The primary goal of life is to perpetuate the survival of the genome (genetic code). This is the reason we fear and avoid danger for ourselves and others. Survival is the reason for compassion, empathy, the sex drive, as well as all forms of pain and suffering. We can only manage what we can measure, and the primary metric of survival of the self and genome is the perception of pain and pleasure. Optimal function depends on the timely perception of pain and pleasure and how it relates to the survival of the self and of others in an ever-changing environment with ever changing threats.
Pain compels us to avoid harm and pleasure motivates us to pursue rewards that are essential to our survival and the survival of our family, tribe, or species. The ways that pain protects us, and pleasure motivates us are too numerous to count. Let us consider the motivation for maintaining the proper water balance in our bodies.
Approximately 60 percent of the human body is made up of water. A tight balance of water volume must be constantly maintained. Too much or too little water in our bodies can be deadly. One of the ways that the body regulates its fluid volume is by the perception of
pain and pleasure. If an individual is deprived of constant replacement of lost water from the body, their conciseness will perceive a form of pain called thirst. As a result, that person will develop a strong behavioral compulsion to approach a water cooler, a soda machine, or a glass of iced tea to satisfy this compulsion. Swallowing the liquid will provide a sense of pleasure and as a result, the body does not go into hypovolemic shock or suffer any other consequence of dehydration. Caloric and nutritional maintenance are governed by the same principles of pain and pleasure in the form of hunger and satiety.
The reason that we are motivated to expend time and energy to take our next breath is motivated by the fact that it is painful to allow carbon dioxide to build up and oxygen levels to fall. Our bodies are equipped with chemoreceptors that constantly analyze our blood chemistry and report to our central nervous systems on the need to adjust our behaviors to maintain homeostasis. In the case of respiratory drive, it is painful to go too long without a breath and it gives a slight sense of pleasure to inhale and exhale every few seconds.
Under ordinary conditions, comfort marks the goal of optimal function and subsequent survival odds. This is only true if the perception of pain and pleasure is based on true perception of the environment and is not chemically altered. Once exogenously produced, dopaminergic rewards are added into the mix, our perception of pain and pleasure is no longer a true compass of our function and our survival, but is rather simply determined by the chemical content of our blood as it courses through our brain’s mesolimbic system.
In 2023, over one hundred thousand Americans died of an opioid overdose. The actual cause of death was the fact that each person took pleasure producing drug that falsely elevated the individual’s hedonic tone into such a state of pleasure that they could not even detect the harm posed by
the lack of oxygen and the buildup of carbon dioxide. Hypoxia and hypercapnia, under ordinary circumstances, are a painful conditions that compel us to take our next breath. Pain and pleasure provide a compass for our motivations and behaviors. When these perceptions are blunted, our bodily functions are often flying blindly. It is important to point out that opioid pain medications do nothing to heal damaged tissues or other bodily structures. They are simply a way to treat the mind. Oxycodone does not heal a broken bone, opioid and benzodiazepines simply changes a patient’s consciousness, lowering the salience of the broken bone or the fear. In this sense, both are purely psychiatric treatments.
To better understand this perspective, let us consider the following hypothetical. If a person finds their hand in a fire, burning the flesh, should they remove their hand from the fire or take a medication so they do not suffer with the destruction of the hand? Of course, the logical answer is to remove the hand from the fire, but far too often in modern American society, we leave our hand in the fire and take a pill so that we do not suffer from the damage and then wonder why we have lost function in our hand. Drugs that mitigate the consequences of our behaviors allow us to continue the harm and subsequently, we lose function. Drugs that provide a chemical comfort from the protective nature of pain often allow us to sacrifice function for the sake of comfort.
This book reveals many of the complexities involved in the ethical use of controlled substance medications in clinical practice. Medical decisions must involve a wisdom based in scientific data and tempered by the experience of a trained medical professional.
Federal and state regulatory authorities have collectively determined that some therapies involve such complex considerations of the risk to benefit ratio that unanimous agreement must be established by both the patient and a licensed medical professional. The patient clearly has a right to veto any treatment that he/she feels is inappropriate. State and Federal governments have added a second requirement for patient protection before moving forward with prescription therapies. The assessment of a favorable risk to benefit ratio for both short-term and long-term side effects must be established by the both the patient and a licensed medical professional to move forward with the therapy. If either party feels that the risk to benefit ratio (non-maleficence / beneficence), for both of short term and long-term adverse effects is unfavorable, each has the responsibility to block the therapy from moving forward.
Withholding end-of-life care, controlled substances should be used in the lowest dose and for the shortest duration possible. This cautionary approach will reduce the risk for unintended, adverse effects to the nervous system. If at any point the patient or the treatment provider feel that the risk to benefit ratio is no longer favorable, each has a duty to responsibly taper the medication or to otherwise find a safe exit strategy from the therapy.
In hospice cases, when end of life is near, the priority of treatment goals may be reversed, with comfort taking priority over function. While certain comfort measures, such as the use of respiratory depressant medications, may contribute to functional decline of the patient, these priorities are proactively discussed and agreed upon with the patient and legal caregivers. In such cases, more aggressive use of comfort medications such as opioid and benzodiazepines may be warranted.
In the case of controlled substance management, the medical professional must carefully consider the ratio of beneficence and non-maleficence both for the short term and for the long term. This is particularly important if the therapy in question is only intended to provide comfort, and that comfort may reasonably be expected to compromise function. If after careful discussion and patient education, the medical professional and the patient cannot reach a treatment agreement based upon each of their assessment of the risk to benefit ratio (non-maleficence/ beneficence), paternalism must prevail over autonomy as a fail-safe protection to the potential harms of these powerful and complicated therapies.
In the words of Socrates on the perception of pain and pleasure as recorded by his student Plato, circa 399 BC:
“What a strange thing that which men call pleasure seems to be, and how astonishing the relation it has with what is thought to be its opposite, namely pain. A man cannot have both at the same time. Yet if he pursues and catches the one, he is almost always bound to catch the other also, like two creatures with one head.”
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