Backpedaling on Opioid Use

To correct what they believe was an overly zealous approach to pain control that put patients at risk for opioid addiction, some physicians are now telling their patients to expect to have some pain. A recent article on Medscape explains that “Doctors at some of the largest US hospital chains admit they went overboard with opioids to make people as pain-free as possible, and now they shoulder part of the blame for the nation’s opioid crisis. In an effort to be part of the cure, they’ve begun to issue an uncomfortable warning to patients: You’re going to feel some pain.”

Nurses—and some physicians—have a wide range of views on the issue. Some believe that patients are being overmedicated, but others worry that we are taking a step backward and patients will suffer. In the discussion after the article Hospitals Hone New Message in Wake of Opioid Epidemic: Expect Pain, nurses described their own experiences with undertreated pain and their reluctance to undergo needed medical procedures out of fear that they will have uncontrolled pain.

The Fifth Vital Sign Initiative

“The fifth vital sign approach has backfired on us all,” wrote one reader, who was not alone in this assessment. Many readers suggested that the “pain as the fifth vital sign” initiative—introduced by the American Pain Society in 1996—is at least partly to blame for the current opioid crisis. This concept stresses that assessment of pain is as important as measurement of the standard four “vital signs,” and that clinicians must act when patients report pain.^[2]

“I don’t remember many addiction problems until ‘pain as a fifth vital sign’ subtly implied that pain was an avoidable part of life, if only insensitive doctors would prescribe more drugs,” one reader commented. Another wrote:

Making pain a vital sign caused more harm than any benefit, unless of course someone is traversing toward end-of-life or symptom-based palliative care, either owing to a terminal illness or severe physical disability. More objective pain assessments should be utilized in the acute care setting as opposed to a subjective Likert scale (ie, numerical pain scale based on 1-10).

“The Joint Commission should share some of the responsibility for the opioid epidemic. For a long time, citations were imposed on facilities for not doing enough to manage patients’ pain. As a matter of fact, they came up with the slogan that pain should be the fifth vital sign,” another commented, erroneously.

The Joint Commission addressed these misconceptions in an April 18, 2016, statement on pain management, clarifying their position:

The only time that The Joint Commission standards referenced the fifth vital sign was when they provided examples of what some organizations were doing to assess patient pain. In 2002, The Joint Commission addressed the problems in the use of the fifth vital sign concept by describing the unintended consequences of this approach to pain management and how organizations had subsequently modified their processes.

Their current standard: “The hospital assesses and manages the patient’s pain,” allowing organizations to develop and implement their own policies.

The Joint Commission does not require pain to be treated until the pain score declines to zero. Instead, they require individualized care that is tailored to specific patient needs. Furthermore, these pain treatment strategies “may include pharmacologic and nonpharmacologic approaches.”

Data from the National Institute on Drug Abuse disproves the belief that the Joint Commission’s pain standards caused a steep rise in opioid prescriptions. The number of opioid prescriptions actually increased steadily during the 10 years before the release of the standards in 2001, when insufficient pain management began to be recognized as a widespread problem. The Joint Commission writes:

It is likely that the increase in opioid prescriptions began in response to the growing concerns in the United States about undertreatment of pain and efforts by pain management experts to allay physicians’ concerns about using opioids for nonmalignant pain. If there was an uptick in the rate of opioid use, it appears to have occurred around 1997-1998, two years prior to release of the standards.

 

The Downside of Unrelieved Pain

Many nurses remember a time when patients’ pain was inadequately treated, driving some patients with chronic pain to suicide, and they fear we might return to those days. One of these older nurses summarized this view: “We had to fight for good pain control in the 1970s to keep patients moving after surgery, thereby avoiding complications. We seem to be going back in time rather than taking appropriate steps to address the real issues at play here.”

 

Another reader said, “This opioid epidemic cannot be solved by going back to the previous paradigm. It is a multifaceted problem.”

 

Pain makes it harder for postoperative patients to get up and move around, take deep breaths, and cough—all necessary for their recovery. One nurse noted, “You heal better when your muscles aren’t tense because of pain. That doesn’t mean you need to send a patient home with a script for Percocet with several refills.”

 

Several readers commented on the risks for kidney and liver damage and gastrointestinal bleeding associated with excessive acetaminophen or nonsteroidal anti-inflammatory (NSAID) use.

 

A physician said, “Centers for Disease Control and Prevention statistics show that there were 20,000 overdose deaths in 2010, and over 30,000 in 2016. At the same time the number and dosage of narcotic prescriptions were decreasing. It is wrong to indict my postop patients for the problem.”

 

Many nurses related their own experiences with pain that wasn’t properly addressed. One said she was given no pain medication when she broke her elbow, and another said she had been “in terrible agony” in an emergency department with a kidney stone and was given only a muscle relaxer. “It did nothing, and it made me think they thought I was drug-seeking,” she wrote.

 

Another nurse said that when she went to the emergency department with “crushing pain” from a herniated disc, she was sent home with naproxen. “The pendulum has swung, but too far,” she continued.

 

After gastrointestinal surgery, one nurse said, “I cried until I was finally given narcotic pain medicine a few hours postoperatively. I was all for the new initiative to use a nerve block, gabapentin, intravenous acetaminophen, and Toradol (ketorolac). But it wasn’t enough. I even had to beg for pain meds upon discharge.”

 

Readers expressed concern that the anticipation of unrelieved pain could induce patients to avoid needed surgical procedures. On nurse whose pain was not adequately managed after knee replacement surgery explained, “The thought of pain relief being unavailable to me because somebody else might be addiction-prone makes me cringe. If I have to experience that degree of pain, I will never work up the courage to have the other knee replaced.”

 

Another reader who anticipates surgery in the near future commented, “I am terrified that the hospital will decide that a couple of acetaminophen tablets will suffice.”

 

Achieving a Balance

Some nurses who think that opioids are overused talked about refusing opioids for pain relief and how they had successfully used other methods to manage pain, including massage, chiropractic care, meditation and visualization, Epsom salt baths, and distraction. And several readers suggested cannabidiol oil or marijuana as alternatives to opioid medications.

 

Readers said that patients need to have realistic expectations about pain, and not to expect no pain. An emergency department nurse wrote, “I have learned to tell the patient asking for pain meds that ‘the ability to feel pain means you are alive.’ Not feeling anything at all seems abnormal.”

 

One nurse said that she “was taught that pain meds were to take the edge off the pain, not to make the patient pain-free. If a patient is pain-free and something is wrong, no one would know.”

 

“Patients think they have the right to feel no pain; it’s very unrealistic. We need to have a balance,” another commented.

 

Nurses on both sides of the issue said that steps to improve the quality of pain management must include patient education about realistic expectations; alternative treatments; and effective use of nonopioid medications, such as acetaminophen and NSAIDs. Good observation skills and interviewing techniques are also important, others pointed out.