Author: MYLES GART, MD
After years of exaggeration, misinformation and a national epidemic of opioid and heroin abuse, the nation is finally coming to terms with the fact that pain is not the fifth vital sign. This heresy, as I understand it, has existed for close to three decades and, in my opinion, has been directly responsible for the deaths of thousands of patients and lethal drug overdoses of hundreds of thousands of American citizens. The misguided acceptance of pain as the fifth vital sign has been and still is the single biggest mistake in the history of modern medical pain management.
In the early 1990s, the American Pain Society opined that there was a national epidemic of untreated pain in our nation’s hospitals and announced that pain should be classified as the “fifth vital sign.” This assertion is riddled with many problems. Vital signs are clinical measurements, specifically: pulse rate, temperature, respiration rate and blood pressure, that indicate the state of a patient’s essential body functions. These clinical measures are very objective in character and include an assortment of relevant numerical values. Pain is a subjective feeling that is impossible to accurately and consistently quantify across patient populations. Therefore, for providers to assess pain as a vital sign, they must ascribe a numerical value for it, such as zero to ten based on the Universal Numeric Pain Scale. As a result of equating pain as a vital sign, medical practitioners must come up with a reliable and effective treatment if and when a patient subjectively rates their pain high on the scale.
In 1998, the Federation of American Medical Boards issued a policy reassuring physicians that “in the course of treatment,” large doses of opioids were acceptable. In 2001, the Joint Commission mandated that hospitals across the country assess pain on each patient they treat. While not stating how facilities should assess pain, the nation relied on what the prevailing thought that pain should be considered the fifth vital sign and treated on the zero-to-ten pain scale. With the support of the Joint Commission, The Federation of American Medical Boards urged individual state medical societies to make the under treatment of pain punishable for the first time.
With misinformation and external pressure by state and national oversight agencies, American hospitals and medical professionals were “steered” to overtreat acute and chronic pain. Failure to comply was tantamount to patient abuse and battery, punishable by citations from medical boards and Joint Commission. Thus, this “virtual” national epidemic of untreated pain and subsequent adoption of pain as the fifth vital sign has, in my view and the view of many clinicians, resulted in the brutal, harsh reality of a national opioid and heroin crisis. As evidence, since pain became the “fifth vital sign,” the number of prescriptions for opioids have escalated from around 76 million in 1991 to nearly 220 million in 2011.
Looking at some recent data from the American Society of Addiction Medicine, one can truly see that the adoption of pain as the fifth vital sign resulted in many adverse and unintended consequences:
- Drug overdose is the leading cause of accidental death in the United States. There were 47,055 lethal drug overdoses in 2014 alone. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers and 10,574 overdose deaths related to heroin.
- From 1999 to 2008, overdose death rates, sales and substance-use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate.
- In 2012, 259 million prescriptions were written for opioids, which, in numeric terms, equates to one bottle of pills for every adult American.
- Four out of five new heroin users started out misusing prescription painkillers. As a consequence, the rate of heroin overdose deaths nearly quadrupled from 2000 to 2013. In 2014, more than 467,000 adolescents were non-medical users of a pain reliever.
How do we pull ourselves out of this opioid abyss and begin to reverse these sobering statistics? First and foremost, we must bury the claim of pain being the fifth vital sign and replace it with a 21st-century pain assessment tool which incorporates objective evidence and measures of pain. We must provide improved pain management education for our health care providers. In June 2016, The American Medical Association (AMA) removed pain as a vital sign. The AMA was followed, in September 2016 by the American Academy of Family Physicians (AAFP). The AAFP voted to drop pain scores as the “fifth vital sign,” partly in reaction to being seen as a scapegoat for the nation’s opioid overdose epidemic. Even Tom Frieden, MD, MPH, director of the CDC, has called the opioid epidemic “doctor-driven.” But physicians in many specialties have explained that they feel pressure to overprescribe opioids to attain higher patient-satisfaction scores for themselves and their hospitals. The Joint Commission must also take steps to remove the threat of hospital sanctions for the perceived under treatment of pain. The federal government, likewise, through the Centers for Medicare and Medicaid, must move towards the removal of the so-called subjective patient assessment of pain from the value-based payments that hospitals receive.
At the same time, when the shackles of state and federal oversight pressures are finally removed, we must embark on a national education program, with the primary emphasis on safely and effectively managing patients with acute and chronic pain. For more than three decades, opioids have been the foundation of acute pain management. In 2014, a database consisting of close to three million patients revealed that 73 percent of those in hospitals receiving intravenous analgesics received only opioids. That number should be zero! The standard of care for acute pain management should be based on a non-opioid platform, better known as a multimodal analgesic (MMA) approach for balanced pain management. Many professional and regulatory organizations support the MMA approach since there has been mounting evidence that this method reduces the amount of opioids required resulting in improved patient safety and outcomes. Failure to comply with this particular approach would result in unnecessarily exposing hospitals and healthcare providers to medical liability. Reducing or eliminating the need for opioids in the hospital setting is not only a mandatory risk-mitigation tool but also a way of improving the prescribing practices outside the walls of health care institutions.
Let us work together to take pain as a vital sign out of our lexicon and begin a new campaign to manage pain in a way that is safe and effective. Inaction is not an option. When faced with the embarrassing fact that the United States makes up just 4.6 percent of the world’s population yet consumes more than 80 percent of the global opioid supply, decide for yourself whether a change in our pain treatment paradigm is urgently needed.
Myles Gart is an anesthesiologist.