How pain scores escalated the opioid crisis

“It’s an 8,” I heard him say from behind the curtain as I walked into the room.

The nurse’s aide dutifully recorded the number while the automated blood pressure cuff searched for his pulse, and the plastic clip on the tip of his index finger measured his oxygen saturation.

“What does an 8 mean?” I asked.

“Oxycodone!” he chirped cheerfully, without a moment’s hesitation.  “An 8 means oxycodone.  Five milligrams!”

“Ah, but you’re wrong,” I corrected him.  “An 8 means intravenous morphine to your nurse.  Have you asked for Vicodin?”

“No,” he responded.  “They just keep bringing me morphine.”

His pain score, when he entered the hospital before his colectomy three days ago, was an 8, dutifully recorded by the pre-op nurse.  Which for him means Vicodin, thank you: one tablet, containing 5 mg of oxycodone and 350 mg of Tylenol, four times daily.

It was only three days after his colectomy, and I was amazed to see how well he had done.  He was older, overweight, with chronic pain, and no pressing obligations calling him home.  But here he was, taking morphine to cover his back pain and wondering what fuss was about.  I had to get him home.  Fast.  Before something bad happened to him.

You see, the orders in our computerized hospital medical record system have standardized, sophisticated orders for pain management.  A pain score of 7 to 10 gets you intravenous narcotics: morphine, Dilaudid, Fentanyl.  Never mind that one person’s 3 is another person’s 9; that some patients can be sedated to the point that they are barely breathing and yet, if you shake them awake, they will rate their pain a 10; that some pain responds better to anti-inflammatories or anxiolytics or a good night’s sleep than to narcotics.

Yesterday I noticed that a young man that I had cared for some years ago had been seen in the emergency room the night before, complaining of 10 out of 10 abdominal pain. His temperature, heart rate, blood pressure, oxygen saturation, laboratory studies, and obligatory CT of the abdomen were all normal.  Diagnosis:  Abdominal pain.  Disposition:  Discharge with hydromorphone 2 mg tablets, #30.

My heart sank.  Though I hadn’t seen him in a couple of years, I saw his mother recently, and she told me that he was doing better.  He was working, and he had a girlfriend.  He had completed a 30-day residential drug and alcohol rehab program in Arizona.  He was his old self again.  And he had just been given 30 tablets of hydromorphone — because pain is what the patient says it is.

In the 1990s, the American Pain Society began the “Pain as the 5th Vital Sign” initiative, intended to make routine pain assessment part of all of our medical encounters, along with the traditional vital signs of pulse, blood pressure, temperature, and respiration. It became the cornerstone of a Veterans Administration strategy to improve pain management, and all hospitals seeking Joint Commission accreditation were required to monitor, record, and manage pain symptoms routinely for all patients.  Electronic health records facilitated the recording of pain scores, and computerized order entry triggered narcotic administration by the numbers.   Primary care physicians turned their patients over to hospitalists, and pharmacy pain protocols emerged to help manage the most difficult pain patients, further disassociating the care of pain from the global care of the rest of the patient.  HCAP scores were implemented that linked payments to patient satisfaction with pain control.

At the same time, pain came to be defined as a subjective experience known only to the patient; it was what the patient said it was, and it was strongly implied that we weren’t competent, caring doctors if we didn’t prescribe narcotics to treat it.  In California, all physicians were required to take continuing medical education on management of pain and end of life issues.  I remember vividly the educational session that I attended in 2002, in which the instructor described the case of an elderly man dying of metastatic lung cancer, whose family successfully sued the doctor under California’s Elder Abuse and Dependent Adult Civil Protection Act for prescribing an inappropriate narcotic for his pain: Demerol.  It could be me, we all thought to ourselves that day, imagining the loss of our medical licenses and the possibility of prison.

Fifteen years later, prescription drug abuse has overtaken illegal drugs as the major cause of drug overdose in the U.S., and oxycodone has become the gateway drug to heroin.  Several states have enacted tight new controls on the prescription of narcotics, and presidential candidates from both parties have blamed physicians for the opiate epidemic.   Doctors have rightly been identified as the new pushers.

Proposed remedies include more education and discipline of physicians, greater availability of naloxone, and increases in the amount of Suboxone that can be prescribed. Absent is any discussion of the role that pain scores have had on the opiate epidemic.  Temperature, blood pressure, heart rate, oxygen saturation, height and weight: These are data that can be measured objectively, and for which there are unequivocal health implications. Yet none of these triggers an automatic intervention.  Anxiety, depression, isolation, loneliness: These are subjective sensations for which, I would argue, reporting might have important implications for the care of our patients — yet none are scored or treated by protocol.  The pain score on the other hand, subjective and unverifiable, leads predictably to the administration of dangerous, addictive drugs in a world in which admonitions to treat pain are stronger than the admonitions to treat tobacco dependence or diabetes or obesity or depression.

Frankly, I resent what the opinion leaders in organized medicine did when they declared pain the 5th vital sign, with no science behind this declaration and no surveillance of its consequences; when they created an environment in which the liberal prescription of narcotics became the measure of good medicine and the recognized standard of acceptable care; when they distilled an experience as complex as the sensation of pain down to a simple number that triggered the reflex prescription of narcotics; when they made it politically incorrect to question the self-reporting of pain; when the programs that they mandated, and that we implemented, began to destroy the lives of millions of patients whom we were supposed to protect.

Shame on us.

Mark Vierra is a surgeon.

Image credit: Shutterstock.com

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