Thursday, June 1, 2017

The opioid epidemic: What was the Joint Commission's role?

Last year the Joint Commission issued a statement written by its Executive VP for Healthcare Quality Evaluation, Dr. David W. Baker, explaining why it was not to blame for the opioid epidemic. If you haven’t already read it, you should. Here is the first paragraph of that document:

“In the environment of today’s prescription opioid epidemic, everyone is looking for someone to blame. Often, The Joint Commission’s pain standards take that blame. We are encouraging our critics to look at our exact standards, along with the historical context of our standards, to fully understand what our accredited organizations are required to do with regard to pain.”

With the help of an anonymous colleague, I looked at some of the historical context.

In December 2001, the Joint Commission and the National Pharmaceutical Council (founded in 1953 and supported by the nation’s major research-based biopharmaceutical companies) combined to issue a 101-page monograph entitled “Pain: Current understanding of assessment, management, and treatments.”

Here in italics are some excerpts from it. My emphasis is added in bold.

Page 4: In 1968, McCaffery defined pain as “whatever the experiencing person says it is, existing whenever s/he says it does. This definition emphasizes that pain is a subjective experience with no objective measures. It also stresses that the patient, not clinician, is the authority on the pain and that his or her self-report is the most reliable indicator of pain.

This set the tone for clinicians—i.e., patients are always to be trusted to report pain accurately.

Page 16: For example, some clinicians incorrectly assume that exposure to an addictive drug usually results in addiction. Table 6: Common misconceptions about pain: Use of opioids in patients with pain will cause them to become addicted. Page 17: In general, patients in pain do not become addicted to opioids. Although the actual risk of addiction is unknown, it is thought to be quite low.

We now know that everything in the paragraph above is untrue.

Page 38: Long-acting and sustained-release opioids are useful for patients with continuous pain, as they lessen the severity of end-of-dose pain and often allow the patient to sleep through the night. Page 67: Table 38. Administer opioids primarily via oral or transdermal routes, using long-acting medications when possible.

We now know that long-acting pain medications often do not last as long as they are supposed to, and the use of long-acting drugs may create more addicts.

The recent Joint Commission statement says it never endorsed the concept of pain as a vital sign. While an explicit endorsement of pain as the 5th vital sign is not contained in the JC/NPC monograph, it is mentioned five times.

Page 21: In 1996, the American Pain Society introduced the phrase “pain as the 5th vital sign.” This initiative emphasizes that pain assessment is as important as assessment of the standard four vital signs and that clinicians need to take action when patients report pain. Page 29: Reassessing pain with each evaluation of the vital signs (i.e., as a fifth vital sign) is useful in some clinical settings. Routine screening for pain with a pain rating scale provides a useful means of detecting unidentified or unrelieved pain.

These are strong recommendations to assess pain levels frequently in conjunction with the standard vital signs. We knew from the start that pain was not a vital sign. In 2014, I blogged about this.

Dr. Baker alleges another misconception about the Joint Commission is that it said pain must be assessed for all patients. He wrote, “The original pain standards stated ‘Pain is assessed in all patients.’ This requirement was eliminated in 2009 from all programs except Behavioral Health Care Accreditation.” Therefore, “pain is assessed in all patients” was a standard that existed for almost the entire first decade of this century, a time when opioid deaths were increasing with each passing year.

The Joint Commission deserves at least some of the blame for the opioid crisis. The American public deserves an apology.

This post is updated from one that appeared on Physician’s Weekly last year.


artiger said...

We'll get a Joint Commission apology right after AORN publicly admits it erred about the surgical cap nonsense.

When people ask how I can stand working in a very small rural hospital, one of the reasons I Joint Commission crap. We take care of patients quite well without them.

Skeptical Scalpel said...

I thought the rules say a hospital must be JC accredited or state accredited to participate in Medicare.

"For any organization to receive funding from Centers for Medicare and Medicaid Services (CMS), that organization must meet either the "Conditions for Coverage" or the "Conditions of Participation". These are a set of minimal standards which must be met before CMS will ever issue any reimbursement for Medicare and Medicaid Services. Two kinds of organizations can review a health care provider to check for compliance with these conditions - either a state level agency acting on behalf of CMS, or a national accreditation agency like the Joint Commission."

orthodoc said...

In a just world, the Joint Commission and Russell Portenoy, the Purdue Pharma paid shill, would be hung upside down and beaten with sticks for creating a nation of addicts.

artiger said...

Scalpel, we are state accredited. I have found it to be much less onerous (read: reasonable) than JC.

Dr. Soup said...

Maybe now my PACU nurses will stop waking my immediately postop patients to ask if they are having pain? Cuz, y'know, you can't trust the patients to tell you....

Pam said...

I live & work in a rural SD hospital that participates in Medicare. Like a previous commenter, we are also not JCAHO certified, but we are surveyed by CMS.

Oldfoolrn said...

Never trust an entity that keeps changing it's name. JCAHO was something I had never heard of until I deduced that it was the bastard spawn of JCAH. Decades ago a JCAH inspector shut down our entire OR suite claiming that out knee actuated valves on our scrub sink needed to be converted to foot pedals.

AORN was always known to me as Association of Operating Room Nurses. I think they also changed their name to exclude LPNs. If they are preoccupied with membership criteria maybe they will lay off on such foolishness as surgical cap requirements

artiger said...

OldFoolRN, you should change your username to OldWiseRN.

Skeptical Scalpel said...

Thanks for all the comments. That's a good point about the name change by the AORN.

I too found most patients are not reluctant to speak up when they have pain. One could infer that if you have to ask the patient about his pain, maybe it is not that bad.

Todd J. Scarbrough, M.D. said...

You should see the NCCN guidelines for pain. On a 1-10 scale, they call 7-10 "severe" pain. NCCN recommends admission in some cases if the patient has a 7-10 pain level. Of course you would be surprised how many patients smile and seem quite fine at self-reported pain levels of 7-10. One attending I had told the story of the patient who had a pain level of 10 and was recommended to come in to the hospital by a fellow as a "pain emergency." "Doc, maybe we can reschedule the emergency to day after tomorrow because I need to work today and tomorrow and have lots to do at home."

Skeptical Scalpel said...

Todd, thanks for your comments. You story about the patient with the "pain emergency" is LOL funny.

Autumn said...

Another small rural hospital was told that all pain med orders had to be written with pain scale ratings included, eg plain tylenol for pain up to a 4, a tylenol/narcotic combo for a pain of 5-7 and a parenteral narcotic for pain above an 8. Therefore if you(the RN) needed to deviate from this you had to call the physician. Ok, I see this to a point, didn't like it much, but the day my 80 something patient told me her pain was a 7 but she didn't want Percoset because she was going to PT. I was obliged to call a physician to obtain this one time order for tylenol that was already in her med profile...yup the doc was...rather unhappy. As you can tell I'm still steamed months later. Let me document the pain level as the patient states it, along with the patients request for tylenol instead, don't make me destroy any limited value of using a pain scale by teaching said patient how to give the right number for the desired medication. "The Joint Commission" belongs in the joint for the mess they've made!

Skeptical Scalpel said...

Autumn, good story. It's a nice illustration of how regulating every bit of minutia doesn't work.

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