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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