Pain Is a Vital Sign

By Roger Chriss, Columnist

Pain is a vital sign because it is vitally important. In fact, pain is what brings most people to a doctor, whether it’s their primary care physician or an emergency room doctor. And identifying the cause of the pain and figuring out how to address it is fundamental to medical care.

But pain cannot be objectively measured. And so some people trivialize or criticize its relevance.

“Unlike heart rate or blood pressure, there is no objective way to measure (pain). Doctors and nurses must depend on patients to report the intensity level of their pain, which provides an opening for addicts to abuse the system,” Hadley Manning recently wrote in an op/ed in The Oklahoman.  "Pain shouldn't be considered a vital sign."

The American Medical Association (AMA) also takes a dim view of pain, passing a resolution last year recommending that pain be removed as the “fifth vital sign” in professional medical standards.

"Just as we now know (the) earth is not flat, we know that pain is not a vital sign. Let's remove that from the lexicon," James Milam, MD, an AMA delegate told MedPage Today.

While it is true that there is no way to objectively measure pain, this is hardly unique to pain. After all, many health conditions that doctors deal with cannot be objectively measured:

• In gastroenterology: appetite, nausea, or fullness
• In neurology: numbness or tingling, muscle spasms, or loss of balance
• In ophthalmology: double vision, light sensitivity, or blind spots
• In otolaryngology: tinnitus, dizziness, or difficulty swallowing
• In psychiatry: anxiety, depression, mania, or psychosis

This is part of why medicine is both an art and a science. Clinicians have to work directly with people and not just numbers and algorithms. Various instruments exist to formalize this process, including disability indexes for the neck and lower back, and a method for measuring adult depression.

Pain is included in many such instruments. And there are instruments that attempt to quantify pain. For instance, the Mankoski Pain Scale tries to characterize pain in a clinically useful way. The 0 to 10 scale goes from “Pain free” to “Can’t be ignored for more than 30 minutes” to “Pain makes you pass out.”

A number of medical conditions involve pain severe enough to be incapacitating or even crippling. Prevention Magazine put together a list of “The 10 Most Painful Conditions,” which includes kidney stones, postherpetic neuralgia, and cluster headaches.

To be clear, the abdominal pain of kidney stones is not just a “tummy ache,” but more like having your kidney sucked out through your navel. The pain of neuralgia is not just “numb toes and other woes,” but the agonizing burning that makes even a light touch a terrifying prospect. And a cluster headache is not a big “ice cream headache,” but an utterly incapacitating attack. You lay on the floor in a fetal position without even the mental resources to wonder if anyone will help.

Of course, pain can also be psychiatric in origin. The book Is It All In Your Head? True Stories of Imaginary Illness by neurologist Suzanne O’Sullivan, MD, describes how medically unexplained symptoms can be psychosomatic in nature but are nonetheless clinically real, and how a skilled specialist can make the distinction between organic and psychiatric causes of pain.

Thus, pain is a vital sign that cannot be ignored. It is the primary way that the human body communicates its needs and troubles. And it is the means by which people describe their medical problems.

Claims that patient complaints about pain create an “opening for addicts to abuse the system” ignore how healthcare works. Physicians don’t just look at a patient’s “pain score” and then write a prescription. They assess and evaluate the patient, and come to a diagnosis based on a combination of their clinical skills, lab work and testing.

And physicians sometimes err on the side of caution about patients’ descriptions of pain. The National Institutes of Health found that pain is often underestimated in women and racial minorities and often undertreated in socioeconomically disadvantaged groups.

While some patients may exploit the desire of a physician to help, it is also true that some physicians may ignore a patient’s legitimate need for help. Facile critiques that oversimplify the complexities of modern pain management diminish both the hard work of healthcare professionals and the suffering of people dealing with painful medical disorders.

Although pain is personal, subjective and not readily measured, it is very real. To diminish its importance because of an impractical standard of objectivity is to miss the fact that medicine is about relieving suffering.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society.

Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

AMA Defends Dropping Pain as Vital Sign

(Editor’s note: Last week we published a story on the American Medical Association’s decision to support the removal of pain as a “fifth vital sign” in professional medical standards – a move that some believe will make it harder for pain patients to be properly diagnosed and treated. Patrice Harris, MD, Chair of the AMA’s Board of Trustees, sent us the following letter objecting to how the AMA’s vital sign policy was characterized by PNN.)

By Patrice A. Harris, MD, Guest Columnist

The American Medical Association (AMA) unequivocally supports a patient’s right to receive the highest level of compassionate, comprehensive care for his or her pain.  It is unfortunate that the recent actions at the AMA House of Delegates were painted as anti-patient (“AMA Drops Pain as Vital Sign”), when the actual debate was focused entirely on how to ensure physicians have the necessary tools to deliver optimal care to our patients. 

Reducing the stigma of pain and advocating for comprehensive pain care are key recommendations from the AMA Task Force to Reduce Opioid Abuse – part of our multifactorial plan to ensure that balanced policies are in place to ensure patient’s access to care and promote the best evidence-based pain management practices, while reversing the nation’s opioid misuse, diversion, overdose and death epidemic.

When called for by a physician’s clinical judgment, this includes the use of opioid analgesics as a potential component of individual treatment plans.

Contrary to the claims in the article, however, our new policies complement and further our longstanding advocacy that emphasize the importance of treating each patient as an individual and tailoring care for that individual.

PATRICE HARRIS, MD

Pain satisfaction surveys, physician satisfaction surveys, even the Joint Commission’s Pain Care standards have not been shown to result in comprehensive improvements in pain treatment or protocols, or improved outcomes, but are clearly motivating forces for opioid prescribing. 

Patients with chronic pain deserve to benefit from the research and scientific approaches as envisioned by the National Pain Strategy, which the AMA strongly supports.  Not a single physician said, suggested, or hinted that anyone should “stop asking patients about their pain” as your recent article suggested.  Perpetrating this baseless, stigmatizing claim does your readers a tremendous disservice and does not reflect the opinions or practice of the nation’s physicians. 

We are well-aware that efforts to reduce the supply of opioids in the United States, without due consideration for unintended consequences and impact on chronic pain patients, have taken firm hold, and that many such patients have experienced disruption in their care and suffered. Many physicians at the AMA meeting decried the stigma that their patients experience. Others highlighted the audits and investigations by law enforcement among their colleagues.  And many noted the importance of treating all physical, psychosocial and behavioral aspects of pain. 

Furthermore, all discussed the importance of effective, evidence-based care, including the fact that vital signs are those that can be objectively measured and quantified. Identifying, treating and managing pain is central to medical practice, but it is not a readily quantifiable physiologic vital sign.  

We recognize that the pendulum has clearly swung too far. We know that the stigma of pain and opioid use has become pervasive, and we believe physicians and patient advocates must work together to restore balance.  But we can’t ignore the fear and stigma that pervades our society – and affects physicians and other health care professionals. We see (and experience) the increased scrutiny by law enforcement and government regulators.

In response, some physicians no longer treat chronic pain or prescribe opioids. But there are committed physicians in every city, town and state who provide the type of compassionate care that our patients need and deserve.  There are many examples of physicians doing all that is necessary to provide the type of complex, thoughtful care that chronic pain patients need. That is the vision we have for pain care in the United States.

We will, always stand up and speak out in support of patients who are in pain. We have done this countless times in Congress, with our state and specialty society colleagues, in front of the National Association of Counties, National Conference of Insurance Legislators, National Governors Association and many other leading organizations. 

We know all too well that pain is the number one reason patients come to us. We will continue to seek all avenues to provide the care our patients need – whether pharmacologic or non-pharmacologic – and insist that insurers cover the multimodal therapies required for effective management of chronic pain. 

The nation’s opioid misuse, overdose and death epidemic has harmed far too many, and the AMA is committed to working to ensure that patients with pain are not among those who must now become innocent bystanders in the regulatory response to this public health epidemic. To suggest anything less is to ignore the body of our advocacy and the mission that is central to our proud history.

Patrice A. Harris, MD, is Chair of the AMA Board of Trustees and Chair of the AMA’s Task Force to Reduce Opioid Abuse. A practicing psychiatrist based in Atlanta, Dr. Harris has served on the board of the American Psychiatric Association, as President of the Georgia Psychiatric Physicians Association and as Director of Health Services for Fulton County, GA.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

AMA Drops Pain as Vital Sign

By Pat Anson, Editor

The nation’s largest medical society is recommending that pain be removed as a “fifth vital sign” in professional medical standards – a move critics say will make it even more difficult for pain sufferers to have their pain properly diagnosed and treated.

Delegates at the annual meeting of the American Medical Association in Chicago also passed several other resolutions aimed at reducing opioid prescribing and increasing access to addiction treatment. The AMA represents over 200,000 physicians in the U.S. and is very influential in setting public health policy.

The AMA’s new president said physicians played a key role in starting the so-called opioid epidemic by overprescribing pain medication, and now must do their part to end it.

“We have taken ownership of that, and physicians have taken ownership of being part of the solution,” AMA president Andrew Gurman, MD, told Modern Healthcare.

The AMA’s main “solution” to the opioid problem is to stop asking patients about their pain.

Pain was first recognized as the fifth vital sign in the 1990's, giving pain equal status with blood pressure, heart rate, respiratory rate and temperature as vital signs. The policy encourages healthcare providers to ask patients about their pain.

But critics say pain is not a vital sign, but more of a symptom, and cannot be measured like a patient's temperature or blood pressure. They also claim The Joint Commission,  a non-profit that accredits hospitals and other U.S. healthcare organizations, sets pain management standards too high, which contributes to opioid overprescribing.

"Just as we now know (the) earth is not flat, we know that pain is not a vital sign. Let's remove that from the lexicon," James Milam, MD, an AMA delegate said in MedPage Today. "Whatever it's going to take to no longer include pain as a vital sign ... Let's just get rid of the whole concept and try to move on."

“I am astounded that physicians don't believe we should assess pain on a regular and ongoing basis. That is exactly what removing pain as a vital sign means,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine and vice president of scientific affairs at PRA Health Sciences.

Webster says dropping pain as a vital sign would setback pain care three decades.

“The problem is that too many physicians and policymakers equate assessing pain with giving opioids,” he said in an email to Pain News Network. “It appears that advocates for removing pain as a 5th vital sign are suggesting that if we just ignore pain then we won't have to deal with pain and opioid abuse will disappear. That is not only fantastical thinking, it is harmful to millions of people in pain.” 

"This is a very unfortunate decision, one that creates the very real possibility that we will see a decrement in the quality of pain care delivered in various institutions," warned Bob Twillman, PhD, Executive Director of the Academy of Integrative Pain Management.

"The Joint Commission standards say you need to assess pain in every patient; record the results of that assessment; provide some kind of treatment; re-assess to see if the treatment was effective; and teach staff how to manage pain. They do not say we should ask patients how much pain they have on a 0-10 scale and give them opioids until the pain level is 4 or less. Not asking about pain does not make pain go away, and it does not relieve healthcare providers of their moral and ethical obligation to treat that pain effectively."

AMA Adopts PROP Policies

AMA delegates also passed a resolution urging The Joint Commission to stop requiring hospitals to ask patients about the quality of their pain care. Medicare has a funding formula that requires hospitals to prove they provide good care through patient satisfaction surveys.  The formula rewards hospitals that are rated highly by patients, while penalizing those that are not. 

"Judging health care facilities on an overly subjective measure – that is, how well it is perceived that they treat pain -- is an overly simplistic approach to measuring clinical effectiveness," said AMA Board chair Patrice Harris, MD, in a statement.

Passing the two resolutions means the AMA has essentially adopted the same policies as Physicians for Responsible Opioid Prescribing (PROP), which is also lobbying the Joint Commission to weaken its pain management standards.  PROP is funded by Phoenix House, which runs a chain of addiction treatment centers. 

“At a time when millions of individuals in pain are under siege, the AMA has made it clear they are no friend to people in pain as they are opposed to being accountable for the pain care they provide, “ said David Becker, a patient advocate and social worker. “The AMA has become regressive, vision less, and hard-hearted toward the suffering that millions of people in pain endure on a daily basis. It is clear that the AMA is in need of moral reform.”

A recent survey of over 1,200 patients by Pain News Network and the International Pain Foundation found that many were dissatisfied with their pain treatment in hospitals. Over half rated the quality of their pain care as either poor or very poor, and over 80% said hospital staff are not adequately trained in pain management.

The AMA House of Delegates also passed a resolution calling for greater access to naloxone, which reverses the effects of an opioid overdose, and adopted a policy urging health insurers to increase coverage of non-opioid and non-pharmacological pain treatments.

“Insurers must cover non-opioid and non-pharmacologic therapies that have proved effective. Insurers must take a broader view to give patients and physicians more choices," said Harris. “These policies will save lives. That's the bottom line.”