How pain as a vital sign contributed to prescription pill mills

At this point, few would argue against the need for increased oversight of the legions of so-called pain management clinics that have sprung up in the past decade.

After all, an annually increasing majority of them are nothing more than lucrative cash and carries for the legal sale of prescription narcotics to anyone with a need or want — and the cash in hand. They have become a public mental health problem, an embarrassment to the mainstream medical community and an insult to the legitimate pain management specialty society. Yes, increased oversight and regulation of these bad apples is definitely needed.

Yet, the case could be made that regulation — particularly capricious and meddling regulation — as in the instance of The Joint Commission’s ill conceived 2001, Pain: The Fifth Vital Sign, national campaign—may have been instrumental in the birth of the current prescription “pain killer” epidemic.

In 2001, the organization responsible for monitoring the safety and quality of our nation’s hospitals, The Joint Commission, launched an ambitious and vigorous campaign into that year’s hospital inspections. It was launched in The Joint Commission’s usual authoritative and mandatory style, and they referred to it as their Pain: The Fifth Vital Sign campaign. And so, in 2001, The Joint Commission began focusing that pain in our nation’s hospitals was being under-treated.

During the Joint Commission’s campaign, I was serving as in-house medical officer for a 150-bed state psychiatric hospital, and was appalled one day to find prominent notices posted throughout the hospital, for reminding patients that they had a right to evaluation and treatment for any pain issues they had. Human nature being what it is, this approach would have been ill-conceived and fraught with problems — even in a general medical hospital population — let alone in a psychiatric hospital, where close to forty percent of the patients were dual diagnosis patients (they had both a psychiatric diagnosis and a substance abuse diagnosis.)

This resulted in pandemonium on the wards, and a nightmarish and dangerous ward milieu for several months, until the medical staff’s clinical judgment eventually prevailed over the administration’s Joint Commission hysteria. Even so, from that time forward, it was obvious, that a heretofore conservative clinical standard — with regard to prescribing narcotic pain medications — had become much more open-handed, among many of the staff physicians.

Outside of hospitals, other physicians reacted to The Joint Commission’s Pain: The Fifth Vital Sign campaign, in a more entrepreneurial manner. And, overnight, so-called “pain clinics” sprung up in old houses and store fronts, across the country. As stated in The Medical Profession Is Dead and the Doctor Is “Critically ill!”:

Sometimes these new medical practices were located in old store-fronts, or sometimes within buildings that formerly were small residences, but all of them were calling themselves “Pain Centers” or “Pain Management Clinics.” None of them, from their doctors’ titles, or from size and appearance of their buildings, gave any reason for believing that they were staffed with a board certified pain management physician, psychologist, physical therapist, or anesthesiologist, as would be expected to be the case in a bonafide medical-mainstream pain management clinic. Most of them, having only a single physician’s name on the office shingle, it is almost certain that these “pain clinics” all were the result of a physician having been emboldened sufficiently by the Joint Commission’s Pain: The Fifth Vital Sign campaign, for deciding to limit his/her practice to seeing only patients in need of pain medications.

And, so, today the news media remains filled with stories of skyrocketing problems of misuse and abuse of prescription pain medications, physicians of all specialties having their licenses for prescribing narcotics revoked, over-doses and deaths among all age groups due to prescription narcotics at an all time high, and crimes involving prescription drugs on the rise — all since 2001, the year that the Joint Commission launched its aggressive campaign. The CDC’s recent painkiller epidemic article states that “the quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was 4 times larger in 2010 than in 1999.”

Coincidence or regulatory unintentional consequences?

Alan Cato is the author of The Medical Profession Is Dead and the Doctor Is “Critically Ill!”

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  • http://twitter.com/MGastorf Melissa Gastorf

    I think that you are absolutely correct.  Though this thought continues to prevail.  My husband who moonlights in the local ER had to attend a mandatory meeting on Thursday where they discussed the importance of patient satisfaction.  While that was all good, a majority of the complaints on their surveys regarding my husband were that he either would not refill his medicine through the ER or that he wouldn’t give them pain medicine for something as benign as a splinter.  I have heard similar stories from others who attempt to link patient satisfaction to bonus structure.  In our clinic, we don’t have to worry about such nonsense in those that we identify as merely wanting to use narcotics.  We merely recommend them go somewhere els.  (Our system is not perfect, but we do try)  However, linking patient satisfaction to determine whether or not appropriate care was received will contradict federal law in many cases.  Instead of throwing out those unsatisfied merely due to lack of a narcotic prescription, hospitals have focuses on those.  And have helped to encourage the pill mills.

    • Anonymous

      The article may be a bit overreaching, but the point is still a solid point–we’ve gone too far with this pain control idealism, to the point of dangerous consequences for patients, and others who are just innocent bystanders (ie, victims of crime).

      My associates and I have also seen the potential pit of tying bonuses to patient satisfaction.  My most negative reviews have come from patients who were denied narcotics, but that is not factored into the system. I do prescribe chronic pain meds, but never maryjane, and try to use long release meds that actually have less street value.  Of course, I’m still burned at times, but I’m getting better.  New Mexico has a state funded controlled substance web site where providers can track all scripts for these drugs, helping us to identify the “frequent shoppers” and stop the cycles.

    • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

      Melissa, I confess that I too am at loss to explain any consistent and meaningful correlation between patient satisfaction surveys and quality of care rendered.  These surveys are business management tools and, as such, serve as an unpleasant reminder that medicine-the-profession is increasingly being usurped by “medicine the business.”  Don’t forget, it was the business management world that came up with the slogan:  “The customer is always right.”  And, in business mangement’s hands, it is a short and slppery slope between a “passing” patient satisfaction survey and a-customer-is-always-right edict.  Like your husband, I took my hits on the satisfaction surveys, from the dual diagnosis patients with substance abuse diagnoses.  Try explaining the ”first-do-no-harm” tenet to an addict withdrawing—although I always made the attempt to make them understand.  My satisfaction surveys, under these circumstances, always focused on my not providing what they asked for, and never once did one of them mention my explanation to them for my actions.  

  • http://twitter.com/redbirds12 John Key

    Speaking as one physician who was duped by the “fifth vital sign” campaign I fell victim to all its propaganda:  “dual diagnosis”,”people with pain don’t get addicted”, “OxyContin can’t/won’t be abused”, etc.  Fortunately I soon wised-up to the legion of abusers entering my waiting room and returned to a more traditional approach. 

    There’s definitely a place for narcotic pain relievers, even Class IIs, but the provider needs to be very vigilant.  It’s easy to become a pill mill if you aren’t careful and when the financial wolf is at the door it is even harder.

    A colleague who is in recovery insists on giving nothing stronger than NSAIDs + hydroxyzine for pain.  I used to think he was nuts but there is some wisdom in his approach.

    • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

      John, You are correct, of course, There is ,and will continue to always to be, a proper and genuine need for pain relievers, even class IIs.  You are also are absolutely correct, that physicians must remain extrememly vigilant, and I would add—but not paranoid in regard to their use.  We can learn to be more vigilant, but the magnitude of the current problem today suggests that, within a small subset of clinicians, their exuberant & irrational use of these agents suggest a problem much deeper than lack of prudence, or insufficient vigilance.  Perhaps a good topic for future discussions would be: what are the factors and forces that are increasingly eating away at the pride, aspirations, integrity and character of those entering—what used to be, a nigh universally homogeneous “Proud Medical Profession.”   

  • Anonymous

    I wonder how many people the Joint Commission has harmed with this campaign? 
    Good call on the timeline of those events. Could it be possible the Joint Commission was influenced by Pharma to promote this issue?

    • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

      I don’t know the answer to either of these two questions, Leo.  I well remember their Pain the Fifth Vital Sign campaign,however, and the vigorous manner in which they waged it.  Having power over the Medicare purse strings, hospital administrations are quick to learn to dance to their newest tunes.  So, at the very minimum, I feel that unintentional ”enabler” describes their role.  Thanks for your comments.  Your questions are reasonable.

  • http://pulse.yahoo.com/_6C65YWGCC7P5C6CGMMBK7VMFXE JenniferL

    Brillant analysis by Dr. Cato. 100% correct.

    The dead hand of bureaucracy can often injure and/or kill patients.

    And that dead hand is just getting started, as indicated by the escalating disappearance of hundreds of basic medications (especially in oncology and emergency medicine) secondary to federal regulations.  Not to mention the anihillation of private insurance under the onslaught of ObamaCare.

    • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

      Thank you, Jennifer.  No question about it.  Bureaucracy in medicine is an exponentially increasing problem in medicine—for physicians , patients—and the US economy.

  • http://pulse.yahoo.com/_GJCNF5QLKW7ROYAZZGB7HFH57Y jamesp

    OTOH… http://www.nytimes.com/2007/06/17/magazine/17pain-t.html?pagewanted=2

    Dr. C, as a primary care physician, I can say your post above is VERY one-sided.