PAIN: THE FIFTH VITAL SIGN
Waqar Aziz, MD
"Every form of addiction
is bad, no matter whether
the narcotic be alcohol,
morphine or idealism."
- C.G. Jung
P
ain management is the topic on every
provider’s mind these days. Since the
Centers for Disease Control’s latest
statistics reported 28,000 opioid deaths in
2014, with over half of those deaths from
prescribed opioids, the pain management climate has changed. The monster that is being
created in the United States is very real.
We have all seen patients come into the recovery room rating their
pain a 10 without being asked and still so drowsy from anesthesia
they are slurring their words. In the provider offices, teenagers will
come in smiling but say their sprained ankle pain is a 10/10, when
just a few years ago these same teens would have continued their
sports, never reporting their pain for fear of being put on the sidelines. The United States prescribes 80 percent of the world’s opioid
prescriptions. It is hard to believe that our country has more pain
than all other countries combined. When pain started being assessed as the fifth vital sign, a Pandora’s Box was opened that has
let forth a multitude of woes and everyone in health care is in crisis
mode.
According to an April 18, 2016, Joint Commission statement
on pain management issued by Dr. David Baker, Executive VP of
Healthcare Quality Evaluation with Joint Commission, there are
five misconceptions about JCAHO standards that he feels need to
be addressed:
• The Joint Commission endorses pain as a vital sign.
• The Joint Commission requires pain assessment for all patients.
• The Joint Commission requires pain be treated until the pain
score reaches zero.
• The Joint Commission pain standards push doctors to pre6
LOUISVILLE MEDICINE
scribe opioids.
• The Joint Commission pain standards caused a sharp rise in
opioid prescriptions.
In the quest to find someone to blame for the current epidemic, he
feels JCAHO has been unduly singled out. Dr. Baker states it was
never JCAHO’s intent for pain to be assessed as a vital sign or the
use of opioids to get patients' pain to a zero.
In 1995, then President of the American Pain Society, Dr. James
Campbell contended that by addressing pain just like other vital
signs we would assure that pain was considered at each and every
patient encounter. This idea caught the attention of not only JCAHO but also the Veterans Health Administration (VHA). Having
these two powerful organizations on board helped the adoption of
the current standards used throughout the United States for pain
assessment.
Pharmaceutical companies delivered long-acting opioids such
as OxyContin, the opioid that would treat pain but not addict the
patient. It was considered unlikely to be abused because of the
time-released coating. There has been a 300 percent increase in
subscribed opioids over the past years and patients quickly learned
how to crush, snort and inject these medications, not always with
the best of results. Emergency room visits for abscesses, cellulitis,
DVTs, overdoses and death from injecting medications that were
never meant to be used intravenously soared. In 2010, over 12 million Americans said they used opiates for causes other than their
intended use.
Patients quickly found the magic number that would get them
the pain medication they wanted. They also knew what diagnoses
would get the prescriptions they wanted and be difficult for providers to refute. Soon there was an increase in diagnoses of back pain,