Pain as a Vital Sign

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The death rate from overdose of prescription narcotics now exceeds that of automobile accidents; and the number of overdose deaths from prescription pain relievers has more than quadrupled since 1999. In order to understand the drastic rise in prescription opioid and heroin addiction over the past two decades, it’s important to consider contextual changes that have taken place simultaneously.

In 1996 the American Pain Society introduced pain as a 5th vital sign, and the Joint Commission adopted it as a standard in 2001. So, in addition to the objective vital sign which serve as indicators of a patient’s health status (respiratory rate, temperature, blood pressure, and pulse), medical professionals are required to ask if patients are in any immediate pain. If the answer is yes, they ask patients to assign a number to their pain on a subjective scale of 1 to 10 with10 being the most painful.

It’s no coincidence that when pain was introduced as a vital sign, the number of opiate pain reliever prescriptions rose dramatically, pain clinics began to pop up in cities all over the country and the rates of opiate addiction (and overdose deaths) began to skyrocket. Yet, many people fail to connect the dots between increase in exposure to prescription opiates and the rise of the heroin epidemic. Inappropriate and negligent prescribing of opiates has been a major culprit in the increase of addiction and a major contributor to relapse among those who have achieved sobriety.

Fortunately, a few weeks ago the American Medical Association in Chicago recommended that pain be dropped as a vital sign. In response to this resolution, critics have argued that with this change, patients’ pain will be ignored, and it will make it harder for pain to be assessed and treated.

If this change makes it harder for pain to be treated in the irresponsible way that we’ve been doing it, then I am all in favor. But for critics to suggest that advocates of this reform are in favor of disregarding or ignoring pain is really missing the mark. With the fast-paced speed of our healthcare system, rooted in our “fix it” (and quickly!) culture, “treating” pain has become synonymous with writing narcotic pain med scripts.

With an average office visit for a primary care patient lasting only 15 minutes, physicians are rarely afforded the time to administer the comprehensive psychosocial evaluations, pain treatment history, addiction risk assessment and psychiatric evaluation that were initially recommended by the American Pain Association as an integral part of pain assessment—a necessary step prior to treating or prescribing. Further, most physician receive precious little in the way of addiction training as medical students, and become doctors who are unequipped to assess addiction risk or identify early (even late) warning signs. What we are left with is a system in which physicians rely solely on the number a patient assigned (1-10) to their pain in order to determine the course of treatment, and most jump to opioid pain medication as the first line solution. Unfortunately, “treatment” often comprises spot treating symptoms, while neglecting to attend to the whole person, and failing to consider long-term consequences of a “Band-Aid,” one-size-fits-all approach to healthcare.

Of course physicians are not ultimately to blame in this equation. Really, this issue speaks to some of the broader problems with our healthcare system today: the separation of mind and body, the lack of adequate training in addiction, behavioral health, and alternative therapies, the emphasis on symptoms rather than wellbeing, and even the reimbursement system which rewards quantity over quality of care.

The debate should center less on what is or is not considered a vital sign, or how we are assessing pain, and more on how we are responding to it. Pain, just like emotion, is our body’s way of communicating a need. What if we were to listen to this message and hone in on the function of our symptoms? If we are too quick to numb, distract from, or extinguish symptoms, we may miss the smoke signal that our body is sending us; potentially putting ourselves in danger or at risk of creating secondary problems down the line.

As with most experiences, pain is multidimensional. According to the Cleveland Clinic, “psychological factors always play a role in pain – they may increase it or diminish it and can even eliminate it all together.” The Cleveland Clinic also notes “many chronic pains are due to changes in the nervous system rather than due to illness or damage to the body.” Since we know that trauma often leads to neurobiological and neurochemical changes in the body—to include abnormal regulation of opioid neurotransmitters— it makes sense that we should attempt not only to identify the root causes of a patient’s pain but also to look at pain from a bio-psycho-social-spiritual framework.

Particularly problematic would be to write a prescription for opioids for the trauma survivor whose pain may have a large psychological component. The opioids would likely mask the underlying issues while potentially introducing the patient to a host of new problems—since she is already more vulnerable to developing an addiction due to the lasting physiological and emotional impact of her earlier trauma.

The bottom line is strong medicine comes with strong side effects. Opioid medications are not an appropriate first line of treatment for many patients with pain.

Imagine an approach to treatment in which an integrated team worked together to create a patient-centered care plan with a rehabilitative emphasis. What if your primary care doctor worked in collaboration with a psychiatrist, physical therapist or musculoskeletal specialist, and psychotherapist to provide coordinated care with an emphasis on sustainable, long term, health outcomes that matter to the you? What if your doctor took the time needed to assess your history and risk factors? What if your doctor had the training to do so and also the knowledge about alternatives to just writing another prescription?

If we could spend more time unifying around a comprehensive approach to treating pain, and less time worrying that people will lose access to opiates, I imagine opioids would no longer be making headlines and would no longer be followed by the word “epidemic.”

And I believe we can do so in a way that does not interfere with those patients who need long term opiate medications being able to get them.

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