treatment of Chronic Noncancer Pain
      CNP = chronic noncancer pain; DEA = Drug Enforcement Administration.
      * CNP = chronic noncancer pain; DEA = Drug Enforcement Administration.

      THE NEUROLOGIST AND CNP

      The increasing role of the neurologist in treating CNP within a multidisciplinary treatment plan is documented in the recent survey by the American Academy of Neurology (AAN); the Practice Characteristics Subcommittee of AAN indicates that neurologists provide extended and long-term management of several conditions associated with CNP, including headache (77.4% of respondents) and spine or limb pain (47.6%).
      • American Academy of Neurology Practice Characteristics Subcommittee
      The general neurologist will also be evaluating and possibly treating multiple disorders including neuropathy, “failed back” syndromes, radiculopathy, and postherpetic neuralgia.
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      • Carver A
      • Payne R
      • Foley K
      Herpes zoster [letter].
      Neurology residency programs and postresidency neurology practice should provide the background and basic skills for the treatment of CNP. However, the current training programs and educational opportunities for practicing neurologists need further improvements. This enhanced education will translate to skills that will facilitate a better “comfort” level for general neurologists in the diagnostic assessment and treatment of patients with CNP.
      • Galer BS
      • Keran C
      • Frisinger M
      Pain medicine education among American neurologists: a need for improvement.
      The AAN recognizes these issues and “encourages every neurologist to support and participate in initiatives in their institutions to improve the assessment and treatment of pain, and advocates a balanced public drug policy on the use of controlled substances to treat patients with chronic pain and neurologic disease.”
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      Through a comprehensive neurologic assessment, appropriate diagnostic testing, individualized and strictly monitored treatment programs including multidisciplinary consultation, neurologists can improve a patient's quality of life and functioning at all levels.
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      • Cassel EJ
      The nature of suffering and the goals of medicine.
      • Wilson JF
      • Brockopp GW
      • Kryst S
      • Steger H
      • Witt WO
      Medical students' attitudes toward pain before and after a brief course on pain.
      Stabilization of the clinical situation through a structured treatment plan combined with patient and family education about CNP contributes to these benefits. Teaching is not limited to patients and their families. Educating other physicians and health care providers about the treatment of CNP is another opportunity for neurologists to improve the therapeutic environment for their patients with CNP.

      SUBJECTIVE AND OBJECTIVE ASPECTS OF CNP

      The subjective nature of pain is an issue for many physicians including neurologists. This concern has a historical precedent that arose from the separation of mind and body through Cartesian dualism.
      • Cassel EJ
      The nature of suffering and the goals of medicine.
      • Rich BA
      A legacy of silence: bioethics and the culture of pain.
      The mind (spiritual) was historically the realm of religion, whereas the body (objective) became the accepted territory of medicine.
      • Cassel EJ
      The nature of suffering and the goals of medicine.
      • Rich BA
      A legacy of silence: bioethics and the culture of pain.
      Ideally, medicine recognizes the importance of the mind- body connection, and current neurochemical research and neurophysiological research confirm this connection for CNP.
      • Petrovic P
      • Ingvar M
      • Stone-Elander S
      • Petersson KM
      • Hansson P
      A PET activation study of dynamic mechanical allodynia in patients with mononeuropathy.
      • Urban MO
      • Gebhart GF
      Central mechanisms in pain.
      • Carver A
      • Foley K
      Facts and an open mind should guide clinical practice.
      Like the previously “subjective” migraine headache, research in neurochemistry, neuropharmacology, neuro- imaging, and neurophysiology has moved CNP from the purely psychological (subjective) to the neuropathologi- cal (objective). The localization of subcortical pain centers on positron emission tomographic scans,
      • Petrovic P
      • Ingvar M
      • Stone-Elander S
      • Petersson KM
      • Hansson P
      A PET activation study of dynamic mechanical allodynia in patients with mononeuropathy.
      identification of specific receptors like N-methyl-D-asparate receptor,
      • Urban MO
      • Gebhart GF
      Central mechanisms in pain.
      • Carver A
      • Foley K
      Facts and an open mind should guide clinical practice.
      and delineation of central and peripheral pain pathways with clinical neurophysiological testing help to clarify the problems and potential treatments of CNP.
      • Doubell TP
      • Mannion RJ
      • Woolf CJ
      The dorsal horn: state-dependent sensory processing, plasticity and the generation of pain.
      • Petrovic P
      • Ingvar M
      • Stone-Elander S
      • Petersson KM
      • Hansson P
      A PET activation study of dynamic mechanical allodynia in patients with mononeuropathy.
      • Urban MO
      • Gebhart GF
      Central mechanisms in pain.
      • Carver A
      • Foley K
      Facts and an open mind should guide clinical practice.
      Preventive neurochemical regimens for CNP include agents that are familiar to neurologists, including anti- convulsants, anti-inflammatory agents, and antidepressants.
      • Mohamed SA
      • Mohamed K
      • Borsook D
      Choosing a pharmacotherapeutic approach: nonopioid and adjuvant analgesics.
      The treatment plan for the patient with CNP may include use of medications like opioids, which are unfamiliar to many neurologists.
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      • Portenoy RK
      Opioid therapy for chronic nonmalignant pain: a review of the critical issues.
      The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain Medicine and the American Pain Society.
      Understanding the basic neurophysiology and neurochemistry will help to identify new neuropharmaceutical agents for patients with CNP.

      NEUROLOGIST EDUCATION AND ATTITUDES ABOUT CNP

      Regulatory requirements and bioethics dictate the need for a change in the emphasis on pain management in undergraduate, graduate, and postgraduate neurology education.
      • Joint Commission on Accreditation of Healthcare Organizations
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      • Cassel EJ
      The nature of suffering and the goals of medicine.
      • Pilowsky I
      An outline curriculum on pain for medical schools [editorial].
      • Galer BS
      • Keran C
      • Frisinger M
      Pain medicine education among American neurologists: a need for improvement.
      • Rich BA
      A legacy of silence: bioethics and the culture of pain.
      The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain Medicine and the American Pain Society.
      • Federation of State Medical Boards of the United States, Inc.
      Model guidelines for the use of controlled substances for the treatment of pain, May 1998.
      • North Carolina Medical Board
      Management of chronic non-malignant pain.
      The Joint Commission on Accreditation of Healthcare Organizations established pain control issues as the “fifth vital sign” with the assistance of the consensus statement of the American Academy of Pain Medicine and the American Pain Society.
      • Joint Commission on Accreditation of Healthcare Organizations
      The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain Medicine and the American Pain Society.
      Health care providers will need to address pain control issues in patients in hospitals and affiliated outpatient facilities and clinics daily because documentation of treatment and response to pain control is now mandated. Unrelieved pain and suffering are unethical, and neurologists need to know the appropriate treatment through training and education. Education should not be limited to medications, but other treatment modalities, including physical therapy, spiritual counseling, assessing family and social issues, diagnostic and therapeutic activities such as specialized imaging and block techniques, and evaluation for possible psychiatric comorbidities, should be addressed. Appropriate consultation with other health care specialists should be emphasized and defined. All members of the health care team will need to be aware of pain-modifying factors particularly related to medications, including dosing, routes of administration, equianalgesic dosing, half-lives, and adverse effects. The role of the neurologist in the multidisciplinary treatment of pain needs to be experienced by neurology residents. Educational goals should also include attention to attitudes and negative bias often surrounding patients with chronic pain.
      Undergraduate medical education can affect medical student attitudes toward patients with CNP. A specific 6-hour course at the University of Kentucky had a lasting and positive effect on medical students regarding the perception of pain that patients experience.
      • Wilson JF
      • Brockopp GW
      • Kryst S
      • Steger H
      • Witt WO
      Medical students' attitudes toward pain before and after a brief course on pain.
      A study of pain medicine education among American neurologists published in 1999 suggests a need to improve the current neurology residency training in pain medicine and provide more pain symposia at the AAN meeting for practicing neurologists.
      • Galer BS
      • Keran C
      • Frisinger M
      Pain medicine education among American neurologists: a need for improvement.
      In this study, 29% of residency programs had neurology pain specialists. Only 5% of the programs required residents to undergo rotation in a pain clinic; 62% of neurology residents had no clinical training in a pain clinic environment.
      • Galer BS
      • Keran C
      • Frisinger M
      Pain medicine education among American neurologists: a need for improvement.
      Neurology pain fellowships were offered in only 9% of the 155 residency programs that responded to the survey (of 164). This situation will change because of the AAN emphasis on enhanced pain education during residency.
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      A forum to exchange information on the treatment of patients with CNP is provided by the AAN Pain Medicine Section for its members.
      • American Academy of Neurology
      2001-2002 Membership Directory.
      The American Board of Psychiatry and Neurology recognizes this subspecialty and has specific examination and training requirements for certification in the subspecialty of pain management for neurologists.
      • American Board of Psychiatry and Neurology
      In 2000, the first year of certification, 39 certificates were issued.
      • American Board of Psychiatry and Neurology
      Certification statistics as of January 1, 2001.
      Educational approaches for neurologists in the diagnosis and treatment of CNP include increased acceptance by major neurology journals of quality articles on the topic of CNP, expansion of training under guidelines from the Accreditation Council for Graduate Medical Education for neurology residents, more neurology grand rounds on CNP issues, more opportunities for practicing neurologists through continuing medical education programs, and broadening the scope and number of courses on CNP topics at professional meetings such as the AAN annual meeting. Well-designed, controlled basic and clinical research on the pathophysiology and the treatment of CNP should be encouraged and supported.
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.

      PSYCHIATRIC COMORBIDITY AND CNP

      At the graduate and postgraduate level, the few “difficult drug-seeking” patients can taint the neurologist's perception of all patients with CNP. A 1-year study of patients with pain at all the emergency departments of Calgary, Canada, showed that only a small percentage (4%-5%) of all patients seen for chronic pain was responsible for about one third of the total emergency department visits. This minority of patients generated negative perceptions by physicians and nurses toward the 90% to 95% of patients with similar pain problems.
      • MacLeod DB
      • Swanson R
      A new approach to chronic pain in the ED.
      Recommendations from this study included improvement in identifying patients with a diagnosis of drug dependency with referral to the appropriate specialists for detoxification and psychiatric treatment; there was an associated improvement in the medical staff perception of patients with pain in general with this approach and recognition of a different or comorbid psychiatric problem.
      • MacLeod DB
      • Swanson R
      A new approach to chronic pain in the ED.
      Like other chronic syndromes and diseases in neurology, comorbid psychiatric illness can occur in patients with CNP.
      • Fishbain DA
      Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient.
      The comorbid psychiatric disease needs to be diagnosed and treated. For neurologists, an example would be the patient with Parkinson disease with the comorbidity of depression and anxiety; the presence of these psychiatric comorbidities does not discount the underlying Parkinson disease and its need for treatment. A review of psychiatric diagnoses associated with CNP would be helpful in educating practicing neurologists and staff.
      After identification of a comorbid psychiatric disease, referral of the patient to a psychiatrist should be a part of the treatment plan. Good communication between the neurologist and psychiatrist would help to address the pain needs of the patient with comorbid psychiatric disease. Documentation of the psychiatric comorbid disease, including addiction and depression, is essential. This documentation will protect the patient and the neurologist.

      FEAR OF PRESCRIBING CONTROLLED SUBSTANCES FOR CNP

      Despite recent changes in institutional attitudes and policies, fears of audits and reprisals by state and federal agencies for the use of controlled substances persist. Education in the use of opioids, including dosing, adverse effects, patient monitoring, avoidance of medication diversion, appropriate use in treatment plan, and current federal and state regulations, would help neurologists at all levels of training and practice.
      Regulatory agencies have recognized the undertreatment of CNP and have supported active and comprehensive treatment for this condition, including controlled substances. The Drug Enforcement Administration (DEA) in its Physician's Manual: An Informational Outline of the Controlled Substances Act of 1970 (revised March 1990) specifically addresses the issue of pain medications and physician fear and anxiety of reprisals for narcotic pain prescriptions: “These drugs have a legitimate clinical use and the physician should not hesitate to prescribe, dispense or administer them when they are indicated for legitimate medical purpose. It is the position of the Drug Enforcement Administration that controlled substances should be prescribed, dispensed or administered when there is a legitimate medical need” (in the section entitled Narcotics for Patients With Terminal or Chronic Disorders).
      • Drug Enforcement Administration
      The American Academy of Neurology Ethics, Law and Humanities Committee describes the ethical obligations and the necessary assessment and treatment plan with documentation that would be consistent with the DEA recommendations.
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      Controlled substance diversion is a major concern of the DEA, and steps by neurologists to avoid this problem are clear, simple, and straightforward. These steps are delineated by the DEA
      • Drug Enforcement Administration
      as well as the model guidelines established by the House of Delegates of the Federation of State Medical Boards of the United States, Inc.
      • Federation of State Medical Boards of the United States, Inc.
      Model guidelines for the use of controlled substances for the treatment of pain, May 1998.
      Patients with CNP are included within these guidelines; the model guidelines will help effective treatments, avoid medication diversion, and protect against patient addiction.

      CNP AND OPIOID ADDICTION

      Although prescription drug abuse and addiction are serious medical and societal concerns, myths about pain medications and their administration have contributed to the subtherapeutic dosing of opioids and other pain medications for patients with CNP throughout the past 3 decades.
      • Marks RM
      • Sachar EJ
      Undertreatment of medical inpatients with narcotic analgesics.
      • Portenoy RK
      Opioid therapy for chronic nonmalignant pain: a review of the critical issues.
      If the current analgesic medication or its dose does not provide pain relief for the patient, more potent medications should be prescribed or the dose increased until pain relief or pain medication adverse effects occur.
      • Carver A
      • Payne R
      • Foley K
      Herpes zoster [letter].
      The myths add to a hostile environment for using opioids in conjunction with other therapies for patients with CNP.
      • Portenoy RK
      Opioid therapy for chronic nonmalignant pain: a review of the critical issues.
      Continuing education programs for physicians, nurses, pharmacists, patients, and their families are necessary to remove the stigma associated with CNP.
      Using the database of the Drug Abuse Warning Network (source for drug abuse data) and the Automation of Reports and Consolidated Orders System (source for medical use data), a retrospective study from 1990 to 1996 concluded that the increasing medical use of opioid analgesic medications to treat pain does not appear to contribute to an increase in opioid analgesic abuse.
      • Joranson DE
      • Ryan KM
      • Gilson AM
      • Dahl JL
      Trends in medical use and abuse of opioid analgesics.
      The Pain and Policies Studies Group at the University of Wisconsin Medical School, Madison, is an excellent source for current information on pain treatment and the latest federal and state policies on pain management.
      • Joranson DE
      • Ryan KM
      • Gilson AM
      • Dahl JL
      Trends in medical use and abuse of opioid analgesics.
      Opioid tolerance is not abuse. It is an adverse effect of long-term opioid therapy, and both a verbal and a written description of this and other adverse effects of opioid therapy need to be given to the patient if opioid therapy is considered a component of the comprehensive CNP treatment plan. A policy statement by the Federation of State Medical Boards of the United States, Inc, and a position statement by the North Carolina Medical Board on management of chronic nonmalignant pain delineate the differences between medication tolerance and substance addiction.
      • Federation of State Medical Boards of the United States, Inc.
      Model guidelines for the use of controlled substances for the treatment of pain, May 1998.
      • North Carolina Medical Board
      Management of chronic non-malignant pain.
      Substance addiction is a psychiatric condition, whereas medication tolerance is an expected adverse effect of opioid therapy. As with other medications for chronic neurologic syndromes, the doses of opioids require scheduled monitoring and adjustment because of the potential long-term adverse effects. For example, effective long- term treatment of Parkinson disease usually requires an increase in the dose of levodopa/carbidopa, and its long- term use has potential adverse effects. In addition, a dependence on this drug will occur, and the immediate withdrawal of levodopa/carbidopa may lead to severe medical complications.
      • Lang AE
      • Lozano AM
      Parkinson's disease: second of two parts.
      As with therapy for Parkinson disease, counseling, scheduled monitoring, and medication adjustments are essential in CNP treatment.
      A consensus statement from the American Academy of Pain Medicine and the American Pain Society provides excellent definitions for tolerance, physiological dependence, medication withdrawal, addiction, and pseudoaddiction (Table 2).
      The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain Medicine and the American Pain Society.
      • Federation of State Medical Boards of the United States, Inc.
      Model guidelines for the use of controlled substances for the treatment of pain, May 1998.
      • Joranson DE
      • Ryan KM
      • Gilson AM
      • Dahl JL
      Trends in medical use and abuse of opioid analgesics.
      Table 2Current Definitions of Pain Treatment With Opioids
      The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain Medicine and the American Pain Society.
      • Federation of State Medical Boards of the United States, Inc.
      Model guidelines for the use of controlled substances for the treatment of pain, May 1998.
      • Joranson DE
      • Ryan KM
      • Gilson AM
      • Dahl JL
      Trends in medical use and abuse of opioid analgesics.
      • Addiction—a compulsive disorder in which an individual becomes preoccupied with obtaining and using a substance, the continued use of which results in a decreased quality of life
      • Pseudoaddiction—pattern of drug-seeking behavior of patients with pain who are receiving inadequate pain management that can be mistaken for addiction
      • Tolerance—physical adaptation of the body to an opioid with decreasing pain relief with the same dose over time
      • Physical dependence—physical adaptation of the body to the presence of an opioid; it is characterized by signs of withdrawal when use of an opioid is stopped abruptly or an antagonist is administered
      • Withdrawal—acute physiological response to the abrupt discontinuation of long-term opioid therapy or to the administration of an opioid antagonist
      Controlled substance diversion can be prevented. The model guidelines for the use of controlled substances for treating pain are outlined by the policy of the House of Delegates of the Federation of State Medical Boards as cited previously and the American Academy of Neurology Ethics, Law and Humanities Committee.
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      • Federation of State Medical Boards of the United States, Inc.
      Model guidelines for the use of controlled substances for the treatment of pain, May 1998.
      A treatment contract with a patient is a powerful instrument for preventing drug diversion and for identifying patients who need treatment for substance abuse. The signed and witnessed contract should contain the key elements noted in Table 3. Copies of this contract are retained by both the patient and the physician. Informing pharmacists and emergency department personnel about use of the treatment contract for patients on controlled substances may provide valuable input concerning deviations and compliance. In this instance, neurologists can assist in creating a positive and responsive environment for pain management by sharing their experience and knowledge in an educational setting with local pharmacists and emergency department staff.
      Table 3Key Elements of Contract to Avoid Drug Diversion
      • Informed consent
      • One physician prescribing controlled substances
      • One pharmacy named in contract
      • Refills during office hours only
      • Notification of the physician's office of any controlled substance prescriptions from another physician during emergency treatment
      • Description of the prescription flowchart in the patient's record
      • Immediate referral to a drug treatment program or dismissal from the practice for violations of the contract

      BIOETHICS AND CNP

      As described by the American Academy of Neurology Ethics, Law and Humanities Committee, neurologists who treat CNP “have an ethical duty to address pain and suffering” with special responsibilities and ethical obligations to their patients and society.
      • American Academy of Neurology Ethics, Law and Humanities Committee
      Ethical considerations for neurologists in the management of chronic pain.
      Practicing general neurologists, neurology residents, and neurology pain specialists should have the skills and training to reduce the pain and suffering of patients with CNP while complying with and understanding well-established bioethical principles.
      The 4 basic bioethical issues for neurologists are patient autonomy, nonmaleficence, beneficence, and justice.
      • Beauchamp TL
      • Childress JF
      Patient autonomy is in part provided through a comprehensive informed consent contract that clearly describes the therapeutic risks, benefits, and obligations inherent in the physician-patient relationship in the treatment of CNP. Nonmaleficence (avoidance of causing harm) is protected by (1) a well-documented medical and pain history and neurologic examination; (2) appropriate neurodiagnostic testing; (3) solid working diagnoses; (4) identification and treatment of comorbidities; (5) clear discussion of medications and their benefits and adverse effects as well as other aspects of the total treatment plan; (6) monitoring of controlled substances to avoid medication diversion and patient addiction; and (7) routine follow-up appointments to assess any clinical changes or necessary adjustments in the medication or treatment plan. Beneficence (benefits and balancing the benefits against risks and costs) is evident in the relief of CNP, which can increase function and reduce suffering, anxiety, depression, and emotional and social isolation of the patient. These benefits are balanced against the risks and costs, including medication adverse effects, required follow-up examinations, compliance with the informed consent-treatment contract, and medication tolerance if opioids are used. Finally, justice (distributing benefits, risks, and costs fairly) is approached through the neurologist's provision of equal access for consultation and treatment of CNP and the patient's choice of accepting or declining the treatment plan and contract.
      The neurologist can be an effective part of the multidis- ciplinary pain management team. Through education, research, and communication, neurologists can contribute to the ethical relief of pain and suffering in patients with CNP.

      Acknowledgments

      We thank Dr Larry Churchill, Stahlman Professor of Medical Ethics at the Vanderbilt University Medical Center, Nashville, Tenn, for his valuable review of the submitted manuscript.

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