Monday, March 10, 2014

Pain as the fifth vital sign: faulty ideas exposed

“Pain is the fifth vital sign” became the slogan of a movement that was launched about a decade and a half ago. It was a campaign to educate us health care professionals, who were not doing a very good job of treating pain. The movement was overhyped and unintended consequences were realized over time. Now at long last some of the original proponents of the campaign have admitted that they were wrong. It's the topic of a post at The Poison Review which references this article from the Wall Street Journal. The revelations in the WSJ piece should come as no shock to those who have been practicing in the trenches for the past few years, who know the negative consequences all too well.

The movement was in high gear when I became a hospitalist in 1999. It was apparent to me early on that this was pure dogma being shoved down doctors' throats. I felt a little intimidated in calling out the pseudoscience at the time, though, because as the WSJ article notes, adherents to the movement were driven by an almost religious fervor:

Steven Passik, a psychologist who once worked closely with Dr. Portenoy and describes him as his mentor, says their message wasn't based on scientific evidence so much as a zeal to improve patients' lives. "It had all the makings of a religious movement at the time," he says. "It had that kind of a spirit to it."

Back then if you challenged the groupthink tempers were likely to flare.

What still baffles me is why so many doctors accepted the biggest and most obvious load of nonsense, the idea that pain, long established in clinical medicine as a symptom, could suddenly become a sign. Even The Joint Commission and my own professional organization, the Society of Hospital Medicine (then known as NAIP) were serving the Kool-aid.

Other nutty ideas were promulgated:

Opiates are safe.
Uh huh. How's that working these days?

Doctors' concerns about opiate addiction are overstated; true opiate addiction is in fact rare.
Ten years or so ago if you pointed out narcotic seeking behavior you would be told, dismissively, that this was not addiction but pseudoaddiction. Pseudoaddiction, they said, was merely behavior exhibited by a patient whose pain was uncontrolled. Put another way, if your patient engaged in seeking behavior it meant you were not doing your job.

Pain can be measured.
Translate: pain is not subjective. Pain does not have emotional components. How many people knew that was a crock but were too intimidated to call it out?

No one should have to experience pain. Pain can be made to disappear from the planet.
Really? How about all those patients on chronic narcotics who have had their doses increased, time and time again, to ridiculously high levels, and are still suffering?

As pain retires from its position as the fifth vital sign the pendulum will swing. Likely it will swing too far. Draconian medical board policies with their unintended consequences lie ahead. NSAID use is likely to increase, despite the cardiovascular risks which for many patients are greater than the hazards of opiates.

Be that as it may it's time to stop the madness. Twenty years ago the field of pain management was in need of improvement. But the improvement needed to be informed by science, not dogma.


Michael said...

Great article, but are the CV risks of NSAIDs always greater than opioids?

Susan L. said...