Palliative Care and Opioids: A Three-Step Ladder to an Epidemic?

Joshua Rushakoff


This paper is pending publication in a professional journal. Further content will be posted as soon as available.
During the evolution of palliative care from a medical afterthought to a recognized subspecialty, palliative care specialists frequently debated pain control and the utility of opioids.  Much of this rich discourse was shaped by changing patient preferences on care at the end of life.  Following episodic endorsement and then abandonment of opioids by these specialists, the rise of the hospice movement in the 1960s and 1970s marked a turning point, setting the specialty on a course towards wider opioid acceptance.  Seeking an easily translatable model, palliative care leaders in the early 1980s developed the World Health Organization three-step ladder for pain control.  This guideline was disseminated to every corner of the globe, recommending a simple titration for cancer pain- aspirin, to codeine, to morphine.  Normalized by the WHO cancer pain guidelines, opioids became an increasingly accepted element of palliation, especially in the United States.  Pain specialists in the 1980s and 1990s aggressively pushed for wider acceptance of opioids, encouraging prescribers to overcome prejudices about this class of medication.  While palliative care specialists designed the 1986 guideline specifically to address malignancy-associated pain, their principles of palliation were then maladapted for acute and chronic pain, leading to widespread opioid addiction and overdose deaths.  The current opioid epidemic thus stands as an unintended consequence of the 1986 WHO guidelines.  The emergence of palliative care and the opioid epidemic ought to serve as a cautionary tale, warning against the cooptation of new areas of expertise and the oversimplification of guidelines.