Wednesday, September 22, 2010

First Annual International Pain Summit reemphasizes the 5th vital sign

---and several other provisions:

In its “Declaration that Access to Pain Management is a Fundamental Human Right,” delegates to the inaugural International Pain Summit proposed that all people:

1. Have a right to the access to pain management without discrimination.
2. Have a right to be both informed about how their pain can be assessed through the recording of a fifth vital sign, and informed about the possibilities for treatment.
3. Have a right to access an appropriate range of effective pain management strategies supported by policies and procedures appropriate for the particular setting of health care and the health professionals employing them.
4. Have a right to access appropriate medicines, including but not limited to opioids, and to access health professionals skilled in the use of such medicines.
5. Have a right to assessment and treatment by an appropriately educated and trained interdisciplinary team at all levels of care.
6. Have the right to a health policy framework that, in governing pain relief treatment in the social, economic and regulatory environment, is compassionate, empathetic and well-informed.
7. Have a right to access best-practice, non-medication methods of pain management (ranging from relaxation and physiotherapy methods to more complex cognitive behavioral treatment) and to specialist-performed interventional methods, depending upon resources of the country.
8. Have a right to be recognized as having a disease entity, requiring access to management akin to other chronic diseases.

Additionally, the declaration proposes that:

1. Healthcare professionals have an obligation to offer a patient in pain the management that would be offered by a reasonably careful and competent healthcare professional.
2. Governments and all healthcare institutions establish laws, policies and systems that will help promote — not inhibit — access to pain management.

When the nurse calls and says a patient's BP is 70/50 I know I have to drop what I'm doing and go attend to that patient immediately, because that patient is in trouble. When the nurse calls and says a patient is voicing “ten out of ten pain” the same onus is on me, but the patient may or may not be in any distress. We all use the numeric pain scale because Joint Commission and our institutional policies say we have too, but at the same time we know (most of us, anyway) that the scale is subjective and, in most cases, meaningless.

This initiative, with apologies to Yogi Berra, is Déjà vu all over again. A pain management movement of sorts gained traction in the US around 1999 with the recognition that we weren't treating pain well. Unfortunately the corrective efforts that ensued were driven more by public pressure than science, and the “education” delivered to doctors was about 80% dogma-based medicine.

The unintended consequences have since been realized. Epidemiologic and research evidence has uncovered patient deaths attributable to the changes in pain treatment strategies.

We need to be constantly looking for better ways to treat pain but it needs to be driven by science, not activism. With this new initiative I'm concerned we may be exacerbating this decade old safety problem just when we were beginning to get a handle on it.

This is one of those rare instances when I'm going to have to disagree with Wesley Smith, who alerted me to the pain summit. I think I know where he's coming from---consistently adequate pain control for patients with advanced illnesses might lower the demand for assisted suicide and euthanasia. I am in sympathy with that view, but there have to be better ways of fixing the problem.

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