How the fifth vital sign led to overprescribing of pain pills

The op-ed by The Dallas Morning News, “At the heart of the opioid crisis,” published in the Statesman on April 10 prompts me to write this opinion.

I certainly agree that the United States has an opioid crisis that is leading to many unnecessary deaths. I also agree that physicians are “overprescribing” opioids. The Dallas Morning News article states, “There is no medical explanation for the rise in opioid use. Sales of prescription opioids nearly quadrupled from 1999 to 2014, even though Americans don’t report having more pain now.” Never mentioned in numerous articles on this topic is what I believe to be the root cause for such overprescribing and our current opioid epidemic. That root cause is JACHO and the “Fifth Vital Sign.”

JACHO, the Joint Commission for the Accreditation of Hospitals, is the federal organization that audits hospitals’ patient care at least once every four years. Hospitals go to great expense to be prepared for such audits, as failure to pass will result in loss of reimbursement by Medicare. Evidently, JACHO was of the opinion that we as physicians were not taking patients’ complaints of pain seriously, and thus that we were failing to treat such pain adequately. It was at that point (approximately mid-1990s) that pain management became one of the major points of emphasis in JACHO audits. It was then that pain became the “Fifth Vital Sign,” joining temperature, pulse, respiration and blood pressure.

In an attempt to meet the new JACHO requirements, hospitals and their associated outpatient clinics placed posters in each patient room depicting a series of faces to demonstrate pain to be rated from zero (no pain) to 10 (the worst pain imaginable). It is now the standard that each patient is asked whether they have pain and to rate it on the scale of 1–10, either at each visit or each time that their vital signs are taken. Adding to this equation, the pharmaceutical industry increased the marketing of its opioids.

Unfortunately, the above factors led many physicians to liberalize their criteria for the prescribing of opioids. Is it coincidence that the JACHO pain initiative began in the mid-1990s and that “sales of prescription opioids nearly quadrupled from 1999 to 2014,” or is there a cause and effect relationship? I personally believe the latter.

Prior to this JACHO intervention, opioids were used primarily for the short-term treatment of acute pain related to surgery, fractures or other such trauma. Chronic opioid therapy was reserved for the treatment of pain related to cancer (the risk of addiction being less of a concern than the risk of dying with severe pain). Injuries such as an acute low back strain or a badly sprained ankle were treated with ice, limited activity and liberal use of ibuprofen. Following the JACHO intervention, offering hydrocodone for such injuries as well as for chronic pain became quite common.

Solutions: Physicians prescribing opioids should follow published guidelines for appropriate use and monitoring; long-term prescribing and monitoring of opioid therapy for chronic noncancer pain should be reserved for pain specialists; and we need to discontinue the routine use of the Fifth Vital Sign. With less pressure from JACHO and pharmaceutical representatives, physicians will be more reserved in the prescribing of opioids.

This story was originally published April 21, 2017 at 9:05 PM with the headline "How the fifth vital sign led to overprescribing of pain pills."