Yes, Assessing Pain Is Vital

By Lynn R. Webster, MD

A Medpage Today article titled “Opioid Crisis: Scrap Pain as 5th Vital Sign?” lays out similar flawed arguments touted by Physicians for Responsible Opioid Prescribing (PROP). The American Medical Association was petitioned by its Illinois delegates to remove pain’s fifth-vital-sign status.

What are these flawed arguments? One is to falsely equate the Joint Commission standard to assess pain with a mandate to prescribe opioids. If anyone believes that administering opioids is the sole and automatic response to managing high pain levels, that in itself demonstrates a lack of education, knowledge and understanding. Such a perceived mandate would be a terrible misapplication.

The problem is not the Joint Commission standard but what happens afterward. This is where the system is failing with inadequate education about assessing and managing pain. Clinicians should assess and treat underlying disorders that cause pain, and they should work to eliminate the pain, but they should also understand that, for some patients with some types of pain, eradicating all underlying causes or the pain itself may not be possible. Yet pain must be prioritized and addressed. To do otherwise puts patients at risk for a host of complications, the most serious of which is the progression to pain as a chronic destructive pathology.

So, is pain, after all, a vital sign? I have argued in the past that it is. But the main point is that assessing pain is indeed vital, whether or not pain is a vital sign. Furthermore, assessing pain as often as vital signs are assessed would seem appropriate. We assess cognitive function, reflexes and laboratory values, none of which are vital signs but are clinically important signs nevertheless. Pain is a symptom; however, it can become a disease when the nervous system changes as a result of it, as the 2011 report on pain in America from the Institute of Medicine, now the Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering, and Medicine, clearly indicates (“Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.” Washington, D.C.: National Academies Press; 2011). It is better to assess pain often and regularly and treat it adequately while it is still a symptom, and before it can progress to the point of disease, at which point it will demand chronic management, much like diabetes.

Another flawed argument is that we as health care professionals would not use dangerous methods to treat pain if only we could remain ignorant that the pain exists. Incredible as it seems, this is indeed the argument. In a letter dated March 28, 2016, the American College of Emergency Physicians (ACEP) wrote to the secretary of the Department of Health and Human Services to claim that asking patients about their pain care could lead to opioid overprescribing. The fear, also expressed by the members of PROP, is that patients who seek opioids will give poor marks to hospitals that do not provide the drugs, thus driving down financial reimbursement through the Centers for Medicare & Medicaid Services (CMS). Like PROP, the ACEP asked the department to remove questions pertaining to pain control from the 32-question survey known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).

But increased reimbursement for improved health care results in a hospital is appropriate, and CMS should not deviate from the objective of creating incentives for better outcomes, particularly quality of pain control. The HCAHPS questions pertain to how often pain was well controlled and whether hospital staff did everything possible to help control the pain. These are quality improvement measures, and pain control is an important part of quality improvement.

Rational, compassionate in-hospital pain treatment would be better informed by considering the following points: Quality pain control is a critical outcome that must be measured. Quality pain control does not dictate prescribing opioids. Patients should be involved in assessing the quality of their care. Asking patients about their quality of pain control does not dictate inappropriate care. What evidence there is indicates that satisfaction scores do not correlate with prescribing quantities. Writing unnecessary opioid prescriptions in pursuit of greater financial reward is unethical. If scores indicate poor outcomes for pain control, this may be an incentive to learn more about how to treat pain.

The HMD report addressed evidence of poorly managed pain by calling for more comprehensive assessment, and this is the direction in which medicine should move. Health care providers have a professional and ethical obligation to assess and reassess the pain of their patients, not to decide that assessing pain levels should no longer be part of routine care because CMS ties a small part of hospital payments to patient evaluations of how well their pain was treated. Patients often demand unnecessary antibiotics, but ethical physicians must learn when and how to refuse them, informed by the ethics of good care, not maximum reimbursement. Ethical, informed clinicians do not prescribe unnecessary medication for the sole purpose of gaining a high patient satisfaction rating.

The drive to end pain control assessment appears to come from the belief that people with substance abuse problems will complain if a practitioner fails to give them the drugs they seek. Thus, ignorance is deemed a better alternative to appropriate clinical judgment. But supporting evidence for this belief is lacking, as a top CMS official recently wrote in JAMA (2016 Mar 10. [Epub ahead of print]): “It has been alleged that, in pursuit of better patient responses and higher reimbursement, HCAHPS compels clinicians to prescribe prescription opioids. However, there is no empirical evidence that failing to prescribe opioids lowers a hospital’s HCAHPS scores. … On the other hand, good nurse and physician communication are strongly associated with better HCAHPS scores.”

Advocates in favor of eliminating pain assessments are attempting to benefit patients and society at large. The principles that not all pain can be relieved and that opioids are not always the answer are good and deserve wider dissemination. But there is nothing in assessing the quality of pain relief or in patient satisfaction surveys that says opioids must be administered, and if such is automatically happening, then education on pain assessment needs improvement. Pain treatment has never been, nor should it ever be, synonymous with opioid therapy. In its zeal to eliminate problems with opioids, society must not dismiss pain, whether that pain is a symptom or a disease.

Sadly, because of today’s opioid crisis, many patients are being denied humane treatment of their pain. There is no rational argument that appropriate in-hospital pain control contributes to the opioid crisis in our communities. This attack on our most vulnerable patients must stop. The problem isn’t that we ask our patients too many bothersome (to the clinician) questions. Neither does the solution to the opioid crisis lie in denying the majority of patients compassionate pain control.

Lynn R. Webster, MD, is a past president of the American Academy of Pain Medicine and author of “The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us.”