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A group of medical organizations has written to the Joint Commission, urging it to drop pain as a 5th vital sign in the wake of the opioid abuse epidemic. Is it time to get rid of pain as a 5th vital sign?
Under comments:
numa turner
Apr 16, 2016
The problem as I saw it was it was totally subjective. We don’t ask people what their blood pressure is. Granted that there is no objective way to measure pain, treating it as a vital sign can cause confusion for doctors and patients. I worked for the VA and our performance was often based on this “fifth vital sign ” and how we responded. I often saw patients on large doses of opioids who still claimed 8 out of 10 on the pain scale. What do you do with that?
This is all about money, not patients. Medicare is trying out different programs to reduce healthcare costs, and performance-based pay is one of them. How to determine if a doctor is doing his job? Ask the doctor or the patients? But PFROP is using the media- and government-hyped opioid “epidemic” to cozy up to all the doctors who hate patient reviews, especially if it’s costing them money. It’s a lesson on how to gain power and influence by increasing the number of people who support anything close to your agenda.
It’s like doctors think the only reason for a patient to give them a low score is because the doctor wouldn’t prescribe painkillers. Of course, the 400,000 patients who die every year due to the mistakes of doctors don’t get a chance to fill out a performance review. I’m guessing that many more doctors will be getting low scores because they will refuse to adequately treat both acute and chronic pain. And don’t you think they know that? This isn’t about patients, this is about money. And ideology.
Just think, if every tooth in your mouth constantly ached and throbbed, what would your pain levels be? My current pain levels average about a 7 on the 1-10 scale, but that hasn’t always been the case. I’m talking about the progression of an intractable pain condition over a 30-year period. How do you track that on a 1-10 scale? Even when I was on opioid therapy, my pain levels progressed, albeit more slowly than during the times when the pain was (and is) under-treated or untreated.
I also estimated that I received, on average, a 25% reduction in pain with opioid therapy. Did that change my average pain levels? Did my pain levels go from a 7 to a 5.25? No, that’s not what happened. The prescription drugs mostly kept me stable at a 7 (and away from a 10 and thoughts of suicide). After all, drugs are a treatment for pain, not a cure.
Let’s also acknowledge that rating pain on a scale of 1-10 is a very basic and inadequate measure of pain. Many things can affect how you rate your pain, like fear, anxiety, depression, insomnia, and anger. And also things like age, gender, and DNA.
“I often saw patients on large doses of opioids who still claimed 8 out of 10 on the pain scale. What do you do with that?”
As a doctor, you should try to understand all of these nuances, and that the pain scale is not an x-ray or blood test (none of which are 100% accurate). And as a doctor, stop putting so much pressure on pain patients to improve — why are you expecting miracles from drugs? Do you think drugs can stop the aging and degenerative processes? Do you expect all of your patients to improve from one treatment option? What kind of improvements are you demanding from your patients?
Patients are afraid to report any improvement in their pain levels. How are doctors going to change that dynamic? I’m guessing that doctors are now understanding how dentists feel, since most patients hate and fear going to the dentist. And do you know why? Because it’s freaking painful, that’s why.
All Things Chronic 
Ex-freakin-actly. It isn’t a cure, and they should know that.
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I am so angered by this idea, knowing how much pain a patient is in will help the doctors know what is going on with the patient. I know that the current subjective scale is nowhere near as reliable, in terms of every patient, because it is subjective, but it is necessary pain and how much there is in an acute situation can help diagnose the illness or problem. Pain control is very important to keeping acute pain just that acute, short term, so it does not get a chance to develop into chronic pain.
Proper treatment for pain even in chronic pain patients is necessary, we are more tolerant in many cases to medications and our pain medication dose, frequency and type need to adjusted to help ease the pain in an acute pain scenario, like when I needed to have my gallbladder. The surgeon thought I was exaggerating the pain I felt because he did not understand how to deal with a chronic pain patient. The ultrasound and CT scan showed that my gallbladder was full of stones. The doctor got a huge surprise when he laparoscopically went in for my gallbladder and found it was about to burst from the number of stones in it and it was blocked on top of beginning to become necrotic. My high tolerance for pain I have developed over the 12yrs I have had from high chronic pain levels so I didn’t realise the discomfort and pain I felt caused by my gallbladder was as serious as it was because I deal with so much more daily.
We need to keep pain as the 5th vital sign because it is more important than bureaucrats and government alphabet soup agencies understand it to be. They are worried about the “Opioid Epidemic,” and will soon have the “Increasing Death Rate Because We Didn’t Value the Importance of Pain Ratings Epidemic.” I am sure they will spin it to place blame elsewhere, but this is just another sign that our Healthcare system is being destroyed by bureaucracies and government alphabet soup agencies.
I’m sorry for such a long comment, but it really angers me how our healthcare system is being destroyed.
-Andrea
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Dude, don’t ever be sorry for the length of your comments. Reading the stories and opinions of other pain patients is how I learn. 🙂
I recently read an article about the increase in cost for diabetes medications, but it also mentioned that during the time frame studied, diabetics increased their use of insulin by 20%. The longer you use a medication, the less effective it becomes; so yes, increased dosages are sometimes necessary (but not always). But increased dosages of opioids are not harmful, unless taken in combination with other drugs. In fact, opioids are safer for long-term use than any other drug, even aspirin. With over-the-counter drugs, you get organ damage and failure; but one of the few dangers of opioids is potential addiction, which only affects a small percentage of those who take these drugs.
It’s funny, I’ve read quite a few stories of pain patients having their gallbladders removed, including my own. The pain in that area didn’t become acute until after I was forced into a cold-turkey detox. At first I thought the detox caused the gallbladder attack, but the surgeon said it was already necrotic. (Funny too, I don’t miss my gallbladder at all.) I’m sure all the medications I was taking masked some of the pain, but my high pain levels are also to blame. (Hey, that rhymes.)
I know a lot of pain patients still rely on their doctors, but I can’t tell you how great it feels to no longer be dependent on doctors for my pain relief. And while I’m still entangled in the drug war, at least I can make my own healthcare decisions.
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People with pain trying to explain the insanity and absurdity of this system to doctors is like teaching a graduate course to kindergarteners. After 100 years of trying to explain, they still don’t get it. All they understand is their own bottom line. Personally I think we should limit the discussion to each other and focus on ways to wrest control of pain medication from these idiots and the government hacks who protect their monopoly.
BTW what that commenter said about the VA is bullshit. Patients don’t do doctor evaluations at the VA and as far as I know there is no performance oriented pay for pain treatment. Why would there be? They routinely ask you what your pain levels are and routinely do nothing regardless of what you report. They may as well be asking you about the weather for all the difference it makes. “Pain as the Fifth Vital Sign” is a farce.
I know Purple Week is over but we need more of this:
http://www.bbc.com/news/world-europe-24607870
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Payne Hertz, I completely agree with you about trying to explain this to doctors and love the analogy you used. I also agree that the government, & I’ll add Big Pharma, are trying to control things. I agree that the VA, at least what I know of from the people I know in their care have never done a doctor evaluation and are good to try to manage pain to the best of their abilities.
I don’t understand what you mean when you said “‘Pain as the Fifth Vital Sign’ is a farce.” I worked in the ER of a hospital system in Texas as a scribe for the ER doctors, I worked side by side with them not the transcriptionist kind of scribe, and we recorded the vital signs of heart rate, blood pressure, blood oxygen saturation, respiratory rate and pain level (based on the 1-10 scale.) Why is pain as a vital sign a farce?
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Because it’s easy for doctors to ignore, especially since they don’t appear to believe in the only system available to rate pain. If one patient says their pain is an 11, and another patient says theirs is a 5, does the 11 get stronger drugs? Treated any differently? If the records say the patient indicated a pain level of 11, yet the doctor only agreed to treat this high level of pain with Tylenol, does anyone get in trouble? Will a doctor get paid any less if he refuses to prescribe painkillers? No, these kinds of doctors will probably get an award from the state or federal government, while some of their patients will start shopping for a gun.
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At the VA, they always ask you your pain level but as I mentioned in my post, they never actually do anything about it. If your blood pressure is high they will ask if you are on blood pressure meds and send a note to your doctor about your levels. Pain? They completely ignore it. There is no obligation to actually do anything for the pain outside the VA as well so yes it is a farce.
It’s interesting that every discussion of pain “treatment” assumes the involvement of doctors as a given, despite the fact the majority are not properly trained or willing to treat pain. In my opinion “pain relief” should be assumed to be a personal issue barring the inability of a particular person to attain relief through his own efforts.
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The only way for patients to get any power in this fight is for all drugs to be legalized. Unfortunately, I won’t be around when that happens.
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