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.