The Real Truth About the 5th Vital Sign – PAIN

Over the past 15-20 years, it is estimated that the chronic pain incidence has doubled. In 2012, it was reported that chronic pain affects more than 100 million Americans or approximately 1 in 4 Americans1. Recently the book, Dreamland, written by Sam Quinones was discussed in Tim Flynn’s post, Oxy Death- It Requires Action by Each of Us. Dreamland is a fascinating read about Mexican black tar heroine and the American opioid epidemic. One aspect of this book I found particularly interesting (and somewhat nauseating) is the role medicine and Pharma played in the opioid epidemic and dare I say the pain epidemic.

Asking about your patient’s pain is likely something you do countless times each day, almost in a hypnotic state, likely without ever considering the effect this may have on your patient or your outcomes. There are many different scales used in medicine, but most commonly, patients are asked to rate their pain from 0 to 10 using the numeric pain rating scale (NPRS). Unfortunately, despite decades of research on pain, there are few tools for clinicians to measure pain objectively, yet pain is known as the “5th vital sign”.

To bring a little clinical scenario to this discussion, last week, I evaluated a 45-year-old female with chronic low back pain for the past 5 years. She is taking heavy doses of narcotic pain killers with a steadily increasing dose over the past 10 months. When I asked her how much pain she was having she reported a 9/10 (but she has a high pain tolerance). I then asked her what her goals are. She bluntly replied “to be pain free”, as if the absence of pain is a god given right. I felt deep compassion for this patient and felt so inclined to apologize to her on behalf of medicine. How did we arrive at the notion that “pain free” is the normal expected state?

In 1996, the president of the American Pain Society, Dr. James Campbell, said in a speech that “if pain were assessed with the same zeal as other signs (vital) are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign”. From this, the idea took hold that America was undertreating pain. This was viewed as an unnecessary epidemic, for medicine now had the tools to treat it…new formulas of opioids.

The following is a timeline of events that may have contributed to this medically induced epidemic:

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In the wise words of Patrick Wall, “If we are so good [at treating pain], then why are our patients so bad?”.

I cannot help but draw the anecdotal conclusion that placing an over emphasis on pain has led to more pain, more medical spending and more accidental deaths as a result. In a 2006 study in the Journal of General Internal Medicine, it was concluded that routinely measuring pain by the 5th vital sign did not increase the quality of pain management. So, why do we continue to place such an emphasis on asking the patient about their pain rating? Why not focus on function? I have been working to change my practice and de-emphasize pain ratings. In stead of asking my patients about pain ratings I now ask them, “If I had a magic switch and could take away all of your pain, what would you go and do?” Taking this approach allows for an honest discussion about the patient’s deepest desires and goals in life. I then use this to focus my plan of care around what is most important to the patient…their function.

So I ask, will you be part of the revolution to change the stigma of pain? I welcome your comments and feedback on this topic.

  1. Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The Prevalence of Chronic Pain in United States Adults: Results of an Internet-Based Survey. The Journal of Pain. 2010;11(11):1230-1239. doi:10.1016/j.jpain.2010.07.002.
  2. Beck M. Doctor’s challenge: How real is that pain? Wall St J. 2011.
  3. Catan T, Perez E. A pain-drug champion has second thoughts. The Wall Street Journal. 2012.
  4. Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J GEN INTERN MED. 2006;21(6):607-612. doi:10.1111/j.1525-1497.2006.00415.x.

11 responses to “The Real Truth About the 5th Vital Sign – PAIN

  1. Selena Horner says:

    If I take a walk back in time, I believe the reason pain assessment became prominent had nothing to do with the outpatient setting. The assessment had everything to do with the inpatient setting. Patients were not being managed appropriately with regard to their pain experience. An inpatient setting is quite different than living in an outpatient setting. Sadly, the yahoos rolled out mandate (AND Medicare has the same mandate) to evaluate pain levels in all settings. There was no thought put into the mandates by the yahoos who created the mandates. The mandate went too far and had the ramifications we now see.

    For years, I broke rules every day at a hospital outpatient setting. I told my supervisors I was not going to report numeric pain levels on every single visit, unless I thought I needed that information and that the information was relevant to the final outcomes.

    With the history you presented… sadly, going back further than when I felt the reality of having to focus on pain, it appears to me, the real reason for the push was mainly for profit. Pharmaceutical profit.

    I’ll disagree with you about pain. We need to know pain patterns and fluctuations. We need to know it is changing. I’ve had at least a dozen or more cases in which the person got the right care because I monitored their pain and their pain responses. Cancer (quite a few times), brain tumor, femoral head necrosis, spinal infection, fungal meningitis, stress fractures, failing surgical plate surgery, failing wired shoulder fracture repairs, osteophyte at end of surgical amputation… just at the top of my head.

    We need to understand their pain experience… help them understand pain… definitely monitor the pain experience (maybe not as closely as the mandates)… and be aware changes in their experience. Please, Brett, don’t ignore their pain experience. We may be the only professional who is taking the time to listen and think. Pain is part of the package: almost every single patient in the outpatient world brings pain to the table. It is our role to determine if it is worrisome or not. Once we know it isn’t anything worrisome, then, definitely, we need to help change the focus. First and foremost though… until we truly believe the pain isn’t worrisome, we need to keep our minds open to insidious possibilities. It may only be insidious a couple dozen times in our full career, but patients are depending on us. We just need to implement a balanced way to assess it – without causing a patient who is overly focused on their pain.

  2. Vicky Workman says:

    As a nurse front line use the pain scale but when asking Patient the pain just show the chart and say Which one of these describes How you feel today. Do note when ask pain level 0-10 get higher level. verse asking How you feel today.

  3. Vicky Workman says:

    Correction from above: When asking the patient about pain level, show them the “Pain Rating Scale” and ask them which one of these describes “How you feel today”. I have noticed that when asking a patient what pain level is from “0-10” the patient reports a higher level. Verses asking “How do you feel today” and showing the patient the “Pain Rating Scale” the patient will report a lower pain level.

    1. Brett Neilson says:

      Thank you Vicky for sharing your experience and thank you for reading.

      Brett

  4. Brett Neilson says:

    Selena,

    Thank you for your comments and sharing your personal experiences. I could not help but draw the same conclusions, that the focus on “treating pain” and pain as the “5th vital sign” was at least in part driven by pharma and backed by pharma with their large pockets.

    As to your “disagreement” with my post, I do not think it is a disagreement at all. You are absolutely right, we need to know the patients’s pain behaviors, pattern’s and fluctuations. We need to thoroughly screen for red and yellow flags. “Pain is part of the package” as you state. I think you said it best, “we need to understand their pain experience” which reaches far beyond the numeric pain rating. This is where I believe we need to change as a profession, stop focusing on the NPRS. We need to have a better understanding of pain neuroscience, discard the old cartesian way of thinking about pain, focus on the patients unique pain experience (that looks at the patient as a person and not a tissue), base goals on function and not on changing pain (this will come with a change in function).

    Thanks again Selena for your thoughts and comments.

    Brett

  5. Gina says:

    As told to me by a very wise Doctor that I work with, number one rule of medicine ” All Pt’s Lie ” . Yes , it seems harsh , but in my 20+ years of nursing in a hospital ER and ICU setting, I can say that about 95% do inflate their symptoms and pain level. The whole “5th vital sign” started this trend of addiction that we see today. Until we are able to accurately measure pain level, just as the other vital signs are measured, I will never believe the pain scale as part of a true assessment. As an experienced nurse, 80% of the time you can read obvious signs of pain and know that the pt is truly hurting. A high BP, sweating, restlessness, doubled over , these are signs of a level 10 pain. Talking on the phone, laughing with family and the pt tells me their pain is still a 10/10 ?? That’s pure BS and a ploy to get some pain meds IV. Pain has never killed anyone, everyone has pain in their daily life at times. That does not justify narcotic use. People need to learn other means of pain control …..

    1. Don Weasley says:

      Bravo.

  6. Rick says:

    Historically there have been many programs with good intentions later discovered to have adverse unintended consequences. The pain as a 5th vital sign is one of several programs that seamed good but resulted in excess mortality. The VA COPD quality initiative is another one. We should never nationally institute programs such as this without evidence these programs have a net benefit. Luckily, the VA COPD program was studied during implementation rather than assuming it would work. The study was halted when excess deaths were noted. In the case of “5th vital sign” the implementation was irresponsible – No improvement in pain and increased death and addiction.

  7. Joseph Tangara says:

    What a shame! As we doctors debate whether or not patients are lying to get pain meds, more patients are committing suicide because they are now blocked from getting the opioids that helped them control their pain and which they used responsibly for the past 10-15 years. I’ve always wondered why we don’t prescribe Narcan more often–for instance, why we don’t ensure that long-term chronic pain patients and their families always have access to Narcan. With the big push the past 2 or 3 years to reduce prescribing opioids, we’ve let the government dictate to us and get between our patients and us. As we prescribe fewer and fewer opioids–even for those who truly need them–the rate of overdose deaths from prescription opioids has decreased. Unfortunately, the rate of death from illegal opioids has increased. I’m an anesthesiologist who believes that the government should not be able to tell me how I should treat my patients. I mean, suppose the government came out with regulations, guidelines and laws that said that bloodletting is an acceptable treatment for pain? Would we do it? Or would we tell the government to stay out of the doctor-patient relationship?

  8. Jan says:

    My concern about chronic pain management is that it doesn’t happen anymore due to the “War on Drugs”. For years I have suffered with severe pain without pain management nor interest in what was causing the pain. In seven cases I needed surgery by the time the cause of the pain and disability was diagnosed. Two of those procedures were major spinal surgeries with multiple fusions. The patients need to be listened to. Anyone who wants to start a war concerning healthcare need not look any further than the obesity rate and daily deaths that result from our American diet. Just sayin’.

  9. R Torres says:

    What a shame! As we doctors debate whether or not patients are lying to get pain meds, more patients are committing suicide because they are now blocked from getting the opioids that helped them control their pain and which they used responsibly for the past 10-15 years. I’ve always wondered why we don’t prescribe Narcan more often–for instance, why we don’t ensure that long-term chronic pain patients and their families always have access to Narcan. With the big push the past 2 or 3 years to reduce prescribing opioids, we’ve let the government dictate to us and get between our patients and us. As we prescribe fewer and fewer opioids–even for those who truly need them–the rate of overdose deaths from prescription opioids has decreased. Unfortunately, the rate of death from illegal opioids has increased. I’m an anesthesiologist who believes that the government should not be able to tell me how I should treat my patients. I mean, suppose the government came out with regulations, guidelines and laws that said that bloodletting is an acceptable treatment for pain? Would we do it? Or would we tell the government to stay out of the doctor-patient relationship?

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