Wednesday, June 26, 2013

Pain Is The Fifth Vital Sign - And If You Don't Have Any, You Might Be Almost Dead

"The cure is worse than the disease", it has been said about some supposed remedies.  We might be at that point in the treatment of acute and especially chronic pain with opioid (narcotic) analgesics.  In this article in the May 9th issue of JAMA Dowell et al make the astute observation that as opioid related deaths have quadrupled in the last decade or so, people have not become more susceptible to the drugs - it's just that their exposure has increased.  Exposure increased because several alleged patient advocacy groups (American Pain Society, Veteran's Health Administration, the Joint Commission) campaigned to convince physicians that they were not adequately recognizing and treating pain, callously leaving countless patients unnecessarily writhing in abject misery.  Led by these and other coalitions of busybodies, we went from possible undertreatment of pain (with narcotics) straight to guaranteed bona fide undeniable overtreatment (with a brief pass through [but not a stop at] optimal treatment).  Part of this overzealous campaign was the coining (original source unknown) of the contagious catchphrase "pain as the fifth vital sign."  

This is interesting because pain is a SYMPTOM, something reported by a patient (part of the HISTORY), whereas a [vital] SIGN is an observation or measurement (part of the PHYSICAL EXAMINATION) made by a practitioner such as blood pressure, heart rate, a bruise on the skin, a pulsatile uvula (Muller's sign), or some other finding.  (The more rare, uncontemporaneous, and useless a sign is, the more likely its name is an eponym.)  But the pain coalition (PC) successfully circumvented this convention by cooking up pain scales and cutesy numbered diagrams bounded by smiley faces and sad faces, adding a cloak of objective legitimacy to the subjective experience of pain.

This is not to say that pain and its recognition are not important.  But any other body, concerned myopically with their own area of interest, could assign "fifth vital sign" status to anything - smoking, sadness, anxiety, dental flossing, exercise, compliance with medications, hunger, thirst, anything.  And what is the consequence of missing pain?  Does anyone die of pain?  (They do indeed die from perturbations in heart rate, blood pressure, respiratory rate, and temperature.  And they die from overtreatment of pain.)  Indeed the focus on pain as something to be treated non-specifically with narcotics is a distraction from the clinical maxim to find and treat the cause rather than the symptom.  But alas, the PC, previously focused on treating patients with terminal cancer, too quickly transferred across domains - treating terminal cancer pain (little consequence of overtreatment) where the cause is known (and cannot be specifically addressed) was domain specific.  Treating pain in other domains is more nuanced.  Perhaps "pain as the fifth vital sign" is appropriate - but only in certain domains.

In any case, the PC was successful, and we are now paying the price.  Ab/use of prescription narcotics is now widespread as frequent news reports document.  In the Salt Lake Valley, this ab/use is rampant.  Hardly a month goes by that I do not sign a death certificate where the proximate cause of death was opioid overdose (either accidental or intentional.)  Is it worth it?  Are these deaths part and parcel of adequate pain treatment or have we gone too far?  It's quite simple - we have gone too far.

Pain is part and parcel of life.  We learn from pain.  Children who have a mutation such that they cannot feel pain are unable to develop appropriate avoidant behaviors and die prematurely or are maimed and cannot lead normal lives.  (See this fascinating NYT article chroniclingthe life of one of these children.)  We must accept pain on a certain level and learn how to cope with it.  The common cold causes pain and is a nuisance.  But our bodies become immunologically stronger (antifragile) as a result of it.  We may not like to go to the bathroom (it is a nuisance) or brush and floss our teeth, or eat healthy food, but we do it as part of the necessity of life.  Vigorous exercise is often acutely and subacutely quite painful, and society is suffering from a dearth of such suffering.  Chronic pain such as lower back pain caused by obesity and a sedentary lifestyle, or diabetic neuropathy takes the place of the acute pain of exercise and diet - but the latter is far preferable because it is within our control.  Some women opt for "natural" childbirth so as to not deprive themselves of the pain that has, for almost all of human history, been an unavoidable part of that experience.  Thus, I reject the basic premise that all pain is bad and must be treated.  Some pain is OK and we should learn to live and cope with it.

Pain, especially acute pain and pain associated with surgery and trauma, should be adequately treated.  But the pivotal word is adequate.  Too often do we enter the room of a patient with normal vital signs who is asleep or appears to be.  When roused and asked about pain, the patient (or an [over]concerned family member) reports that there is pain.  Well sure there is!  You just had major abdominal surgery!  The key question is, is the pain tolerable?  We are trying to hone in on the severity of the pain, like with the smiley face scales.  And all too often, the pain is reported as a 10 on a scale of 10.

So let me get this right - you have normal vital signs and were just asleep, but you're having 10 out of 10 pain?  It's very unfortunate, but I have had to resort to the following analogy:  10 out of 10 pain is when a civil war barber cuts off your unanesthetized leg with a carpenter's saw (a bullet to chew on and a shot of whiskey to take the edge off supplied as a contemporaneous coursesy).  That's 10 out of 10.  How does your pain compare to that?  I'm not convinced that this debiases the question, but it's a start.   Because one of the problems with the pain scales is that they have no objective reference.  And they're inherently flawed.  After you've received opioids already, your pain, which was 10 out of 10 before, can't be 10 out of 10 now.  It HAS to be better (unless it's gotten worse).  While that could be the case (it's gotten worse despite treatment), the carpenter saw analogy is brought into keener focus - now you're saying your current pain treated with narcotics is worse than crude leg amputation without treatment with anything save for 200 grains of lead to clench with your teeth and 15 grams of ethanol.

The elephant in the room is that some of the patients are drug seeking (frank discussion of this possibility is taboo except among health care providers behind closed doors).  Because of the subjectivity of the pain scales, and the PC edict to treat all pain, we are prone to, even coerced on some level to overtreating pain, often against our better judgment - and we have been doing this for some time now.  So rather than pretend that a symptom is a sign, maybe we should start looking for actual signs of pain - splinting, wincing, sweating, grimacing, tearing, tachycardia, hypertension, etc. that may be attributable to pain - that is, we should look for evidence of pain.  In addition, as with all judgment and decision making, we should think about goals and possibilities.  What are our goals and are there concurrent goals (identifying the cause of pain as well as treating pain)?  And what are possible ways of achieving our goals?  Will getting out of bed help manage the pain?  Will an entertaining and distracting movie help?  A nicotine patch?  Are there non-opioid alternatives?  Is the pain manageable without treatment?  What are the costs and risks, both acute and chronic of treatment?  Are patient (and provider) expectations of tolerable pain associated with a given condition realistic?

These are not trivial questions and neither is it trivial to suffer pain.  But we have seen young people's lives destroyed - such as the young woman who 10 years ago was given narcotics after a motor vehicle accident, became addicted, ruined her young adult life with prescription and illegal narcotic ab/use, and then was admitted with sepsis and peritonitis due to bowel obstruction and perforation associated with chronic prescription narcotic use.  Cases such as this are the inevitable and tragic consequence of the push to treat all pain.  Some pain we are better off living with.

Which is why I say, "If you feel some pain, be thankful - it means you're alive."  And if I take it all away, you might just wind up dead.


  1. As always, very well stated. I just had a conversation with a colleague (a family practitioner who just finished residency), who did not know that Dilaudid came in pill form....
    We are doing a disservice to humanity by the way we deal with pain and complaints of pain.

  2. Can I use your photo with credit in my pain talk (since I evidently am becoming a regional speaker on this topic)?
    -James Knight

  3. As an 18-year advocate for chronic neurological face pain patients, I find your casual approach to agony to be deeply reprehensible. Many Trigeminal Neuralgia patients do not respond to opioid medications. But for those who do -- and who are resistant to the common anti-seizure medications used off label for TN, as perhaps 50% are -- opioids can literally be life savers. That life saving intervention is now being denied to patients whose doctors are afraid of being persecuted and prosecuted by government authorities for prescribing pain killers. Many have already left pain management practices.

    So yes, pain medications are indeed over-prescribed and widely abused in the US. And yes, steps are needed to better manage pain medication for people who should not be using it chronically. But to focus ONLY on this restrictive policy is fundamentally irresponsible and downright evil. These are people who go through life with 10 out of 10 pain every day of their lives. To simply write them off is NOT ACCEPTABLE.

    Richard A. Lawhern, Ph.D.
    Resident Research Analyst
    Living With TN, an online community within Ben's Friends.

  4. We disagree on an important premise - whether or not the pain from TN is indeed 10/10. Start cutting off the gangrenous extremity, and 10/10 comes into clearer focus. Surely, something less than an amputation will suffice to prove this point.

    1. You can disagree all you want. But it's clear that you haven't read very much about trigeminal neuralgia, Scott, and have probably never seen a patient who suffers with this monster (it's rare enough to be regarded as an "orphan" disease, so that would not be surprising in any GP). TN pain is almost universally recognized as the most severe form of neurological pain known in medical practice. For whatever this is worth, I edited and coordinated external validation of the most recent release of the NINDS Fact Sheet on Trigeminal Neuralgia. I suggest that you read it. You might also benefit from looking up "Atypical Trigeminal Neuralgia" on Wikipedia, parts of which I also wrote.

  5. More importantly - you suggest that my paradigm should not be universally applied. And I suggest that neither should yours be generalized to justify wanton prescription of opioids.

    1. I have bilateral Trigeminal Neuralgia (Dx 1998) and Charcot-Marie-Tooth Disease. Because of the CMT I can't take the typical TN meds because they're sodium blockers and, when I take them I become too weak to walk or function. Vicodin is the only thing I can take for TN pain.
      My pain comes and goes. I fight taking meds as long as possible. And, when I did take Vicodin, I tried to not take it 2 days in a row because I was worried about dependence. Many---really most--- of the people who take pain meds would prefer not to....we'd give our eye teeth to not be in this situation.
      Yes, TN can and does come in and stay at 10/10 for extended periods. I've had other pain...broken foot bone from a car accident, broken ribs from a fall. We can distance ourselves from some pain. But face or head pain is different because it hits where we "live". You can divorce yourself somewhat from limb pain. But there's nowhere to go with head/face pain....nowhere!!
      And, there's a difference between bone, muscle and nerve pain. Each will respond (or not) to different types of meds. Opioids are the best choice for some pain.
      I personally think your writing here is as dangerous and simplistic as the 'pro-pain-mgmnt' groups you're swinging at. And, sadly, you've moved from a physician's perspective to a politician's perspective. Stop formulating broad opinions about groups and get back to TREATING individuals or you're sure to violate your oath of 'doing no harm.' As a person with a lifelong disability who NEVER fit into any of the cookie-cutter molds held by doctors and teachers, I can tell you that your broad brush strokes toward pain patients are dangerous and insulting. I hope you choose to do better going forward.....your arrogance will be devastating to someone in true pain because pain makes you fragile. Remember that before telling someone their pain can't b be as bad as they're reporting because you're forgetting the exhaustion factor. A pebble in my shoe for 10 feet is different than 10 blocks and different still than for 10 miles. When someone has had the pebble for 10 miles, it's now a bigger deal than when it started. Try to release your biases and meet the patient where they a true healer and not a politician....please! ~Dinah~

    2. You draw a false and misleading analogy, Scott. I'm not advocating for a universally lax standard of prescription for opioids. I AM advocating for a balanced approach which acknowledges the challenges of opioid management and at the same time recognizes that these pain relievers are essential for some patients, some of the time. You simply cannot write off millions of ACTUAL chronic pain patients in the name of correcting the over-prescription of opioids.

  6. The exceptions do not prove the rule wrong. Do no harm can be construed to mean many things, such as saving people from the harms of opioids. The fact remains that there are over 16,000 deaths from opioids per year. It is for each person to judge whether this is an acceptable price to pay for the treatment of pain in general or in specific cases. I have rendered my judgment. I have taken no oath that prevents me from speaking freely about these issues on my own blog, or lobbying politically (which I have not done.) I am addressing a serious problem, something that healers much do, even if the medicine is difficult to swallow. I stand behind this post entirely.

  7. Look y'all, never did I say that opioids should be banned and never used, only that they should be used judiciously. The entire point here, which has been lost on those who wish to convince us that the author of the post is a heartless scoundrel who delights sadistically in imagining patients writhing in pain, is that they are being used injudiciously, wantonly, and recklessly in too high a proportion of cases. Those with legitimate pain and a need for opioids have nothing to fear, there is no campaign to take their meds away or to declare all pain a state of mind that demands no treatment.

    1. Dr.Aberegg, sadly, your statement that "Those with legitimate pain and a need for opioids have nothing to fear, " isn't born out by patient experience. I talk with chronic pain patients every week whose practitioners have decided not to renew their pain prescriptions, despite the fact that they can offer nothing in replacement. Practitioners in pain management are also being driven out of practice by overly restrictive and punitive US State policies.

      US FDA policy on management of opioids needs to be explicitly broadened and nuanced to support the treatment of chronic as distinct from acute pain or short term post-operative pain. At present, a great number of doctors are reacting to a perceived threat to their professional licenses, by simply closing down the elements of their practices which most directly pertain to people in desperate need of help. That is reality, Scott, not conjecture.

  8. Like all matters in public health, there will be winners and losers. In a perfect world, we would be perfectly calibrated such that no practitioners under- or over-prescribe and no patients drug seek and abuse the medications, thus disrupting the calibration. But alas, we do not live in a perfect world. We must make compromises. I, as a rational decision maker, am willing to consider that a compromise may be that certain patients may have to endure some pain, so that some other multiple of patients may live and not have their lives ruined by overdoses and death. If I were to take a unidimentional approach, an prioritize treatment of pain over all else, and pretend the world is perfect and so is calibration, then I would agree with you. But I do not.