The endless swirl of competing issues can make it a dizzying task for even experts to remain focused while working to achieve reasonable solutions to slow down the steamrolling opioid and heroin epidemic.  Stakeholders have been swept up into a tornado-like momentum which, quite frankly, has been fueled in part by the tug of war between controversial public health platforms that are decades old.  The push to acknowledge undertreatment of pain served to offset consistent regulation in prescribing opiates and potentiate erratic prescribing patterns along with growing a largely unregulated multibillion dollar niche market of pain control practices.

Regulatory agencies, hospitals, medical education and patients all started keying in on how pain was the new fifth vital sign that had not been properly identified or treated.  Providers were portrayed as negligent, essentially accused of flagrant disregard for controlling pain.  Health care delivery systems and their providers were collectively viewed as insensitive and arcane, leaving patients to suffer with untreated pain.  Despite efforts to make an effective transformation to more selectively and thoughtfully address pain, essential elements were left unattended and too much got lumped together.

“The US Department of Veterans Affairs (VA) is instructing physicians and nurses who treat veterans to regard pain as the ‘fifth vital sign’…   Numerous studies indicate that pain is often unrecognized or inadequately treated.  The new directive, aimed at addressing pain in a more systemic and thorough manner, is part of an effort to reduce pain and suffering experienced by many of the 3.4 million veterans cared for by the VA.”  Health Agencies Update, Veteran’s Pain a Vital Sign, March 17, 1999. 

As one of several recognized resources, others too, including the Joint Commission in 2001, endorsed the transformation to recognize pain as the fifth vital sign as a standard of care.  There was lots of room for misinterpretation, which forced many providers into a much compromised position, challenging best practices to be offset by overly simplified mandates, for more aggressive treatment of pain across the board. 

One of my first pharmacology lecturers dedicated to pain and pain management was to become aware of pain being a learned and subjective response, not a vital sign.  To that, management of pain must be tailored to individual patient needs, not pushed so generically nor restricted widely based on smiley face pain scales put in front of patients nor rationed just as randomly and broadly based on knee jerk efforts to curb overprescribing.  I attempted to share a similar rationale with a 61 year old patient yesterday, with over 100 emergency department (ED) visits in less than a year, demanding opioids for a mild wrist injury.

“No, pain is not the 5th vital sign. It’s not a sign at all. Vital signs are the following: heart rate; blood pressure; respiratory rate; temperature. What do those four signs have in common? They can be measured. A sign is defined as something that can be measured.” Is Pain Really the 5th Vital Sign? Physicians Weekly, Oct. 28, 2013. “Doctors are caught in the middle. If we don’t alleviate pain, we are criticized. If we believe what patients tell us—that they are having uncontrolled severe pain—and we prescribe opioids, we can be sanctioned by a state medical board or even arrested and tried.”  Is Pain Really the 5th Vital Sign? Physicians Weekly, Oct. 28, 2013.

There has been a myriad of evidence causing us to pause and inquire about shared interests and motivation regarding the fifth vital sign campaign, as to why it was perpetuated, without any intervening wide-reaching public health policy to redirect it, based upon early awareness of the catastrophic consequences.   There remains speculation that there was too much upside revenue to act accordingly, despite such awareness. 

Not much was done to prevent the rapid rise in the opioid addiction epidemic while moving forward with the fifth vital sign campaign.  Even as the number of overdoses and overdose-related injuries and fatalities surpassed those related to automobile crashes as far back as 2008.  “This marked increase has coincided with ‘Pain as the 5th Vital Sign’ campaign, a push that some have suspected was encouraged and supported by pharmaceutical companies as a marketing tool”. Was the Pain as a 5th Vital Sign campaign in part a marketing ploy? The Poison Review,  Nov. 19, 2012.  Embedded and at the hub of it all are providers and our practice patterns.  We are faced with a small percentage of providers and practices that simply have no regard for the current state of affairs and still choose not to take accountability, yet are responsible for the lion’s share of overprescribing and abuse.  This is noted across the country.

We all are faced with the challenges of how to prescribe controlled medications. In EDs it occurs in multiples, daily, as it does for most PCPs and others. We must be able to properly prescribe and effectively control pain, for those with legitimate issues.  Just as necessarily, we must be able to calmly and rationally redirect many others who not infrequently push back and seek other means to get prescription medication from providers, and do so with ease.

We all need to support the mounting ground swell in stopping the heroin and opioid epidemic as the largest and fastest growing public health crisis in our state and across the US. 

A shared vision and purpose through an economy of efforts can make a big difference in short order.


Lukas Kolm, MD, MPH

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