Pain as the fifth vital sign; the story that needs to be told

Pain was introduced as a fifth vital sign propelled the mismanagement of pain into the stratosphere and the breeding grounds for this almighty f*&$ up are still here. Through this blog I will explore why the story that is being told about this chain of events is missing the point. I will delve into the gruesome details of yet another unfortunate turn for people in pain and explain that we still lack the basic understanding to steer this ship back on course.


The story that is being told is one of drugs, lies and corruption - we are missing sex and rock n roll, but it remains a fascinating tale. The introduction of pain as a vital sign was initiated in 1998 by the Veterans Health Administration (VHA) as part of a altogether altruistic push to improve the suffering of those in hospital care (Ref). This national agenda required care givers to assess patient’s pain based on a scale of 0 to 10 during every clinical encounter. Although this was meant to improve how those in pain are cared for, it has had far reaching, very devastating consequences. And while other nations have definitely been impacted, these consequences have been felt most in the US.


The opioid epidemic now kills almost two times as many people than guns do in one year in the U.S., and it has a causal link to pain becoming the fifth vital sign (Ref). There is a clear relationship between the VHA initiative and a rapid rise in opioid overdose deaths. It has been claimed that VHA and the American Pain Society received undisclosed funding from opioid manufacturers (Ref). There has been three distinct waves of the opioid crisis, each deadlier than the last. The first wave tapered when legislation clamped down on opioid overprescription, leaving addicted patients to seek out elicit heroin as a substitute for their addiction (Ref). The final spike in death rates is related to cheaper, more pure forms of synthetic opioids like fentanyl, which is more readily available than opioids (Ref). It is a story which begs to be told, and it needs to be. But are we missing the point?


Although Australian rates of opioid deaths have been increasing, it is slower and more controlled than in the US (Ref).


Something else that has increased slowly over the past 20 years is the low back pain burden. Years lived with disability caused by low back pain have increased by more than 50% since 1990 (Ref). People with low back pain are suffering more than they used to (Ref). And although guidelines no longer recommend prescribing opioids for low back pain, it is still alarmingly common (Ref, Ref). There is no evidence of effectiveness in using opioid in acute low back pain, in fact there is no evidence of even the mildest form of medication being effective in acute low back pain (Ref, Ref). Which begs the question, why is this still prescribed?


The push to make pain a vital sign has not been effective in the very thing it set out to achieve. There is good evidence to show pain management has not improved in any metric in acute care as a result of this initiative (Ref). This is not to say pain isn’t a vital sign mind you; it is vitally important and quantification of pain is necessary. Unfolding of clinical events, however, between the start of ‘pain as a fifth vital sign’ demonstrates the untold side to this story. The more pernicious side. A case study in harmful reductionism. The push to have pain better recognised and treated was done in haste and to ensure assessment can fit into all manner of brief clinical encounters. Typically the numerical rating was used, as it is reliable and quick to use. A numerical rating may be important, but pain is about much more than a number.


Pain is a complex, subjective experience; asking clinicians and patients to make a meaningful interpretation of this with a quick-fire one digit answer is incredibly difficult - for both parties (Ref).

In fact, nurses performing these evaluations continue to find the whole thing confusing (Ref). There is, thankfully, a move away from reductionist practices towards more multifactorial pain assessments, but it is far from being abandoned (Ref).


The real issue with the ‘pain as the fifth vital sign’ campaign is that it reflects a persistent ignorance to pain's true nature. You can quickly, reliably and definitely measure blood pressure, heart rate and oxygen levels but you just cannot do the same with pain; it’s just different. A lack of understanding by clinicians leads to confusion and patients feeling invalidated (Ref). A lack of understanding by a system has led to deaths, on a horrifying scale.


Pain does need to be a vital component of every clinical encounter, but probably not in the way it currently is. We do want to reduce suffering. But when pain assessment and management is continually employed with a lack of understanding, it allows a big problem to grow into an unstoppable one. The breeding grounds of the opioid crisis haven’t changed, the story that should be told is one of continual ignorance. And that needs to change.


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