It’s a Start

There is a deadly explosion of opioid addiction in the United States. While it is clear that nothing this complex or widespread can have a single cause, it is also clear that American prescribing habits have been a significant contributing factor.

According to the Department of Health and Human Services more than 240 million prescriptions for opioids were written in 2014, and it is well established that prescription oral analgesics are the principal gateway for heroin and other injection narcotics.

It is also true that use of narcotic analgesics is much higher in the United States than in other countries. Here again, the difference between the US and the rest of the world probably has multiple causes, including pharmaceutical marketing, and the easy availability of drugs. Recently, CMS implicitly acknowledged another cause: the creation of patient expectations around pain control, and the subsequent pressure that has had on US physicians’ prescribing habits.

Starting with the Joint Commission establishing pain as “the fifth vital sign” (after blood pressure, heart rate, temperature and respiratory rate) an entire generation of US physicians was trained to eradicate pain aggressively. I recall being taught that aggressive pain management was an essential element of good patient care, and that it had a low likelihood of leading to addiction or abuse.

CMS got into the act by including questions about pain management on the mandatory HCAHPS hospital patient experience survey. Since HCAHPS scores are tied to hospital reimbursement, institutions nationally were incentivized to implement intensive pain assessment and treatment protocols, nearly all of which relied heavily on the use of opioid analgesics.

Reacting to the epidemic and to the perception that its policies may be counterproductive, CMS announced recently that:

Although CMS is not aware of any scientific studies that support an association between scores on the pain management dimension questions and opioid prescribing practices, we are proposing to remove the pain management dimension of the HCAHPS survey for purposes of the Hospital VBP [value based purchasing] Program in an abundance of caution.

It won’t change the landscape of opioid abuse overnight, but it seems to me like an important step in the right direction.

What do you think?

2 thoughts on “It’s a Start

    1. Dr. Nash –
      maybe my perspective as a Nurse is a bit different, but what I remember about the evolution of pain as the 5th VS was not so much focused on “eradicat[ing]e pain aggressively”, as much as RECOGNIZING it, and including it in the assessment so it is addressed it in a patient’s overall health plan.
      I think it is an important question to ASK, and that having a standardized way of assessing is a good thing (to me the Vital sign piece was about trying to capture and Quantify that). And recognizing it’s impact on your patient’s overall health issues is important.
      It makes no sense to treat a patient’s BP as if they have “hypertension” if when they are in less pain they are not hypertensive.
      Unfortunately, for the overworked provider, who on has limited time with their patient (maybe related to insurance, needs to increase productivity etc) the “fast” answer is to write a prescription — and that has contributed to the opioid crisis.
      A provider might want to consider other ways of treating pain, but they are labor intensive to manage. (lots of other options other than a narcotic prescription – including for example – meditation, physical therapy, etc). But to say that making Pain the fifth vital sign was all bad is also incorrect.
      As one who lives in Chronic pain, and am NOT using anything stronger than NSAIDs, I fear the pendulum will swing too far the other way on this one before we get to a more reasoned approach.

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