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UBC Theses and Dissertations

Negotiating the ethics of trust and addiction in chronic pain management Buchman, Daniel Zvi Baker


Pain is one of the main reasons that adults seek health care, yet the management of chronic nonmalignant pain (CNMP) is framed by epistemological, ontological, ethical, and clinical uncertainties. As a subjective experience, CNMP presents challenges for both patients and health care providers. Opioid analgesics are commonly prescribed for CNMP. However, recent research questioning the long-term benefits of opioids for CNMP and the rapid rise in public health harms from prescription opioid abuse have led to concerns about iatrogenic addiction, drug-seeking behaviour, and medication diversion. Such concerns pose risks to the patient, to the health care provider, and to society, and may threaten the trust that provides the moral foundation of the therapeutic relationship. Drawing upon an interdisciplinary literature and methods from both bioethics and empirical neuroethics, this in-depth, multi-component single study focused on adults living in an urban setting in the Lower Mainland of British Columbia, Canada. Semi-structured interviews (N=27) were conducted with participants with chronic low back pain to explore their experiences of trust and trustworthiness in CNMP management. Grounded theory analysis of the data yielded four major themes: (1) fidelity and iatrogenic suffering; (2) communicating the invisible and subjective condition of chronic pain; (3) motive, honesty, and testimony; and (4) stigmatized identities. The findings were response-validated by two feedback groups comprising re-contacted interview participants (N=4) and physician specialists drawn from the same setting who care for patients living with CNMP and addiction (N=6). Qualitative analysis suggests that trust in CNMP management is challenged when patients perceive that their accounts of pain and suffering are considered by health care providers to lack credibility, feel unfairly accused of being deceptive, or sense a combination of both lack of credibility and deception. The dissertation concludes with a discussion of the practical implications of these findings in the context of the broader health care system, and with a proposal for how a trust- centred ethics of CNMP management can involve greater epistemic humility toward improved patient care.

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Attribution-NonCommercial-NoDerivs 2.5 Canada