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Rational Perioperative Opioid Management in the Era of the Opioid Crisis: Reply.

To the Editor: The Kharasch et al. editorial is very timely because there is pain with its physical, psychologic, socioeconomic, and spiritual constituents and then there is suffering attributable to pain’s physical, psychologic, socioeconomic, and spiritual consequences. It is ironic that the evolving opioid epidemic may have created an anomaly. Herein overregulated medical practices to contain overzealous prescription of analgesics may be paradoxically inducing iatrogenic pain and thence iatrogenic suffering leading to iatrogenic suicide ideations, behaviors, attempts, and completions. Can it be safely said that no one ideates, behaves, or attempts to commit suicide unless in pain and suffering? Even those who ritually or culturally presume their completion of life as an indication to take the leap of faith toward ending that life may be suffering as a result of spiritual pain associated with futility of existence within the matrix when existence within the matrix spiritually reveals itself as eternally purposeless to them. One of the biggest questions regarding analgesic overdosing incidents has been about when, how, and why to delineate and differentiate these incidents into intentional (suicidal) overdosing versus unintentional (accidental) overdosing. Essentially, each overdosing incident should always be appropriately categorized as suicidal or accidental even if such categorization may seem difficult to impossible after completed suicides. Appropriate categorization can ensure that true incidence of intentional self-harm does not get obscured by falsely higher incidence being deemed to accidental overdosing incidents. Exploration about intent to self-harm may be especially important after near-fatal overdosing incidents so that the survivors can appropriately receive self-directed violence (suicide) prevention management. Correspondingly, the overcautiously defensive healthcare providers may have to also understand that undertreated pain-induced suffering can also lead to self-directed violence wherein providers and their conscience may feel burdened, especially when their patients’ dependence on analgesics may have been iatrogenic and their dependent patients’ helplessness during evolving policy-based withdrawals from analgesics may be iatrogenic too. Thus, shouldn’t the healthcare providers be aware of and concerned about iatrogenicity playing a role in their patients’ suicide ideations, behaviors, attempts, and completions? Moreover, in the presence of unreasonable and inexplicable limited access to buprenorphine, which has low abuse potential as the first-line analgesic to counter pain and suffering, do over-the-counter cannabidiol (CBD) oil and legalized marijuana for recreational and medical purposes become a win–win situation for healthcare providers as well as patients aiming to overcome undertreated pain and suffering? Summarily, there may not be any clear-cut answer for healthcare providers managing pain patients. However, it has been, is, and will always be about striking and then maintaining the delicate balance between (1) prompt diagnosis and management of pre-existing pain, suffering, and self-directed violence among their patients, and (2) astute prevention and containment of iatrogenic pain, suffering, and self-directed violence among their patients.