Doctors urge pain management rethink amid opioid abuse crisis

In a continuing effort to stem the opioid overdose crisis, delegates from the American Medical Association (AMA), which represents more than 200,000 U.S. physicians, called for the removal of pain as the “fifth vital sign,” at their annual meeting in June. Some advocates warn the move does nothing to address the abuse of pain killers and will make it more difficult for sufferers to have their pain properly treated.

Vital signs—pulse rate, temperature, respiration rate, and blood pressure—provide a basic assessment of body functions. In 1996, believing pain to be grossly under-treated, the American Pain Society (APS) introduced pain as a “fifth vital sign.” In 2001, the Joint Commission, which accredits U.S. hospitals, required healthcare providers to ask all patients about their pain as part of Pain Management Standards. In 2011, Medicare tied reimbursement to patient satisfaction survey scores and asked patients how well a physician or hospital treated their pain. Low scores result in lower reimbursement.

But the emphasis on pain didn’t lower the incidence of perceived suffering. A survey by the International Pain Foundation of more than 1,200 patients revealed more than half rated the quality of their pain care as either poor or very poor. More than 80 percent believed hospital staff did not have adequate training in pain management.

As assessments of pain increased in hospitals and doctors’ offices, so did the demand for stronger medications. Sandy Zuggi, a 32-year nursing veteran, recalled treating one patient who requested 30 Vicodin tablets for a sunburn.

“These patients usually have a sense of entitlement and want their demands met immediately,” Zuggi explained in a hospital newsletter.

Many physicians believe categorizing something subjective like pain as a true vital sign is inappropriate.

“Pain is a symptom, not a vital sign. Blood pressure, heart rate, respiratory rate, and temperature are vital signs that can be objectively measured,” the group Physicians for Responsible Opioid Prescribing (PROB) said in a letter to the president of the Joint Commission. It requested the commission’s pain standards be re-evaluated immediately.

In a separate letter to the Centers for Medicare & Medicaid Services (CMS), PROB asked the agency to remove pain-related questions from patient satisfaction surveys.

Some physicians believe the emphasis on assessing and relieving pain has generated an unrealistic expectation on the part of American consumers that pain can be eliminated in nearly every circumstance.

“What if we correctly promote that pain must be present for us to live and that some pain is good?” anesthesiologist John Hsu wrote in the Pain News Network.

But many clinicians see very little good in enduring physical pain and believe the call to remove pain as a fifth vital sign is a step backward that does not protect those who need and use opioids appropriately.

Hsu disagrees.

“Pain has never killed anyone, but opioids killed over 29,000 Americans last year,” he wrote. “They don’t have any vital signs.”