Pain is the 5th vital sign, problem for opiate abuse?

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.

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6 responses to “Pain is the 5th vital sign, problem for opiate abuse?

  1. Conspiracy – You Be the Judge

    In 1996, the American Academy of Pain Medicine and the American Pain Society issued a set of guidelines for the use of opioids in the treatment of chronic pain. These guidelines are referred to as a “consensus statement.” The statement leaning toward a more liberal use of opiates was adopted just as the marketing push for OxyContin began.

    The guidelines began with a statement that there were currently no nationally accepted consensus for the treatment of chronic pain not due to cancer. The guidelines argued for the expansion of the role of opiates from limited treatment of acute pain to a wider and looser interpretation of chronic pain. It emphasized the clinical differences between addiction, physical dependence and tolerance and even advised that addicts experiencing severe pain could take opioids under careful supervision.

    This consensus statement was produced by a task force, which was headed by J. David Haddox, DDS, MD, and former president of the American Academy of Pain Medicine, who was senior medical adviser for Purdue Pharma – the maker of OxyContin. The opioid guidelines grew out of a series of 11 regional workshops conducted by the University of Wisconsin Pain and Policy Studies Group – to which Haddox was a member. This task force produced the opioid statement, which became the precursor to other guidelines including that issued by the Federation of State Medical Boards in 1998.

    Haddox was quoted as saying that “the point was to gather consensus. If you are going to do this, this is how it should be done.” There was question as it whether it was ethical for Haddox to be associated with a pharmaceutical maker to guide the formation of a document that would play a key role in promoting the use of products made by the company – Purdue Pharma.

    Haddox guided the formation of a consensus statement that played a pivotal role in promoting the use of products made by the company he was employed by – the product name was OxyContin. Conspiracy? You be the judge.

  2. I think a bigger problem is the way that pain management interacts with a doctor’s need to know their patients. Some people exhibit extremely high likelihood of developing addictions while others do not. Over-prescription of various medications reflects a real challenge in today’s medical practice. Instead of conspiracy, I think the call should be for more holistic patient care.

  3. Marianne, The consensus statement of 1996, the case of Haddox and the subsequent criminal and social suits against Purdue (and the later settlement) are well documented. I do not wish to argue whether there was conspiracy in this case. I do not know if there was. There was a clear conflict of interest that should never have been allowed. Again, I was not in APS at that time and know nothing about the particulars of the decisions that happened at the time of the statement.

    On the other hand, the authors of the article in question appear to draw a connection between the consensus statement (as alluded to by the Purdue sponsorship) and the pain as the 5th vital sign campaign. I see no evidence of a connection. In fact, a good deal of the pain as a fifth vital sign campaign was based on long standing evidence that pain is the primary reason that people seek medical attention but that pain is infrequently treated. It was also based on completely inadequate treatment of cancer pain. This was clearly contrary to the basic science findings emerging at the time and the pain as the 5th vital sign campaign dealt directly with the problem.

  4. I appreciate your comment and I do believe there was a conspiracy and Haddox is up to his eyeballs in questionable activity as relates to the marketing of OxyContin. I also recognize that patients consult physicians regarding pain issues and their treatment of the pain. My work focuses on the criminal activity of Purdue Pharma and has never been the denial of medical treatment for pain.

  5. Christian Emmanuel V. Mancao MD

    I agree that pain is one of the five vital signs – it is the most common cause of patients to seek medical consultation. But, I do not agree to the practice of using drugs as the first line approach to treating pain. Most of the pain syndromes can be relieved easily by a 15 second manipulation that I have designed. A one second manipulation easily relieves migraine and tension/stress headache attacks instantly. Other areas of pain can be easily modified by just alkaliizing the area of pain. The results are just in minutes with the least of side effects. There is no need to use NSAID’s and opioids as a first line approach to relieving pain. Pain treatment protocols should be based on non-invasive, simple yet very effective methods that can easily be applied to a patient in pain yet gives relief immediately without the unwanted and yet expected side effects of drugs. I estimate more than 80% of patients suffering from chronic pain syndromes or even more instantly benefits from the approach. If you are interested for the immediate relief of pain of patients and even for yourself then look up Dr. Christian Emmanuel Mancao or Mancao Myotherapy. Life begins when pain ends..let us enjoy quality life beyond boundaries unless of course you are a masochist.
    Doc Chris

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