Drugmonkey points out that the graphic I linked to in the Las Vegas Sun last week was part of a series of articles on growing rates of narcotic abuse in Nevada. In part one of that series Marshall Allen and Alex Richards take issue with the American Pain Society and the Veteran’s Affairs campaign called “Pain is the 5th vital sign”:
The use of narcotics to treat pain got a tremendous boost in 1995 from the American Pain Society. Its corporate members include the pharmaceutical companies Purdue, maker of OxyContin; Abbott, maker of Vicodin and UCB, and Watson, maker of the hydrocodone drugs Lortab and Norco.
The society set guidelines saying proper pain management includes urging patients to report unrelieved pain. At the time studies had shown that cancer patients were suffering needlessly because they were not being given enough painkillers.
In January 1999, the Veterans Affairs Department, citing the American Pain Society’s statement that pain is one of the main reasons people consult a doctor, launched a campaign known as “Pain is the Fifth Vital Sign.”
The initiative encouraged health care providers to monitor a patient’s reported level of pain — a subjective symptom — as they did the four measurable vital signs: blood pressure, breathing rate, pulse and temperature. Health care providers asked patients to rank pain on a scale of 1 to 10, and were then urged to treat it.
Dr. Mel Pohl, a Las Vegas addiction recovery specialist, criticizes the pharmaceutical industry’s role in making pain the fifth vital sign.
“The rationale was that we don’t want people to suffer,” Pohl said. “In the best case that’s what it was about. In the worst case, somebody was working this out with the (financial) bottom line in mind. Probably both factors are part of it.”
Soon after, the methods advocated by Veterans Affairs were endorsed by the Joint Commission, the agency that monitors and regulates hospitals. Every hospital is now expected to measure pain in a similar manner.
What is the problem here?
First, a disclaimer. I am an American Pain Society (APS) member. I was not a member back in 1995 (when I was starting undergrad). It is worth noting that American Pain Society now has very strict rules concerning conflict of interests for members holding leadership positions in the organization. I do not know, and I cannot find the relevant information, how long this has been the policy of APS — but the policy has been in place since I became a member.
But the problem does not appear to be with APS per se, rather, the authors quote Mel Pohl who questions whether pain as the 5th vital sign wasn’t really a conspiracy put in place to improve Big Pharma’s bottom line. I find this patently absurd. The first problem with this assertion is that the pain as the 5th vital sign campaign was initially brought about because of the problem of suffering in cancer pain patients (as the authors state). Most cancer pain patients have metastatic cancers that have moved into the bone. Bone destruction as a product of metastatic cancer is horrendously painful. Moreover, it is generally an indication of cancer of a terminal nature. Hence, a good deal of the impetus for this movement came about as an effort for improved pain control for patients also dealing with end of life issues. I find it more than a little offensive to conflate Pharma’s bottom line with alleviating pain in patients that would merely like to die in peace.
Another problem with the assertion of the authors is the nature of the basic science findings that were also involved in driving the pain as the 5th vital sign campaign. At that time (mid 1990s) we (the pain research community) were just beginning to gain a fuller understanding of how central sensitization contributes to chronic pain. The problem with central sensitization is that it does not easily reverse and it is enhanced by inadequate pain control during the initial time frame of an injury or disease process. Hence, adequate pain control early on (for instance when someone shows up in the ER) is important for preventing a transition from a transient painful event to a chronic problem which has an adverse effect on individual quality of life, overall health care costs and societal productivity. Major advances in basic science at the time showed quite clearly that analgesia administration at early time points could have a large impact on eventual outcomes. The fact of the matter is that the current state of knowledge still supports this claim and greater vigilance on the part of hospitals (and in particular emergency departments) is an important aspect of avoiding chronic pain problems in many potential chronic pain patients.
I think it is important to consider the notion that pain treatment and narcotic addiction and abuse are coincident problems based on very real physiological redundancies. We all have endogenous pain control systems and these systems are organized in areas of the brain that are separate from the reward areas that contribute to positive reinforcement effects that important for narcotic abuse. By some accident of evolution it so happens that these brain areas utilize the same neurotransmitter systems — endogenous opioids. Narcotics that are used to treat pain are almost all mu or delta opioid receptor agonists (most hit both receptors). These receptors are also important for the positive reinforcing effects of these compounds. Pain control is limited by physiology. We cannot wish for a pain control compound and make it be so, they must be based on physiology. It is unfortunate that narcotics that are used to treat pain also carry a high abuse liability. It would be more unfortunate to stop treating pain because we are afraid of creating abuse problems. There is a very real lack of effective analgesics that do not carry abuse liability. This is not due to some lack of effort on the part of basic scientists or Big Pharma. The list of magic bullet targets without abuse potential is long and distinguished — and littered with failed clinical trials. In the meantime there are patients suffering from chronic pain that deserve to have their pain managed without care-takers making value judgements on whether an individual is telling the truth about their pain condition.
In closing, it is unfortunate that narcotic abuse is growing at such alarming rates throughout the US. The problem is not, however, a grand conspiracy based on the pain as the 5th vital sign campaign. On the contrary, the pain as the 5th vital sign movement has been effective in improving pain management in some of the most vulnerable patient populations. Moreover, it is based on a solid basic science foundation that continues to grow. The bottom line on this issue is not Big Pharma’s, it is improved alleviation of suffering in chronic pain patients.