Simple It's Not I'm Afraid You Will Find

Pain As Fifth Vital Sign.PNG

I read a post on the blog Skeptical Scalpel written by an anonymous retired U.S. surgeon. The writer proposes that the 1999 Veteran's Health Administration campaign of "pain as the 5th vital sign" — the goal was to make measuring pain as routine as taking vital signs such as heart rate and blood pressure — lead to the discovery of new diseases with pain as the only symptom, the creation of a whole bunch of new pain clinics, and the current epidemic of prescription opioid drug abuse. With the utmost respect, I think it is not so simple. There is risk in proposing that a complex problem has a simple cause because there is the potential of proposing a simple, misguided solution and feel that you are done. We are programmed with mental shortcuts by evolution in order to make survival decisions in a complex, dangerous world. Unfortunately, these biases can make it difficult to solve modern complex problems. 

Searching through the document from the VHA referencing the campaign, you will find the words "opioid", "narcotic", "hyrdomorphone", "oxycodone", "fentanyl", or "Percocet" do not appear at all. The word "morphine" appears exactly once in a reference list. Prior to the VHA campaign, the American Pain Society coined the phrase "pain as the 5th vital sign" in 1996 in an awareness campaign driving at the importance of pain assessment. It was a concept, not a clinical practice guideline and also said nothing about treating patients with opioids.

Conditions or diseases with pain as the most obvious symptom, like fibromyalgia or complex regional pain syndrome, or back pain, are not new. They've been around and documented for centuries but called by different names and all have suffered from varying degrees of stigma depending on the cultural and scientific understanding at the time. To say that because we pushed to make measuring pain standard caused these conditions to spring into existence is wrong. 

While it is true there are more pain clinics now, they are mostly single modality clinics that either give injections or medications or both and are thus firmly routed in biomedical broken part thinking. We know that pain is a multidimensional experience so when we solely focus on biomedical treatments they can have a high failure rate at improving long term function. These clinics exist because multidisciplinary clinics were disbanded as too expensive and we paid people well to do things like injection therapy and medications and we stopped paying for things that are more time consuming like education, self management support, and integrated care across space, discipline and time. This is more common in the U.S. system.

Credit:  Guian Bolisay

Credit: Guian Bolisay

There is no doubt we have a major problem with prescription opioid abuse and overdose deaths. The evidence is clear that it a growing problem that coincided with prescribing opioids for chronic non-cancer pain (and don't think that because the blogger is in the US system that it is different in Canada. The evidence is that the problem is just as big here.) But, the causes of that problem are more complex than a campaign aimed at making sure we ask people about their pain.

Back to thinking errors, the error in linking all these problems to a simple cause, like measuring pain, is that the obvious solution (mistaken) is to stop measuring pain. This would be a panicked over-reaction. If you stop measuring pain (the blogger did not suggest this, but may have been implying it by linking it to the opioid abuse problem) you'll end up with a lot of unintended consequences in the other direction: more pain stigmatization; further entrenched ideologies; pain in the closet; less research; more difficulty accessing pain treatment including when opioids are helping and not harming; etc, etc, and the pendulum will continue to swing.  

In this amazing artistic infographic I've summarized my bird's eye view of progress and setbacks in pain management in human civilization*:

* opioid abuse and deaths are indeed a very scary problem and I'm not making light of it — it's what we do next that counts

* opioid abuse and deaths are indeed a very scary problem and I'm not making light of it — it's what we do next that counts

The push to measure pain within VHA institutions and by the APS was the right thing to do, launching advances in pain care and pain research. But like all advances there can be problems. Measuring and asking about pain was one of many factors that created fertile ground for the massive prescription drug abuse problem. It was associative, but not causal in it's own right. For more on the story of opioids afterward read this, which explains how the good intentions to measure pain may have become tied to prescribing opioids liberally without safeguards.

We now have a choice. We can either reflexively react with a backlash against pain awareness and measurement, or we can take an urgent and collaborative approach to work our way out of it with the twin goals of improving chronic pain outcomes and reducing deaths from prescription drug abuse and diversion.

The blunt tool used by regulators to limit opioid supply through making it more difficult to access opioids, more difficult for doctors to prescribe them or to make them scared enough to not prescribe them will not solve the problem. Like the war on illicit drugs, prohibition works to a degree, achieving partway the goal of reducing harm, but creates a lot of other harms and does not lead to further understanding and solutions.

Here are some ideas for a recipe out of the prescription opioid problem:

  1. Develop mentoring programs to help build skills and confidence in primary care settings to assess, manage, and yes, measure pain and functional outcomes
  2. Host conversations and create action oriented collaborative structures for those healthcare communities that manage pain and those that manage addiction, to reduce ideological positions and improve outcomes and safety
  3. Create integrated systems that cross disciplines, cross healthcare settings, and span time to assess and manage the multidimensional experience of pain
  4. Develop prescription opioid policies, regulations and education that will both improve access AND improve safety, reducing diversion and deaths
  5. Create public awareness about the proper role of opioids in pain management, their limitations and harms including:      
    1. that there is a balance between the rights of an individual (access to pain care and opioids) and the rights of society (safety from harms of diverted or abused opioids)
    2. that good pain care does not automatically = opioids
    3. that the goal of opioid therapy (or any therapy) is improved function

There are good things happening. Some examples that I know about:

  1. Atlantic Mentorship Network for Pain and Addiction 
  2. ECHO Ontario, based on successful video mentorship platform in New Mexico
  3. Practice Support Program for pain management in British Columbia
  4. Greater range of self management supports available: Pain BC, and here and here
  5. Innovative community practice models such as CHANGEpain clinic.
Credit:  Theen Moy

Credit: Theen Moy

Does this mean we are done?  No, not even close. My point is that as long as we keep two steps forward and one back, learning from missteps, we will make things better.

Let's continue asking about pain and measuring outcomes.