AMA Defends Dropping Pain as Vital Sign

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(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.

Pain Protestors: 5 Simple Ways to Stand Up

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By Pat Akerberg, Columnist

It frustrates me that there’s such a huge gap between what I’d like to do and what I can actually do to protest how pain care has gone amok. 

The truth is I can’t talk without triggering unmerciful pain.  I can’t make lots of phone calls or present to audiences or groups anymore.  I can’t march, run or walk for any distance now.  Thanks to debilitating chronic pain, I can’t reliably commit my energies to much more than the daily challenges I face. 

Maybe you’re in the same place too? 

As discouraged underdogs, we want to change the lopsided fervor that’s trumping our critical need for safe and humane advancements in pain care.

I wish we could lead the charge, but in reality our compromised bodies often can’t keep up with what that requires. Starting from scratch is tempting, but that’s at cross-purposes with our limited capacities.    

Then I remember “the butterfly effect,” born out of physics and chaos theory.  It refers to a cumulatively large effect that a very small force may produce in a larger system over a period of time.  It postulates how the fluttering of a butterfly's wings in one part of the world may set off currents that will grow into a hurricane in another part of it.

We can’t predict or know when there will be enough pressure, conspiring events or cumulative conditions to bring about the butterfly effect for us.  But progress requires active involvement.

We have strength in numbers, but some patient advocates have called out pain sufferers, questioning where our support and voices of protest have been thus far.  That’s a fairly untapped opportunity.

If we want pain reform, it will take a critical mass of us calling for it.  Pragmatically, we can help build momentum and heighten the pressure for change quicker by supporting and working with current pain advocacy groups.

We have literally dozens of advocacy organizations, but ironically they lack organization.  Each represents a piece of the broader issue -- yet their efforts haven’t coalesced enough around a single goal or goals to gain substantial traction.

If you’re wondering what part you can play or where to put your limited energies, let’s look at some current opportunities.

Step #1

The oldest patient advocacy group, the American Chronic Pain Association, had a seat on a CDC advisory committee when the opioid prescribing guidelines were created.  But somehow that opportunity for active influence was reduced to a complicit check the box activity.

What can we do to call for better representation from such pain advocacy groups?  The well articulated comments that we write among ourselves could be leveraged to that end.  Copy, paste and send them to all national pain advocacy groups, starting with ACPA. Many of these organizations and their e-mail addresses are available by clicking here.  

Get involved.  Raise your concerns.  Urge all of their leaders to rally behind one unifying message for impact.  Ask them to recruit a spokesperson to give pain a face/voice (celebrity, athlete, or public/professional figure), devise ramped-up media and funding strategies, and enlist savvy lobbyists and lawyers.

If each of us would send out 5 letters, e-mails, or make 5 phone calls a week to a different advocacy group each week, we’d reach them all in just 8 weeks. 

Step #2

Have you heard of the LifeBOAT Act? Its legislation that would tax opioid pain medications, introduced by Sen. Joe Manchin (D) of West Virginia, and co-sponsored by Democratic Senators Amy Klobuchar of Minnesota, Jeanne Shaheen of New Hampshire, Heidi Heitkamp of North Dakota, and Tammy Baldwin of Wisconsin, along with one independent, Angus King of Maine.

The legislation is a reverse Robin Hood version of robbery.  Lacking conscience, the LifeBOAT Act would take money from pain patients by punishing them for their medical misfortune.  In turn, an estimated $2 billion of our tax dollars would be given to favored addiction treatment centers to treat opioid addicts.

If you feel strongly about the injustice of this tax, email or call the senators’ offices with your reasoned, opposing comments:

Step #3

The American Medical Association (AMA) recently decided to pass the hot potato by voting in favor of efforts to remove pain as a vital sign in professional medical standards, as well as disconnecting patient satisfaction scores from questions involving pain care in hospitals.

If this setback for pain sufferers pushes your buttons, you can call the AMA at (800) 621-8335 and let them know how you fell.

Step #4

September is National Pain Month, a good time to contact your local media and get them to cover our side of the pain story.  Press kits are readily available from some advocacy groups for this purpose.

Step #5

Our small efforts can quicken the overall cumulative effect, while giving us a personal and purposeful outlet.  A few more examples include:

  • Join advocacy and social media groups (like Facebook) to understand their missions and volunteer for their initiatives
  • Urge advocacy groups to get more media coverage of our side of the pain/opioid story
  • Endorsing petitions sent out on our behalf
  • Spreading the word and soliciting the help of family and friends

The Scottish writer W. H. Murray wrote this about the power of commitment: 

“Until one is committed, there is hesitancy, the chance to draw back, always ineffectiveness. Concerning all acts of initiative (and creation) there is one elementary truth, the ignorance of which kills countless ideas and splendid plans: that the moment one definitely commits oneself, then Providence moves too. All sorts of things occur to help one that would never otherwise have occurred.”

By making a personal commitment on some level, each of us can contribute in ways that our physical limitations will allow. 

Pat Akerberg suffers from trigeminal neuralgia, a rare facial pain disorder. Pat is a member of the TNA Facial Pain Association and is a supporter of the Trigeminal Neuralgia Research Foundation.

Pat draws from her extensive background as an organizational effectiveness consultant who coached and developed top executives, mobilized change initiatives, and directed communications.

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

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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.”

Doctors Have Mixed Reaction to CDC Guidelines

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By Pat Anson, Editor

Although generally supportive of the CDC’s new opioid prescribing guidelines, some doctors are worried that patients who need opioid pain medications may lose access to them.

The voluntary guidelines, which discourage the prescribing of opioids for chronic pain, are intended for primary care physicians, but are widely expected to have a ripple effect throughout the healthcare system and on anyone who prescribes opioids.

"If these guidelines help reduce the deaths resulting from opioids, they will prove to be valuable. If they produce unintended consequences, we will need to mitigate them. They are not the final word," said Patrice Harris, MD, the board chair-elect of the American Medical Association, the nation’s largest medical group.

Like many other medical organizations that submitted public comments on the CDC guidelines, the AMA said it had concerns about the poor quality of scientific evidence supporting several of the recommendations. But the dozen guidelines are largely unchanged from a draft version that was released last September.

“We remain concerned about the evidence base informing some of the recommendations; conflicts with existing state laws and product labeling; and possible unintended consequences associated with implementation, which includes access and insurance coverage limitations for non-pharmacologic treatments, especially comprehensive care; and the potential effects of strict dosage and duration limits on patient care,” said Harris, who chairs the AMA Task Force to Reduce Opioid Abuse.

The lack of clinical evidence was also pointed out by other physicians.

 “There are few well-controlled clinical studies on opioid-prescribing methods for chronic pain. While the guidelines will be updated as new data become available, concerns may be raised that appropriate access to opioids could be negatively affected by federal guidelines based on admittedly weak data,”  wrote William Renthal, MD, of the Department of Neurology at Brigham and Women’s Hospital in an editorial in JAMA Neurology.

The head of the American College of Obstetricians and Gynecologists (ACOG) said he was concerned the guidelines overstate the risks of opioids for women during pregnancy and after labor.

“ACOG agrees with the CDC that opioid should only be used for treatment of pain when alternatives are not appropriate or effective, but we also know that there are times, including during pregnancy and the postpartum period, when such use is both appropriate and safer than the alternative,” wrote ACOG president Mark DeFrancesco, MD. “Opioids may be needed to treat acute pain such as from cesarean delivery, kidney stones, sickle cell crisis or trauma in pregnancy, or as part of an established plan to treat problems associated with substance use disorders.”

DeFrancesco said the risk of birth defects and other problems caused by opioids was low and research demonstrating a connection was lacking.

“We are concerned that some of the CDC's patient education communications regarding use of opioids during pregnancy could discourage women from needed, appropriate care by overstating the risk of rare complications associated with opioid use during pregnancy and by understating the potential risk associated with opioid discontinuation, “ he said.

Two pediatric physicians are concerned the guidelines are only intended for patients 18 and older and do not address pain or opioid use by children.

“Unfortunately, the exclusion of children from the national discussion on pain is not new,” wrote Neil Schechter, MD, of Boston Children’s Hospital and Gary Walco, PhD, of Seattle Children’s Hospital in an editorial in JAMA Pediatrics. “Data clearly show that poorly treated pain in the young has deleterious long-term consequences on the development of pain systems and related responses, as well as psychological well-being. Furthermore, the long-term impact of pain on a developing organism may be quite different than on an adult and may suggest more aggressive, or at least different, interventions.”

Schechter and Walco urged the CDC to provide ”an explicit and definitive statement that this guideline should not be applied to those younger than 18 years of age for fear of untoward consequences.”

The Alliance for Balanced Pain Management (AfBPM), a coalition of patient groups and professional societies, said it was concerned about opioid dosing limits and the CDC recommendation that three days or less supply of opioids “often will be sufficient” to treat acute pain from surgery or trauma.

“When the CDC suggests the exact number of days and the precise dosing limit, the agency may be inserting itself too far, interfering with physician care of patients who live day to day with serious pain,” said Brian Kennedy, Alliance for Patient Access and a member of the AfBPM Steering Committee. “These guidelines mark a milestone in the national conversation about how we treat pain, both chronic and acute. Multimodal approaches to pain treatment make use of non-opioid treatments and have tremendous value for patients, but we shouldn’t tie physicians’ hands when it comes to treatment options.”

 “The data will never be perfect. The measures will never be perfect. The guidelines will never be perfect. And neither will clinicians and their performance,” wrote Thomas Lee, MD, of Press Ganey and Harvard Medical School in a JAMA editorial. “But by acknowledging these imperfections and trying to get better with the tools available, physicians can more effectively reduce the suffering of patients.”

AMA Needs to Get Facts Right About Opioids

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By Pat Anson, Editor

This week the American Medical Association launched a new effort to combat prescription drug abuse in the U.S. The AMA is working with over two dozen state and national medical organizations to address what it calls the “opioid public health epidemic.”

While the effort and its goals are laudable, it was disappointing to see the AMA – the nation’s largest medical group -- announce them in a news release full of cliches and half-truths. 

The news release began with this:

“With 44 people dying each day in the United States from an overdose of opioids, we physicians see people affected by this epidemic on a regular basis.”

The “44 people dying each day” figure comes from a CDC study of prescription drug overdoses, which found that in 2010 “opioid analgesics were involved in 16,651 deaths – far exceeding deaths from any other drug or drug class, licit or illicit.”

The CDC study is cited in virtually every press release, news conference and news story that relates to the issue of prescription drug abuse. Over 16,000 people dying from any cause is a serious problem and an attention getter. At face value, the numbers are frightening.

If only they were true.

As longtime patient advocate Janice Reynolds pointed out in a recent column for Pain News Network, the CDC’s numbers are seriously flawed.

“Unfortunately this study is quoted by many.  If you say a tale often enough, it becomes a version of the truth,” Janice wrote. “The CDC study is based on a review of death certificates and didn’t sort out legitimate opioid prescriptions, illegal use of opioids, suicide, deaths caused by alcohol or other medications, or even if the death was truly from opioids and not from some other disease process.

“Did the patient die from lung cancer or opioid toxicity?  Sometimes the latter is entered as the cause of death when it is not the case.”

A close reading of the CDC study also turns up something else. Other medications, particularly anti-depressants, sedatives, anti-anxiety and other mental health drugs, often were involved in the overdoses -- not just opioids.

To quote from the study:  

“Opioids were frequently implicated in overdose deaths involving other pharmaceuticals. They were involved in the majority of deaths involving benzodiazepines (77.2%), anti-epileptic and anti-parkinsonism drugs (65.5%), anti-psychotic and neuroleptic drugs (58%), anti-depressants (57.6%), other analgesics, anti-pyretics, and anti-rheumatics (56.5%), and other psychotropic drugs (54.2%).

Why do we never hear about an “epidemic” of deaths from anti-depressants or sedatives? Because in all of the deaths involving multiple drugs, only opioids are singled out as the cause of death.

The CDC’s research is obviously flawed, yet --- like a bad zombie movie -- this five year old data has taken on a life of its own.

The Washington Post repeated the opioids “killed more than 16,000 people” mantra a few weeks ago. So did Drugwatch.com, The New York Times, Los Angeles Times and Forbes.   

What about the 44 people dying every day? That zombie factoid was easy to find online in Deadline Detroit, the Magnolia Reporter and the Livingston Daily.

Like Janice Reynolds says, “If you say a tale often enough, it becomes a version of the truth.”

The tale would go away rather quickly if the CDC and other government organizations stopped repeating it or simply conducted a new overdose study with a better methodology. But the CDC seems more interested in keeping the zombie story alive.

Dr. Lynn Webster, a prominent pain physician, pointed out in a column last week that the CDC continues to use “fuzzy reporting” about opioids – raising questions about the agency’s impartiality.

“Given the concerns with accuracy of scientific reporting, is it reasonable to increase federal funding to the CDC to battle prescription opioid abuse, as requested? Only with an understanding of the real reasons for the current opioid problem can we solve the problem. Perhaps more dollars should instead go to the National Institutes of Health, which is in desperate need of more funding for pain research and to develop safer alternatives to opioids,” Webster wrote.

Opioid abuse, overdoses and overprescribing are serious problems. So is underprescribing and making opioids unavailable to people who truly need them.

How far has opioid hysteria gone? In a recent survey of pharmacists and drug wholesalers by the General Accounting Office (GAO), over half said DEA enforcement actions had limited their ability to supply drugs to legitimate patients.  Many said they were fearful of being fined or having their licenses revoked. You won't see that story being reported in The New York Times or Los Angeles Times because the CDC and DEA aren't churning out press releases about it.

As Dr. Webster points out, if we’re truly going to address these complex problems, we better get our facts straight.

So should the American Medical Association.