Pain is a vital sign
Near the end of May, the New York Medical Society brought forward a resolution for the American Medical Association (AMA) House of Delegates to consider. The focus of Resolution 707 is the 2001 Joint Commission standard to assess pain as the fifth vital sign. The drafters of the resolution claim that this standard has led to “misguided” efforts by clinicians to eradicate all pain and an overreliance on opioid medications that have subsequently worked their way into society and caused addiction and overdose deaths. It encourages the AMA House of Delegates to pull support from the fifth vital sign standard, apparently with the goal of eradicating harm from opioid use.
This would be very poor policy, and it is important to speak up now to stop its forward motion. Granted, any state chapter can bring forth a resolution, and passage is far from assured. But even if this resolution dies, the talk it generates could live on. It could get into the societal bloodstream, infecting the conversation and influencing policy creation going forward.
The resolution as written is factually inaccurate and further stigmatizes people in pain. The New York society falsely equates the fifth vital sign designation as a mandate to prescribe opioids. That in itself is preposterous. But it goes further in suggesting that to measure pain as a vital sign puts the pressure on clinicians to eliminate all pain. This is neither true nor possible in many, many instances. Of course, any right-minded clinician prefers zero pain, but with current therapies, that goal is often unrealistic. Yet pain should still be prioritized and addressed. To do otherwise puts patients at risk for a host of pain-related complications, the most serious of which is the progression to pain as a chronic destructive pathology.
This brings up another misunderstanding that could grow out of the resolution: the statement that pain is rarely a disease. There is danger here for the tens of millions of Americans with migraines, peripheral neuropathy, complex regional pain syndrome, rheumatoid arthritis and hundreds of other pain types that affect and change the nervous system. Already, these are people who are castigated as if their pain were self inflicted and life would be fine if they would “get over it.”
Clinicians should assess for and treat underlying disorders that cause pain but also understand that, for some patients with some types of pain, eradicating all underlying causes is not possible although, of course, that should always be the goal. Furthermore, the 2011 report on pain in America from the Institute of Medicine (IOM) clearly indicates that pain can become a disease in itself: “Pain sensation, transmission, modulation, and interpretation are functions of the central nervous system, and when abnormalities in this process occur, pain can be a neurologic disease.” The people who suffer in this manner deserve a scientific understanding of pain as a disease and the toll it takes on human life.
The drafters of the resolution are attempting to benefit patients and society at large. The principles that not all pain can be relieved and that opioids are not always the answer are good. But there is nothing in the standard of pain as a vital sign that says opioids must be administered, and if such is automatically happening, then education on pain assessment needs improvement. Pain treatment has never been, nor should it ever be, synonymous with opioid therapy.
Problems with pain management certainly remain. The resolution discusses research showing that despite being assessed more often since the fifth vital sign effort, pain is no better managed. The IOM report addressed this problem and called for more comprehensive assessment. Medicine should move toward comprehensive pain care and away from automatic reliance on opioid medications. But the assessment itself does not need to cease. To call for such action borders on lunacy or at least denigration of people with severe disabling conditions. Healthcare professionals have a professional and ethical obligation to assess and re-assess the pain of patients. The resolution proposed for AMA House of Delegates consideration is short sighted and should be denied.