by Myra Christopher, PAINS Director
At the end of May, a colleague asked me if I was aware of Resolution 707 being brought to the American Medical Association’s (AMA) House of Delegates (HOD) meeting by delegates from New York State. I was not. The proposed resolution basically asked the AMA to:
- adopt as policy the position that the clinical highlighting of pain as the “fifth vital sign” and a focus on eradication or total resolution of a patients pain is misguided and leads to:
1) inappropriate pain management demands by patient;
2) inappropriate pressure on clinical pain management practices by clinicians; and consequently,
3) the diffuse overuse of opioids (New HOD Policy);
- recommend that “pain as the fifth vital sign” be removed from the clinical practice environment (New HOD Policy);
- encourage The Joint Commission to remove “pain as the fifth vital sign” from its standards. (New HOD Policy)
It also expressed concerns about Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey scores being used in evaluation and review of physicians’ pain performance. It is easy to understand the frustration that underpinned the New York State resolution – both people living with chronic pain and those who care for them, but I was shocked by what I learned.
It is well known that “Pain as a Fifth Vital Sign” which came from the Veterans Administration and led to the Joint Commission developing and promulgating pain standards has increased the assessment of pain but has not resulted in improved pain outcomes. It is well known that the desire to alleviate pain and suffering is what motivates many to enter medicine. Yet, practicing physicians feel poorly prepared to treat pain and hamstrung by regulatory and legal oversight. It is also well-known that these frustrations have been exacerbated by the imposition of patient satisfaction scores in quality review processes.
The Institute of Medicine report, Relieving Pain in America, published in 2011 called for a “cultural transformation in the way pain is perceived, judged and treated” and the forthcoming National Pain Strategy Report developed in response to Recommendation 2-2 of Relieving Pain rebroadcasts that call. Those involved in development of both of these landmark documents have been gratified by the AMA’s support for and response to them and find the New York resolution inconsistent with those responses. In addition, we find 707 inaccurate in that the Joint Commission pain standards do not now, nor have they ever required utilization of Pain as a 5th Vital Sign nor do they impose requirements upon physicians to provide any particular treatments or medications, including opioids.
All of us are concerned about increasing addiction rates and the abuse of opioids. Addiction disorders and chronic pain are both critically important public health issues, and physicians need to be empowered to provide evidence-based care to both patient populations and to be reimbursed appropriately for doing so. To address both of these issues, the physician/patient relationship must be protected. To do so, it will be necessary for physicians to hold to the traditional values that underpin medicine and maintain the highest levels of professionalism.
Pain is the number one reason people seek medical help. At least 100 million Americans struggle to live day-after-day with chronic pain, more than all those with cancer, diabetes and heart disease combined. Although there is a paucity of data, it is believed that approximately one-third of the 100 million live with what the NPS Report has labeled “high impact chronic pain.” Pain is the leading cause of disability in the United States. Its total economic cost when combining cost of care and loss of productivity is staggering: $560-653 billion annually.
In humanistic terms the costs are even greater. Jobs, insurance, income security and families are lost. Ultimately, hope is lost. The suicide rate among those living with pain is estimated to be 2.5-4 times that of the general population. People living with chronic pain are stigmatized as “drug seekers,” “parasites on society,” “whiners,” “frequent flyers,” “weaklings,” and “psychos” or hypochondriacs. Those who treat them are also stigmatized and stereotyped as “pill pushers” and “enablers” and often subjected to unjustified scrutiny of their clinical practice.
We were so pleased to learn that physicians lined up at the AMA Section Committee to speak against New York Resolution and that the matter was referred back to the AMA Board of Directors for further study. As I said to one of the many people with whom we spoke last week, my experience is that even when they feel threatened, if good people are given information and support they will almost always do the right thing. PAINS is pleased that proved to be true again at the AMA House of Delegates meeting last week.