AMA Votes to Eliminate Pain as the Fifth Vital Sign
Credit: mentalfloss.com
In a move that was unsurprising to those who have been following the “opioid epidemic” in the United States, the American Medical Association declared in June that it was rescinding its recommendation that pain be assessed as the “fifth vital sign.” Coming on the heels of the latest pain management guidelines released by the U.S. Centers for Disease Control and Prevention in March of this year, the announcement sounded the death knell for compassionate pain care in the United States, and left millions of Americans wondering, “What’s next?”
Historically in medicine, “vital signs ” included heart rate, breathing rate, blood pressure, and temperature — the most basic indicators of a person’s state of health. But in 2001, the Joint Commission on Hospital Accreditation — responding to the enormous public health problem of chronic, undertreated pain — added standards that required health care providers to include pain in that assessment, usually by asking patients to rate their pain on a scale of zero to 10. The Commission did not provide guidance about pain treatment; that decision was left to the providers themselves.
The AMA also passed a proposal that calls for the elimination of the requirement that hospitals ask patients about the quality of their pain care. Medicare uses this information as part of its overall quality assessment, financially rewarding hospitals who achieve the highest patient-satisfaction scores. Said AMA Chairperson Patrice Harris, M.D., “Judging health care facilities on an overly subjective measure – that is, how well it is perceived that they treat pain — is an overly simplistic approach to measuring clinical effectiveness.“
Dr. Harris did not address the fact that all patient symptoms are subjective by definition, or the fact that controlling symptoms is, in large part, what hospitals and health care providers are paid to do.
Speaking on behalf those who opposed the abolition of pain as a “vital sign,” Lynn Webster, M.D., former president of the American Academy of Pain Medicine, said, “It appears that advocates…are suggesting that if we just ignore pain then we won’t have to deal with pain and opioid abuse will disappear. That is not only fantastical thinking, it is harmful to millions of people in pain.”
“I am astounded that physicians don’t believe we should assess pain on a regular and ongoing basis,” he added. “That is exactly what removing pain as a vital sign means.”
Chronic pain disproportionately affects seniors and people at the end of life
(Credit: wisegeek)
In fact, chronic unremitting pain has for many years been a major public health issue in the United States, and one that disproportionately affects seniors and those at the end of life. According to American Academy of Pain Medicine estimates, about 100,000 million Americans suffer from pain on regular basis, outnumbering those with cancer, diabetes, and heart disease combined. As of 2010, the cost of chronic pain to the American economy — in terms of medical care and lost productivity — was an estimated $560 to $635 billion per year.
Even more disturbing than the sheer number of patients in pain is the number of people who continue to suffer at the end of life. Research shows that more than half of all hospitalized patients experience moderate to severe pain in the last days of their lives.
So what is the impetus behind the AMA’s decision? According to AMA president Andrew Gurman, M.D., the move shows that “physicians have taken ownership of being part of the solution” to opioid abuse. Yet, like the CDC, the AMA has proposed no real alternatives for the millions of patients, many of them seniors, who suffer from chronic unremitting pain. The suggested pharmacologic alternatives to opioids, such as NSAIDS, are contraindicated in the elderly, and few chronic pain sufferers have the financial or psychosocial resources to seek out alternative modalities (such as physical and cognitive behavioral therapy) as suggested by the CDC. What’s more, these therapies have not been shown to be effective in treating those with severe pain or those nearing the end of their lives.
Many hospitalized patients die in pain.
(Credit: telegraph.co.uk)
Perhaps the most scathing commentary on the AMA decision comes from David Becker, a social worker and patient advocate who works extensively with people in pain: “At a time when millions of individuals in pain are under siege, the AMA has made it clear they are… opposed to being accountable for the pain care they provide,” he said. “The AMA has become regressive, visionless and hard-hearted toward the suffering that millions of people in pain endure on a daily basis,” he continued. “It is clear that the AMA is in need of moral reform.”
And so, while the United States struggles with its ongoing and completely failed “War on Drugs,” the battle for compassionate pain management and end-of life care wages on. Sadly, this latest move by the AMA (which represents 200,000 of the nation’s physicians) demonstrates all too clearly that America’s healthcare providers would rather put on blinders than deal with the reality that millions of Americans — both those suffering from chronic pain and those suffering from substance abuse disorder — are hurting and in desperate need of help.
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My Cousin’s Death Taught Me the Meaning of Life
CHANGING THE PARADIGM
There is a concept in the study of rhetoric called “infomeme.” An infomeme is a core term in a rhetoric discussion which is assumed to be true. It is not questioned, but taken as a given. Infomemes are useful because if we are stuck without consensus on an issue, we may want to re-frame the issue by examining the validity of the infomemes. With regard to health care reform, the traditional argument focuses on the term reform. Health and care are infomemes whose meaning and content is seldom questioned. What I would like to do, is question the infomeme, and see if that may produce a different result. The infomeme that I want to focus on is the term “health”.
“Health” is defined generally in the dictionary as (1) a general condition of the body, (2) soundness of body or mind, or (3) absence of disease. All well and good. But what really does “health” mean? It is a difficult term to pin down because at bottom, health is self-defined. If you ask a person if they are healthy, they usually don’t stop to call their doctor, they will tell you based on their self perception. Further, health is defined differently in different cultures and among different ethnic groups. For example, a recent study in the United States found that Caucasian Male Americans tend to define health with respect to function of mind and body parts, while Black Male Americans tend to define health with respect to the absence of pain . So a white who cannot walk well because of a problem with a leg would say that he is unhealthy, while a black who can walk but with pain may state that he is unhealthy.
I am sure that the physicians who read this will say that health is clearly defined by the standard of normal conditions produced through medical research. The difficulty with such studies is that they are based only on averages. In fact, the practice of western medicine is based on averages. When a patient presents to a physician, the physician takes into account all of the presenting conditions and compares them to “normal” ranges and draws his or her conclusions. The fact remains, however, that those conclusions are only educated guesses based on how “most” people function. All of the statistics of hospital mortality, for example, cannot predict whether or not any single patient will be helped or hurt by a medical intervention. If that is startling, consider “despite the cultural centrality of medicine, its undeniable successes in the treatment of complex diseases, and the money spent on medical research and care in the Western world, there is little evidence that medicine has had a major impact on disease pattern in general”
This conclusion is supported by studies in the United Kingdom which found that with respect to declines in mortality since 1700, the causes were (1) improvement in nutritional patterns (e.g. pasteurization), (2) improvement in environmental conditions (e.g. public drinking water, inoculations) and (3) changes in personal behavior (e.g. contraception). And by studies in the United States which found that “for all but one cause of death, the first effective medical intervention occurred after the majority of the decline in deaths from that cause had already occurred.” In fact, the life span of a male over fifty years of age has not increased substantially in the past two thousand years. Of course, the ability to reach age fifty has increased substantially, but clearly due more to societal changes rather than to medical intervention.
Do I think that medicine is unnecessary? Of course not. The specific advances of medicine have produced dramatic results when viewed from the perspective of the individual patient. The ability of an individual with coronary disease to be diagnosed, cut open, have multiple arteries replaced, sewn up and regain normal life in a few weeks is astounding. But on the average, medicine has a long way to go to really understand health. And that brings us to the heart, so to speak, of our discussion today.
Indulge me for a moment. Read on and then sit quietly. Feel your clothes – the weight and texture of the cloth; the smoothness or scratchiness of the material. Did you feel your clothes before I asked? Probably not. Continue to concentrate on your body. Do you feel any discomfort anywhere? Too much pressure, any bit of pain, restlessness? Most of us feel, but don’t pay attention to, hundreds of small discomforts each day. Such is life, and that is my point. We are constantly bombarded by small aches, pains and discomfort – perhaps part of the penalty of walking upright. But most of us live with these small discomforts, and even relish them as indicators of how are bodies are reacting to daily stress, and what levels of rest and recuperation we need. I am not suggesting that every person who goes to a physician to be relieved of pain or discomfort is a hypochondriac, but I am suggesting that until we develop a national consensus of what constitutes health, we are unable to develop a national consensus of what type of health care we need, and how much we are willing to pay for it.
I had a great uncle who served in the Confederate Army in the American Civil War. During that war, he was hit by a train while standing guard duty. I don’t know much of the circumstances, because I only know of his injury by reading the application he filed in 1895, thirty years after the war, seeking a veteran’s pension. In his application, he described that ever since the injury he had an open wound on his thigh, which drained continuously. I can only imagine that he had a flap of granulated skin which failed to adhere to the leg wound. He must have risen every morning, unbandaged the wound, cleansed it probably with alcohol which was very painful, and then repeated the procedure at night. Was he disabled? Insitutionalized? Hardly! He was a farmer who worked from dawn to dusk. And if you asked him if he was healthy, I would bet that he would reply “yes!”. If you asked if he had any health problems, he would probably admit to the injury on his leg, but it would not have occurred to him that he was unhealthy. Today in America, we would not put up with such an injury. We would demand that it be surgically repaired, or that drugs be used to relieve any pain. Our concept and definition of “health” has changed, and the average American no longer feels capable of truly defining his or her own health. We have been sold on the idea that only our health care professionals can truly define our health, and yet there is something profoundly unsettling about this result. Perhaps it explains why Americans visit alternative health practitioners one and a half times more each year than they visit their family physician.
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