Enclara Questions AMA’s Abolition of Pain as 5th Vital Sign

Author: Terri Maxwell, Ph.D., APRN, Vice President of Clinical Education at Enclara Pharmacia

When the American Medical Association — the nation’s largest medical society – recommended last week that pain be removed as a “5th vital sign” in hospital and other settings, it simply buried the issues associated with overprescribing of opioids without solving the problem of finding the most appropriate means to assess and manage pain, with or without opioids. In reality, the abolition of pain as the 5th vital sign will make it more difficult for pain sufferers to have their pain properly assessed, diagnosed, and treated, a challenge that is particularly troublesome for patients suffering from terminal illness, cancer, and other painful conditions.

Over the years, the issues surrounding pain management have generated significant attention. In 1996, the American Pain Society (APS) introduced the phrase “pain as the 5th vital sign,” emphasizing that pain assessment is as important as an assessment of the standard four vital signs and that clinicians need to take action when patients report pain. When pain as the 5th vital sign was instituted, its purpose was to ensure that pain assessment was performed systematically; it did not direct that all pain should be managed with opioids. The Veterans Health Administration recognized the value of such an approach and included pain as the 5th vital sign in their national pain management strategy.

While the necessity for pain assessment has remained unchanged since that time, and the recognition of its importance has continued to expand, the concomitant use and abuse of opioids for routine pain management have grown exponentially. The reason for the growth in opioid prescribing is multifold, and not necessarily due to prescriber pressure that they prescribe opioids when patients report pain during routine pain assessment. Most recently, The Centers for Disease Control and Prevention’s (CDC) issued new recommendations strongly advising against the use of opioids for the routine management of chronic pain.  These directives have shifted the focus away from patient-reported pain control toward mitigating the long-term consequences of opioid abuse. While addressing the public health consequences of opioid abuse is vitally important, it must be done without harming patients legitimately requiring opioids to manage their pain.

The AMA response to the opioid crisis by recommending abolishing pain as the 5th vital sign does little to address the opioid abuse problem or speak to why this measure was put in place in the first place:  the most common reason for the under treatment of pain in U.S. hospitals was the failure of clinicians to assess pain and pain relief.

Positioning pain as the 5th vital sign and reinforcing the need for pain assessment should not lead to inappropriate prescribing and opioid misuse if physicians are trained and have access to non-opioid pain modalities. Conversely, the absence of pain assessment and restrictions around the use of opioids will worsen outcomes for patients who benefit from opioids, including those with cancer or at the end-of-life.

The AMA and others need to recognize that ignoring pain will not mysteriously make it disappear, and lessening an expectation that pain should be assessed will not erase opioid abuse. A multitude of pain management strategies that are safe and effective need to be made available throughout the healthcare continuum to overcome the over-reliance on opioids.

Physician prescribers need education and training so that they have a thorough understanding of how to assess addiction risk factors and manage the risk of abuse among opioid-naïve patients. They also require access to alternatives other than opioids, as well as mechanisms to establish safe prescribing practices – as articulated by the CDC — and ways to inform patients of the risks prior to prescribing opioids.

Hospitals need to invest in providing training programs and other resources for prescribers, with special attention at the point of discharge when patients are sent home with prescriptions and drugs in hand. It is also important to check the state’s monitoring system, where available, prior to prescribing, especially in the emergency department or upon discharge, and develop or expand programs that provide non-drug options for the management of chronic pain, such as behavior modification programs, cognitive therapy, and exercise and physical therapy programs.

Health plans also need to cover these ancillary services as cited above so that patients can afford to access pain management options other than opioid therapy.

Removing pain assessment from the lexicon and dropping pain as a vital sign is a dangerous remedy that could set back pain care by decades. For the millions of people suffering from pain, under- or inadequate assessment may lead to poor pain management, which in turn can result in unintended, yet potentially serious consequences.