In 2001, a year after President Clinton signed into law a bill declaring 2001-2010 to be the “Decade of Pain Control and Research,” JCAHO (Joint Commission on Accreditation of Healthcare Organizations) initiated standards mandating that all patients receive pain screening during their visit to accredited institutions. Pain was declared the “5th vital sign,” along with pulse, blood pressure, respiratory rate, and temperature. Every ER in the nation now includes a pain assessment as part of its triage protocol, most commonly a 1-10 score for adults and a smiley/frowny face score for kids.
0 —— 1 —— 2 —— 3 —— 4 —— 5 —— 6 —— 7 —— 8 —— 9 —— 10
no pain mild moderate severe worst possible pain
With the stroke of a pen, pain management was declared a “patient right.” And it didn’t stop there. Doctors were browbeaten and scolded by the IOM (Institute Of Medicine) for failing to adequately address pain complaints, and when that didn’t work monetary penalties were instituted. As part of a plan to hold hospitals accountable for the care they provide, after-discharge surveys are now conducted where patients are asked a series of seemingly benign questions like: “Did the nurses treat you with courtesy and respect?”/ “Did doctors listen carefully to you?”/ “How often were your room and bathroom kept clean?”/ and “How often was your pain well controlled?” Hospitals receiving poor scores receive lower reimbursement from CMS (Centers for Medicare and Medicaid Services) while those with high scores receive a bonus. Given that 100 million Americans are estimated to suffer from some sort of chronic pain, what’s wrong with using a pain score to incentivize hospitals and doctors to aggressively treat it?
First, in the ER, the “1 to 10 score” isn’t helpful. Remember back a few months ago when Thomas Eric Duncan, the Ebola patient who presented to Texas Presbyterian Hospital in Dallas, rated his abdominal pain an “8.” The media made a big deal out of this and used it as evidence of the hospital’s incompetence for discharging him. For those of us in the know, however, an ”8” means nothing at all. Yesterday I saw a woman with mild pink eye—so mild that I had to ask which eye was bothering her—who rated her pain a “10.” This isn’t unusual. I also saw a patient with an ingrown toenail, one with a rash, and a third with a runny nose who rated their pain a “10.” And this doesn’t count the many patients who rate their pain a “15” or a “20” (i.e. infinite pain). Sorry, pain is not objective, and it’s not a vital sign. I don’t use the 1 to 10 score at all. Instead, I ask if pain is mild, moderate, or severe. When checking after a dose of analgesic, I ask if the pain is the same, a little better, a lot better, or gone. The rest is meaningless outside of research settings.
Second, the “1 to 10 score” doesn’t work. A 2006 VA study found no improvement in pain management despite universal adoption of the pain score. What happened instead was simply a marked increase in narcotic use. In the ER, opioid prescriptions rose by nearly 50% between 2001-2010. Irrespective of the complaint, 30% of ER patients now receive narcotics. A 2013 report from the Johns Hopkins School of Public Health documented that, while the use of NSAIDs and non-narcotic analgesics has plateaued, the use of opioids has skyrocketed, but without any commensurate overall improvement in pain management. We’ve simply created a nation of addicts.
Third, the “1 to 10 score” creates perverse incentives for doctors to over-prescribe narcotics. Don’t misinterpret: No one wants to withhold narcotics from cancer or post-op patients. Every physician I know cares deeply about relieving this sort of pain. But what about someone with a headache or chronic back pain demanding opiates? What if the patient is a drug-seeker simply trying to stave off withdrawal? Should I risk a negative satisfaction score (and possibly my job) or give in? Think you could refuse? What if the patient were crying and sobbing: “Why won’t you help me? You have no idea how bad my pain is. If you did, you’d never make me suffer like this. How can you call yourself a doctor and be so mean?” I hear this song and dance at least once a shift from an addict and it’s tough to turn away the monster you’ve helped create.
How bad is the problem? While accounting for less than 5% of the world’s population, Americans consume 50% of the world’s pharmaceuticals, but more ominously 80% of the narcotics and 99% of the hydrocodone. Last year, there were 5.5 million US prescriptions written for the long-acting narcotic Oxycontin, but nearly 7 million for Suboxone (a narcotic agonist/antagonist used to treat addiction). Prescription opiate drug abuse now outnumbers all other street drug use combined, including heroin, cocaine, and methamphetamine. Beginning in 2011, the number of deaths related to prescription opiates surpassed motor vehicle crashes as the leading cause of accidental death in the US. And when did this epidemic begin? You guessed it; 2001, the same year as JCAHO’s little mandate to rate and treat everybody’s pain. If I’m ever appointed “Medicine Czar” the very first thing I’m going to do is jettison the “1 to 10 score” straight to the nether regions of hell.
If you or someone you know has a problem with narcotic habituation here are some resources to consider:
- Institute Of Medicine, “Relieving Pain In America: A Blueprint For Transforming Prevention, Care, Education, And Research,” IOM, June 2011; Washington DC: National Academies Press.
- S.V. Cantrill et al., “Clinical Policy: Critical Issues In The Prescribing Of Opioids For Adult Patients In The Emergency Department,” Annals of Emergency Medicine 2012; 60, no. 4: 499-511.
- R.A. Mularski et al., “Measuring Pain as The 5th Vital Sign Does Not Improve Quality Of Pain Management,” J. Gen. Intern. Med., 2006: 21: 607-12.
- M. Mazer-Amirshahi et al., “Rising Opioid Prescribing In Adult U.S. Emergency Department Visits: 2001-2010,” Academic Emergency Medicine, 2014; 21: 236-43.
- “As Opioid Use Soars, No Evidence Of Improved Treatment Of Pain,” Sept. 16, 2013, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, www.jhsph.edu/news/news-releases/2013/alexander-opiod-pain-use.html
- T. Brown, “100 Most prescribed, Best-Selling Drugs Through September,” Nov. 30, 2014, Medscape Medical News, http://www.medscape.com/viewarticle/834273
- CDC and Prevention, “Prescription Drug Overdose In The United States: Fact Sheet,” July 3, 2014, Centers for Disease Control and Prevention, http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html
- S. J. Poon et al., “The Opioid Prescription Epidemic And The Role Of Emergency Medicine,” Annals Of Emergency Medicine, 2014; 64, no. 5: 490-95.
Now here’s an appropriate setting for a pain score:
(reprinted form the New Yorker, April 6, 2015.)
For a laugh see: https://www.youtube.com/watch?v=g-W4DvP0qQg