Pain as a vital sign

A recent article in the Family Practice News says that a survey of 225 physicians revealed that 33% of them think that the opioid crisis in the US is caused by overprescribing opioids. 24% said aggressive patient drug seeking and 18% said it is due to drug dealers. How quickly things change.

In 1996 pain was declared the fifth vital sign, after temperature, pulse (heart rate), respiration rate and blood pressure. I disagreed with it because it focused on pain, by telling the nurses in the hospital and the outpatient providers to always to ask about pain. I thought it would be better to focus on level of comfort than pain. I thought we were using opiates far too freely and I thought that patients were getting addicted. The pain specialists said that we had to treat pain, and we were given very few tools other than opioids. Primary care providers were told that they could be sued for too much or too little pain medicine.

I also disagreed with it because pain is NOT a vital sign. That is, the level of pain does not correlate with illness. If a person has a high fever of 104 I am sure they are sick, a fast or very slow heart rate, a blood pressure too high or two low, they are breathing too fast: these are vital signs. They often correlate to illness and help us decide if this is outpatient, urgent or emergent. But pain does not. A chronic pain patient may have a pain level of 8/10 and yet not be an emergency or in a life-threatening state at all. That does not mean that they are lying or that we don't wish to help with pain.

In June, 2016, the American Medical Association recommended dropping pain as a vital sign. https://www.painnewsnetwork.org/stories/2016/6/16/ama-drops-pain-as-vital-sign. The Joint Commission for Hospital Accreditation dropped pain as a vital sign in August, 2016. https://www.jointcommission.org/joint_commission_statement_on_pain_management/.

Why? Not only were people getting addicted to opiates, but they were and are dying of unintentional overdoses: sedation from opiates with alcohol, with anxiety medicines such as benzodiazepines, with soma, with sleep medicines such as ambien and zolpidem. If the person is sedated enough, they stop breathing and die. The CDC declared an epidemic of unintentional overdoses in 2012: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm and said that more US citizens were dying of prescription medicines taken as instructed then from motor vehicle accidents and guns and illegal drugs.

I wrote two poems years ago reflecting how I thought about pain as a vital sign. It is not a vital sign, because a high pain level does not tell me if the person is critically ill and may die. It does not correlate. Pain matters and we want to treat it, but the first responsibility is "do no harm". Letting people get addicted and killing some is harm.

Also, opioids have limited effectiveness and high risks for chronic pain. I have worked with the University of Washington Pain and Addiction Clinic since 2010 via telemedicine. They say that average improvement of chronic pain with opioids is about 30%. Higher and higher doses do not help and increase the risk of overdose and death. And the risk of addiction.

I think of pain as information. Studies of fibromyalgia patients with functional MRI of the brain show that they are not lying about their pain. In a study normal and fibromyalgia patients were given the same pain stimulus on the hand. The normal patients said that they felt 3-4/10 pain. The fibromyalgia patients felt 7-8/10 pain with the same stimulus and the pain centers lit up correspondingly more in their brains. So they are not lying.

Why would opioids only lower chronic pain about 30% even with higher doses? The brain considers pain important information. We need to snatch our finger away from a flame, stop if we smash our toe, deal with a broken bone. I think of opioids like noise cancelling headphones. Say you are listening to music. You put on headphones/take round the clock opioids. Your brain automatically turns up the gain: the music volume or the pain sensors. Now it hurts again. You take more. The brain turns up the gain. Now: take the noise cancelling headphones off. The music/pain is too loud and it hurts! With music we can turn it down, but the brain cannot adjust the gain for pain quickly.

We do not understand the shift from acute pain to chronic pain, yet. The shift is in the brain. I think that we are too quick to mask and block pain rather than use the information. Now the recommendations for opioids are to only use them for 3-5 days for acute pain and injury. For years I have said with any opioid prescription: try not to take them around the clock and try to decrease the use as soon as possible. Some people get addicted. Be careful.

If we don't hand people a pill for pain, what can we do? There are more and more therapies. Jon Kabot Zinn's 30 years of studying mindfulness meditation is very important. His chronic pain classes reduce pain by an average of 50%: better than opiates. Pain and stress hormones drop by 50% in a study of a one hour massage. Massage, physical therapy, chiropracty and acupuncture: different people respond to different modalities. Above all, reassuring people that the level of pain in chronic pain does not correlate to the level of illness or ongoing damage. And pain is composed of at least three parts: the sharp nocioceptive pain, nerve pain (neuropathic) and emotional pain. We must address the emotional part too. We have no tool at this time to sort the pain into the three categories. My rule is that I always address all three. That does not mean every person needs a counselor or psychiatrist. It means that we must have time to discuss stress and discuss life events and check in about coping.

In the survey of 225 providers, 50% estimated that they prescribe opioids to fewer than 10% of their patients. 38% said less than half. 12% estimated that they prescribe opioids to more than half their patients. The survey included US primary care, emergency department and pain management physicians.

Handing people a pill is quicker. But we can do better and primary care must have the time to really help people with pain.

CDC guidelines for treating chronic pain: https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf

In lizardinlaw's WU she says, "We do not understand the shift from acute pain to chronic pain, yet. The shift is in the brain. I think that we are too quick to mask and block pain rather than use the information." Pain is a complicated and important component of both health and healthcare and I would like to add some thoughts from a patient's perspective.

First, we all know that people experience pain differently. Our thresholds for the same objective level of pain vary. I recall a Sports Illustrated article about hockey great Bobby Orr. Late in his career, despite chronic pain in his knees, Orr was still playing at an all-star level. The reporter asked Orr's doctor how much pain Orr's knees were causing. The doctor replied that the average person with Orr's knees would be in a wheelchair full-time. The question is: did Orr not experience the pain others would have felt? Even if we believe the doctor was mistaken in this specific instance, each of us is probably familiar with someone that managed to function in circumstances beyond our understanding. We need to understand how and why.

As lizardinlaw's WU notes there is an emphasis today on asking patients their pain level. From my recent experiences this is usually a numeric scale (e.g., rate your current pain on a scale of 1 to 10). But these numbers are almost meaningless unless we have something descriptive to tie them to and levels of functionality seem the best guideline. What can or can't you do because of the pain you are experiencing? Pain that can't be ignored and that greatly reduces functionality is the pain that has to be managed. This can be totally different than sharp, intense, but episodic or intermittent pain.

In my specific case last fall I knew I had a severe problem and I was eventually diagnosed with cancer in the nasal area. I was in pain, but the most debilitating pain wasn't in the nasal area it was in the cheekbones. For the most part the pain was moderate, but it was constant and intense enough that I couldn't sleep until totally exhausted and then I'd be awake again after just an hour or two. After a week of this I was almost completely non-functional; barely able to think. I was driving myself to doctor's appointments and thinking on each trip that I was probably a more dangerous driver on the roads than a drunk or someone addicted to their phone. I made it my first point of emphasis with both my primary care physician and my ear/nose/throat specialist that this constant, debilitating pain should be the first issue addressed. Neither appeared to appreciate the fact that I was essentially unable to function. The ENT specialist even made the odd comment that he didn't understand why I was in pain.

After three weeks of this I was desperate. Through trial and error I found that massive doses of ibuprofen alleviated the cheekbone pain. When I started seeing a cancer doctor and he found out I was taking 25 to 30 ibuprofen tablets per day (200 mg each) he strongly suggested I cut back. I explained that it was the minimum necessary to keep me functional; able to sleep and work. Extra Strength Tylenol was suggested. I tried, but it was ineffective against the pain I was experiencing. I am not a doctor, but the fact ibuprofen worked while Tylenol didn't is probably a clue as to the direct cause of the pain and probably worth exploring.

My cancer was advanced and required extensive surgery. My nose was removed as well as a portion of the upper lip and 17 lymph nodes. I will start radiation and chemotherapy in a week. After surgery I was prescribed Oxycodone. Yet, the cheekbone pain persists. Fortunately not at the levels prior to surgery, but when I want to be pain-free I don't take the oxycodone I take a couple of ibuprofen.

Through all of this I was asked countless times about pain. And again, the point I'd like to emphasize is that a vague number is not very helpful. I often didn't even know how to answer the question.