Saturday, September 29, 2018

Pain dogma reversal at SHM

Medscape reported on the pain management sessions at SHM 2017 in an article titled Rethinking Pain Can Help Hospitalists Fight Opioid Crisis. I did not attend that year but from the sound of the article it was more like a complete reversal than a rethinking, and a reversal is what is needed.

Starting in about 1999, when this movement was launched, uncontrolled pain was the big public health crisis. Now it’s the opioid crisis. How interesting.

From the beginning of the “fifth vital sign” movement SHM (then known as NAIP, the National Association of Inpatient Physicians) was in lockstep and served up its share of the prevailing dogma. It’s particularly interesting that this occurred when evidence based medicine was the hot new thing, just 7 years following its launch. Near the top of everyone’s mind was the notion that science was here to replace dogma. Except, apparently, when the discussion was about pain. As I read the Medscape piece numerous then and now contrasts started swirling through my mind. I wish I still had my notes from NAIP and SHM sessions of past years but I don’t so I’ll have to do this from memory. I’ll cite a couple of comments from the article followed by my recollections of meetings past:

From the 2017 sessions:

"The message to patients should not be that the goal is to become pain free," she explained. "We should not be expecting opioids to decrease pain by more than 20% to 30%."

Old dogma: nearly all pain can be eliminated and no hospitalized patient should have to endure pain.

"The pattern of reflexively prescribing opioids when a patient in the hospital reports a high pain score needs to be broken, she said."

Old dogma: opioids are just fine. Concerns about addiction are  largely driven by myth. Take patients’ reports of their pain at face value.

Did anyone at SHM stand up and say “we were wrong”?

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