Friday, August 29, 2014

Pain is not the "5th vital sign"

No, contrary to what you may  have heard, pain is not the 5th vital sign. It's not a sign at all.

Vital signs are the following: heart rate; blood pressure; respiratory rate; temperature.

What do those four signs have in common?

They can be measured.

A sign is defined as something that can be measured. On the other hand, pain is subjective. It can be felt by a patient. Despite efforts to quantify it with numbers and scales using smiley and frown faces, it is highly subjective. Pain is a symptom. Pain is not a vital sign, nor is it a disease.

How did pain come to be known as the 5th vital sign?

The concept originated in the VA hospital system in the late 1990s and became a Joint Commission standard in 2001 because pain was allegedly being undertreated. Hospitals were forced to emphasize the assessment of pain for all patients on every shift with the (mistaken) idea that all pain must be closely monitored and treated .

This is based on the (mistaken) idea that pain medication is capable of rendering patients completely pain free. This has now become an expectation of many patients who are incredulous and disappointed when that expectation is not met.

Talk about unintended consequences. The emphasis on pain, pain, pain has resulted in the following.

Diseases have been discovered that have no signs with pain as the only symptom.

Pain management clinics have sprung up all over the place.

People are dying. In 2010, 16,665 people died from opioid-related overdoses, a four-fold increase from 1999 when only 4,030 such deaths occurred. And the number of opioid prescriptions written has doubled from 109 million in 1998 to 219 million in 2011.

Meanwhile in the 10 years from 2000 to 2010, the population of the US increased by less than 10% from 281 million to 308 million.

Doctors are caught in the middle. If we don't alleviate pain, we are criticized. If we believe what patients tell us—that they are having uncontrolled severe pain—and we prescribe opioids, we can be sanctioned by a state medical board or even arrested and tried.

Some states now have websites where a doctor can search to see if a patient has been "doctor shopping." I once saw a patient with abdominal pain in an emergency room. After looking up her history on the prescription drug website, I noted that she had received 240 Vicodin tablets from various doctors in the four weeks preceding her visit.

That's a lot of Vicodin, not to mention a toxic amount of acetaminophen if she had taken them all herself during that month.

What is the solution to this problem?

I don't know, but as long as pain is touted as the fifth vital sign, I do not see it getting any better.

39 comments:

Anonymous said...

What about oxygen saturation?

Bernard Carroll said...

Rather than say “A sign is something that can be measured,” it would be more accurate to say a sign is something that can be observed. Some signs are routinely measured – like vital signs – but there are many classic signs of disease in medicine that we don’t routinely measure. We observe pitting edema of the ankles in heart failure or wheezing in asthma or a positive Babinski sign after a stroke, as just a few examples.

This issue of objective versus subjective clinical data carries over to psychiatry, too. The anti-psychiatry folks like to say psychiatry has no objective signs. But well trained psychiatrists can recognize many signs of psychopathology – pressure of speech, flight of ideas, clang associations in mania; formal thought disorder in psychoses; memory disturbance and confabulation associated with Korsakoff’s syndrome or with thalamic strokes; psychomotor retardation in melancholic depression.

Skeptical Scalpel said...

Yes, SaO2 would qualify as a vital sign in my opinion.

Bernard, you are correct. I was focusing on the vital signs and didn't consider that many clinical signs such as the ones you mentioned and things like Cullen's sign. I should have said that signs are objective and pain is clear subjective. I won't argue with you about whether the psychiatric signs you described are really signs.

Anonymous said...

Also, vital signs are vital. They predict imminent death. No pulse, no respirations, no BP--it's over. Even fever, in the pre-antibiotic days when the classic vital signs were defined, was a predictor of death. Awful as it can be, pain is not a reliable predictor of impending death. O2 Sat, level of consciousness--these are vital signs. Pain is not.

Skeptical Scalpel said...

Anon, that's another good point. "Vital signs are vital."

Anonymous said...

So true. It continues to amaze us when women (invariably first timers) rate their labor pain as 8/10 when they are happily watching TV or using their Ipads...just goes to show that pain is not only subjective, but also based on experience. Not sure anyone who hasn't had really extreme pain can truly imagine it.

Skeptical Scalpel said...

I agree with you. One person's 5 is another person's 9. It is impossible to know what an individual patient is really feeling.

Anonymous said...

When someone designs a probe that measures pain, I'll call it a vital sign. I vote for a rectal probe.

Skeptical Scalpel said...

Why don't you start working on that?

DD said...

A trauma surgeon, working in a burn unit, refused to give an outpatient, otherwise healing well after skin grafting, a refill on Percocet. His reason: "Pain medicine does three things and two of them are bad".

Skeptical Scalpel said...

DD, I'm not sure I get what the three things are. They relieve pain and can be addicting. What's the third one--constipation?

A postop patient who is reliable and has pain should be given the benefit of the doubt when it comes to refills.

Anonymous said...

I've often wished for a "pain calibration" machine, akin to the nerve induction box in the Science fiction book "Dune" by Frank Herbert. You put your hand in the box and it induces progressively severe pain, without causing injury.

If a patient reports 11/10 pain, they could be instructed to put their hand into the #4 "box" for a reference point. Brave souls could try out the #6 box. The #8/10 box would probably never get used.

Skeptical Scalpel said...

Anon, thanks for commenting. That's a very interesting suggestion. I bet it would cut down on unnecessary ED visits. Alas, it will never be happen.

Michael Negraeff said...

I commented on your post on Kevin MD. I get your point about the vital sign thing. It was an awareness tool with good intentions that jumped the shark...AND a whole bunch of other things happened leading to our current mess. Simple it is not in causes or solutions.
I worry now we may swing back the other way too far. Already we have surgeons prescribing little or no opioid after fairly major interventions ("see your GP") and GPs doing the same, nobody in ER wanting to touch the pad, and some doctors turning in their pad altogether. Everyone fearful of lying, addicted, criminally minded patients, and authorities breathing down their necks. These are all very real concerns. It’s a major sad destructive issue - both pain and the addiction.
Docs treating addiction and docs treating pain often remain ideologically entrenched and can't or don't want to find a common way forward.
I'm in Canada, where we have the same problems with over, under, and bad prescribing, but also legitimate patients caught up in the middle. It is a complicated problem with moral, legal, social and scientific layers that we are struggling with.
The solutions lie in examining how we practice medicine (can't deal with this in 8 minute visit, alone, in a silo, without others helping you); public discourse about public knowledge and beliefs about pain and treatment; de-stigmatizing chronic pain; improving education about all of it in medical and other HCP schools; empowering self-management skills so opioids become less attractive as the only or most important tool; find solutions for co-morbidities of pain and addiction, pain and mental health, pain and social determinants of health.
It's hard, but has to be done. We are tackling that work, hosting conversations, and engaging the system in British Columbia with Pain BC Society.

Skeptical Scalpel said...

Michael, thanks for commenting. I agree that many docs are becoming reluctant to prescribe any opioids. Can you blame them?

I hope your project in BC is successful.

Sherry Gilles said...

This jade and sarcasm are working against the patients. Why do you continue to work as a surgeon?

Michael Negraeff said...

No, I can't blame them in the current situation. But the solution is not to go back to not measuring, not asking, about pain. My point is we need to do that and confront the challenges of prescription drug abuse, which has multiple causes. Not an either/or equation.

Skeptical Scalpel said...

Sherry, I don't know what you mean by "jade." I retired about two years ago. I feel sorry for the patients who have real pain because they are the ones most affected by the shift toward prescribing less pain medication and the upcoming reclassification of hydrocodone/acetaminophen as a schedule II drug.

Michael, I understand your point. It's not going to be easy to fix this.

Sherry said...

I am a nurse, disabled and retired due to vision loss, of 23 years. I saw those ortho patients whose doctor claimed he had structurally fixed the patients so they didn't need much in the way of narcotics. I sense no empathy for the patients. Also, an aging population will have more pain. Do you have pain? Not everyone is stoic and, for the most part, I find that it's a good practice to listen to patients and let them define their experience.

Skeptical Scalpel said...

Sherry, sorry about your vision. Thanks for commenting. Postop patients are really not the issue most of the time. The real problem is pain without an obvious cause and no way to be sure how bad it is.

Sherry said...

I entered the field in the time when "pain is what the patient says it is." I still believe that. The whole concept of pseudoaddiction is iatrogenic. As I've gotten older I have more pain. I rarely get a thing for it because my doctor sports the attitude of the young and unbroken. She, and many other doctors, will figure it out when they are no longer relevant. It will be too late. I think that the actions of the DEA are overreaching. I didn't mention that I am also a Certified Death Midwife and a strong supporter of the Death Cafe. We need more compassion and more trust. There are always folks willing to game the system but it's not the majority. As to the Tylenol comment earlier in the thread that med does NOT belong in every other med. That's fixable if unpopular.

Skeptical Scalpel said...

Sherry, if you still believe that pain is what the patient says it is, you haven't been in an ED recently. Lots of drug seekers show up in EDs complaining of pain. If they all received opioid prescriptions, the drug abuse epidemic would be much worse.

Sherry said...

People that see their doctors in their offices are being treated as drug seeking. That's wrong, most of the time. Do you have pain? Or does it matter because you will always have doctor friends who will write for what you need? I'm curious because I learned over the years that the most compassionate doctors have been patients first.

Skeptical Scalpel said...

I don't have pain. I had rotator cuff shoulder surgery about a year ago. Took about 6 Percocets during the first 3 days. (http://skepticalscalpel.blogspot.com/2013/10/on-wrong-side-of-knife.html)

I went to physical therapy twice a week for 4 months where the therapist manipulated my arm. The pain was excruciating because the shoulder had become very stiff due to the immobilization required. I didn't take anything for it because it stopped shortly after each manipulation.

Sherry said...

I appreciate your sharing that. There are many that have pain that is not mechanical in nature. I've had shoulder manipulation and it's a discrete sort of pain as you mention. I asked my question because I think that there are people who don't experience certain types of serious and/or unrelenting pain that just are unable to understand the pain of others, different kinds of pain, pain that never goes away.

Anonymous said...

I'm most worried that drug overdose is now the current leading cause of accidental death in the U.S., with nearly 52% of the 44,000 deaths attributed to prescription painkillers (according to the CDC, 2013). As the number of painkiller prescriptions has tripled since the late 90's, so have the deaths. Perhaps most disturbing is that more than 3 out of 4 people who misuse prescription painkillers use drugs prescribed to someone else. These are the people I want to help and here is my solution-Require all patients to document their consumption of the drugs. So you want a refill? Great let's see a video with a time and date stamp proving you took all those pills.

Skeptical Scalpel said...

You suggestion is interesting but unlikely to be accepted by the general public. I'd rather focus on educating people about the realities of life. Now and then you are going to have some pain that cannot be completely alleviated by any drug.

Anonymous said...

Don't know the guy who wrote this but he's pretty typical of a dumb doc with scalpel in hand. I've run into plenty of them. They think that " If I can't fix it by slicing with a sharp knife, it's doesn't merit my attention". These types also tend to throw a ballistic temper tantrum if one should suggest otherwise. It is SO disappointing that these ignorant fools are allowed to practice medicine. I would challenge him to look up the number of people killed yearly by GI bleeds resulting from NSAID usage ( the anti-opioid doc's usual preferred medicine of choice for pain control).

Skeptical Scalpel said...

I usually do not post comments containing insults [see "Read This Before Commenting above], but I made an exception for anonymous above because I accepted his challenge.

According to an article in MedPage Today [http://www.medpagetoday.com/Geriatrics/PainManagement/32971], the number of deaths per year caused by G.I. bleeding secondary to NSAIDs is 3200. That is about 20% of the number dying from narcotic overdoses every year.

Here is a quote from the article. Lewis Nelson, MD, an emergency medicine and medical toxicology specialist in New York, said, "I could count 100 opioid-related problems for every nonsteroidal recognizable problem I see," Nelson said. "I literally don't see nonsteroidal problems and I see tons of opioid-related problems."

The term "NSAID" does not even appear in my post. I do not know where the commenter got the idea that I was advocating NSAIDs for postsurgical pain relief. In fact, NSAIDs may be contraindicated because they can cause bleeding.

The appropriate use of narcotic pain medication should not be discouraged. I recently wrote about a new law in West Virginia that would penalize doctors for enabling narcotic addicts. Unfortunately, this will cause doctors to think twice before prescribing these drugs for people who really need them. Here is the link to that post http://skepticalscalpel.blogspot.com/2015/06/narcotic-addicts-can-sue-doctors-and.html.

To the anonymous commenter: If you want to discuss this in a civil way, I will be happy to post your response. An insult-filled diatribe will not be published.

Chris W said...

I agree with you about the unreliability of pain as an objective measure. However, I think you are also correct in comments above that there are patients who are truly in pain who are suffering as a consequence of docs' increasing reluctance to prescribe pain medications. And at the same time we as docs are caught in a vice between the expectation that we assess and are responsive to standardized pain instruments (pain visual analogue scale, for instance), but at the same time prescribe no medications that will cause adverse consequences.

As an example, a very typical patient encounter for me as a rheumatologist is a new patient who is 70+ and has a long-standing history of lumbar spondylosis, scoloiosis, and perhaps a few vertebral fractures due to osteoporosis. Most of them have already had kyphoplasty and/or fusion with instrumentation of multiple levels, which was done after failing several rounds of epidural steroid injections. They come to me because their PCP or back surgeon or pain specialist has said "maybe it's arthritis" (ha ha). Their pain scale is 10, but if I go by the books I really can't do anything for this geriatric patient with chronic pain because: A) tylenol doesn't work and causes liver damage, B) NSAIDs will cause kidney failure and ulcers, C) tramadol will cause seizures, D) Cymbalta/muscle relaxants/Lyrica/gabapentin will cause falls, E) tricyclic antidepressants will cause falls and arrhythmias, and F) opioids will cause dependence and constipation and overdose. I also get several referral per week for "my doctor prescribed hydrocodone to me at stable doses without adverse effects for 10 years, but now he says he can't prescribe it anymore because of new rules, but he said that you take it over now."

I find the irony painful that the same people (CDC, CMMS, professional organizations) who keep pushing increasing reliance on standardized measurements of pain (and modification of treatment in response to those measurements) are also the same people who publish (often in the same publication) dire reports of the devastating consequences of any particular treatment for pain. I hate to be a skeptic, but mindfulness and tai chi are probably not going to be adequate to manage every patient with chronic non-cancer pain.

Skeptical Scalpel said...

Chris, great comments. You have summed up the dilemma nicely. Factor in the new ruling by a West Virginia court that addicts may now sue doctors for enabling them. Here's a link to the post I wrote about it. http://skepticalscalpel.blogspot.com/2015/06/narcotic-addicts-can-sue-doctors-and.html

Anonymous said...

You may not be able to alleviate all pain, but surely there is some place for pain relief in the management of diseases and conditions that cause great physical suffering. Doesn't severe pain cause people physical stress, hamper their mobility, increase their likelihood for depression and suicidal ideation, decrease their ability to think and function effectively? Between all the modalities that can bring pain relief--including physical therapy, judicious use of medication as part of a plan to help people regain mobility, etc., you could present this "doctor dilemma" in a much more positive, patient-centered manner, and make these suffering individuals who are trusting you with their care feel less like burdens and more like active consumers and participants in helping to improve their own health.

Skeptical Scalpel said...

I appreciate your comments, but I cannot help the fact that my perspective is from that of a physician. I agree that pain relief is part of our job. But it seems like more and more people are blaming doctors for the opioid and heroin epidemics. As mentioned above, a state supreme court has ruled that doctors can be held liable for patients who become addicted to pain medication. This puts physicians in a very difficult position. I recently read that some doctors are saying they will not treat pain with any kind of narcotic. I think that will be difficult because the options for treatment are not great.

I'm sorry you are suffering, but I did not create this mess. I am simply offering my opinion about it.

Anonymous said...

Agreed Skep. We need people with common sense to make laws, guidelines and rules.

Skeptical Scalpel said...

Unfortunately, that doesn't seem to be happening.

Christopher Johnson said...

I've been a pediatric intensivist for 30+ years and we have it better than you guys: our pain assessments are pretty much based on direct observation. If the child can tell us about their pain, great. But heart and respiratory rates and just plain looking at kids is the biggest thing. Also, kids don't fib or become manipulative about it. (Well, adolescents with other issues occasionally do). Those pediatric smiley face scales are mostly silly. With children it is also amazing how well distraction can work.

Still, we're seeing in the PICU the same spike in narcotic overdoses from suicide attempts and gestures, often because so many home medicine cabinets now have narcotics in them.

Skeptical Scalpel said...

Thanks, Christopher. It must be hard to tell how much pain a 2 year old is having. Interesting comment about home medicine cabinets. I wonder what percentage of US homes have pain meds lying around. I'll bet it's well over 50%.

Jim Ryser said...

As a person with spina bifida who has had 55 surgeries, was on opioids for 18 years and off the past 16, I can appreciate this mess. I appreciate your views. Here are mine! http://www.indystar.com/story/opinion/2014/02/21/jimmy-ryser-addicts-are-set-up-to-die-by-todays-medical-standards/5709569/

Skeptical Scalpel said...

Jim, thanks for your comment and the link. It's a great article.

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