The 5th Vital Sign, Visual Analogue Scale, and the “Patient Experience” Why the Medical Community Still Has No Response to the Opiate Public Health Crisis
T
he faces stare at you. There are six of them and you know them well. You have been assured that they, and the numbers they are associated with, have meaning for you and your patients. Starting in 2001, they have even told you whether you were doing your job or not. The face on the far left smiles at you as if to say “thank you so much, I feel great, job well done!” The face on the far right frowns at you as if to say “I am miserable! How could you abandon me in this pain!? How could you !?” The face on the far right’s next conversation may well be with the hospital’s patient representative — to talk about you. I am speaking of the Visual Analogue Scale (VAS) for pain assessment and the Wong Baker Faces® Pain Rating Scale. The Joint Commission in 2001 released a statement informing all of us involved in direct patient care that part of our professional duty was to aggressively manage a patient’s pain and that some tool for assessment needed to be used and pain repeatedly re-assessed. This VAS became the choice for most hospitals and has been present in every patient room I have worked in since that time. Alongside this scoring system came another mantra — that pain was the “5th Vital Sign.” A creation of the American Pain Society in 1995, we were instructed as health care professionals that the number generated on this scale was to be treated as meaningfully as blood pressure and heart rate. A patient with “10 out of 10” pain thus would be considered as unstable and in as dire a condition as a By Chris Johnson, M.D. MetroDoctors
patient with a persistent blood pressure of 70/40. I had my doubts, though. Unlike the other vital signs, the number generated for pain was a reported number, not a measured one. Essentially it was an opinion that had a numeric value attached to it. That confused the nature of the data, however, because now it was in a form that could be added, divided and standard deviated. Among all the statistical analysis, you would forget that, in the end, it was still just an opinion. During my residency years at HCMC (2000 – 03), the 5th Vital Sign campaign was in full swing and we were reassured that opiates were perfectly safe. In fact, among the studies used by the American Pain Society (who worked with the Joint Commission in 2001) was an article in the New England Journal of Medicine, stating the risks of developing
The Journal of the Twin Cities Medical Society
addiction to narcotics was less than 1 percent. What I was not aware of at the time, however, was a report by the Government Accountability Office which clarified that the “pain management education program” organized by the Joint Commission in 2001 was funded substantially by Purdue Pharma, the makers of OxyContin. And that study in the New England Journal with the “less than 1 percent become addicted” conclusion? It was not a study. It was a five sentence paragraph by two doctors (Porter and Jick, 1980) in a letter to the editor, barely 100 words long. It was not a study. It was a “tweet.” It has been 13 years since the Joint Commission statement and almost 20 since the 5th “Vital Sign,” and we are in the midst of a public health disaster. The number of prescriptions has skyrocketed — in 1991, there were 76 million prescriptions for opiates, in 2011 there were 219 million. The United States now contains approximately 5 percent of the world’s population, yet we consume 80 percent of the world’s opiates. And paralleling the rise in prescriptions has been the rise in overdose deaths. In 1999, there were 4,030 fatal overdoses, in 2010 there were 16,651. The data also show that deaths are just the “tip of the iceberg.” A recent study looked at data for the year 2010 and found that over 92,000 ER visits were due to overdose of prescription opiates. This resulted in $1.4 billion in costs even though less than 2 percent of the overdoses were fatal. (Continued on page 20)
January/February 2015
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