Top 10 issues in hospital medicine for 2007, issue 10: unintended consequences of the 5th vital sign

About a decade ago people began to wake up to the fact that the medical profession was doing a poor job of treating pain. Treatment was all too often irrational and ineffective. Education and quality improvement initiatives were needed. Unfortunately, well-intentioned initiatives were hijacked by activism and pain management became politicized. The scientific rationale of pain management became difficult to distinguish from dogma. As Joint Commission pain management initiatives got into high gear concerns about narcotic addiction, respiratory depression and other adverse effects fell on deaf ears. These were medical myths perpetuated by a culture of undertreatment and underconcern, we were told. Activism really got into high gear and struck fear in the hearts of physicians with the astounding news in 2001 of a $1.5 million verdict against a California internist for undertreating pain. The award was made possible by a novel legal strategy which bypassed California’s malpractice laws and withstood a substantial burden of proof that the doctor had acted with criminal recklessness. This was despite the lack of diagnosis of a terminal condition (only later confirmed to be untreatable lung cancer) and reliance on a nebulous pain scale which had become enshrined as the "5th vital sign." Lacking a firm diagnosis of terminal illness the physician was understandably concerned about the "double effect" of hastening death in the process of providing comfort and was hampered by California’s onerous prescription documentation requirements for strong narcotics.

The case sent shock waves through the media and medical journals. A Western Journal of Medicine editorial about the case was typical:

Another message to physicians implicit in these verdicts is that there is a standard of care for pain management, a significant departure from which constitutes not merely malpractice but gross negligence. Even if professional boards might not hold their licensees to that standard, juries will. With the implementation of the new pain standards by the Joint Commission for the Accreditation of Healthcare Organizations, which recognize the right of patients to the appropriate assessment and management of their pain, public expectations will likely increase exponentially.

Indeed they did. Scientific discourse about pain management was now hopelessly tainted by popular debate. An otherwise well appearing patient walking into the emergency department announcing pain at "10 out of 10" was an urgent indication for narcotics. Adverse effects of narcotics administered on the wards were minimized in importance.

Many of us who realized that the teaching about pain management was based more on dogma than science were worried about unintended consequences. This past year the adverse consequences have been brought to light. A JAMA news report earlier this year documents an alarming rising trend in narcotic related deaths which began in 1999, about the time the new pain management initiatives began to be promulgated. Our pain management dogma that "addiction is rare" was challenged by this systematic review of outcomes for opioid treatment of chronic back pain, which showed addictive behavior to be quite common. Thought leaders this year began to question the science behind the rise in opioid use, calling for the same standards of scientific rigor we apply to other treatments. Finally, a paper from the Journal of the American College of Surgeons earlier this year (H/T Aggravated Doc Surg) demonstrated that since the promulgation of recent pain management initiatives we have changed from a culture of undertreating pain to one of overmedication and underconcern for adverse effects of narcotics, resulting in patient deaths.

Perhaps 2007 will be remembered as the year of appreciation of the adverse consequences of pain treatment dogma.