Pain Scales and the Opioid Crisis

In the last year, physicians and nurses have increasingly voiced their dissatisfaction with pain as the fifth vital sign. In June 2016, the American Medical Association recommended that pain scales be removed in professional medical standards (1). In September 2016, the American Academy of Family Physicians did the same (2). A recent Medscape survey reported that over half of surveyed doctors and nurses supported removal of pain assessment as a routine vital sign (3).

In the 1990’s there was a widespread impression that pain was undertreated. Whether this was true or an impression created by a few practitioners and undertreated patients with the support of the pharmaceutical industry is unclear. Nevertheless, the prevailing thought became that identifying and quantifying pain would lead to more appropriate pain therapy. The American Society of Anesthesiologists and the American Pain Society issued practice guidelines for pain management (4,5). Subsequently, both the Department of Veterans Affairs and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandated a pain scale as the fifth vital sign (6-9). Most commonly these scales ask patients to rate their pain on a scale of 1-10. The JCAHO mandated that "Pain is assessed in all patients” and would give hospitals "requirements for Improvement" if they failed to meet this standard (9). The JCAHO also published a book in 2000 for purchase as part of required continuing education seminars (9). The book cited studies that claimed "there is no evidence that addiction is a significant issue when persons are given opioids for pain control." It also called doctors' concerns about addiction side effects "inaccurate and exaggerated." The book was sponsored by Purdue Pharma makers of oxycodone.

Almost as soon as the standards were initiated, suggestions emerged that pain treatment was becoming overzealous. In 2003 a survey of 250 adults who had undergone surgical procedures reported that almost 90% were satisfied with their pain medications. Nevertheless, the authors concluded that “many patients continue to experience intense pain after surgery … additional efforts are required to improve patients’ postoperative pain experience” (8). Concerns about overaggressive treatment for pain increased after Vila et al. (10) reported in 2005 that the incidence of opioid oversedation increased from 11.0 to 24.5 per 100 000 inpatient hospital days after the hospitals implemented a numerical pain treatment algorithm. As early as 2002 the Institute for Safe Medication Practices linked overaggressive pain management to a substantial increase in oversedation and fatal respiratory depression events (11). Articles appeared questioning the wisdom of asking every patient to rate their pain noting that implementation of the scale did not appear to improve pain management (12). The JCAHO removed its standard to assess pain in all patients but not until 2009.

The US has seen a dramatic increase in the incidence of opioid deaths (13). It is unclear if adoption of the pain scale and its widespread application to all patients contributed to the increase although the time frame and the data from Vila et al. (10) suggest that this is likely.

There have been other factors that may have also contributed to the increase in opioid deaths. The Medscape survey mentioned above asked participants how often they feel pressure to prescribe pain medication in order to keep patient satisfaction levels high (3). Specifically mentioned was the Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS. HCAHPS is a patient satisfaction survey required for all hospitals in the US. About two thirds of doctors and nurses felt there was pressure (3). The survey also asked respondents about the influence of patient reviews on opioid prescribing. Forty-six percent of doctors said the reviews were more than slightly influential. The surveys seemed to carry more weight with nurses. Seventy-three percent said the reviews were influential. Others have blamed pharmaceutical company marketing opioids as a way of reducing pain and increasing patient satisfaction (14). Clearly, there has been a dramatic increase in narcotic prescriptions. Not surprisingly, pharmaceutical companies have done little to curb the use of their products.

Earlier this year, former CDC Director Tom Frieden said "The prescription overdose epidemic is doctor-driven…It can be reversed in part by doctors' actions” (15). Some physicians have taken this as blame for the entire opioid crisis, including deaths from heroin and illegal fentanyl. There may be some validity in this belief since abuse of illegal narcotics sometimes evolves out of abuse of prescribed narcotics. However, the actions of the health regulatory agencies that mandated pain scales and created guidelines for pain management were not mentioned by Dr. Frieden. Also, not mentioned are the patient satisfaction surveys. 

About a year ago the CDC issued guidelines for prescribing opioids for chronic pain (15). These guidelines were developed in collaboration with a number of federal agencies including the Department of Veterans Affairs which was one of the first to mandate pain scales and the Centers for Medicare and Medicaid Services (CMS) which mandated HCAHPS. Pain is a subjective symptom and quantification and treatment are imprecise. The goal cannot be to deliver perfect pain management but to reduce the incidence of under- and overtreatment as much as possible. Someone needs to assess patients’ pain complaints and prescribe opioids appropriately. No one is better qualified and prepared than the clinician at the bedside.

No one condones the unethical practice of widespread prescription of opioids without sufficient medical oversight. However, meddling by unqualified bureaucrats, administrators and politicians emphasizes guidelines over appropriate care. As detailed above, the present opioid crisis may be an unattended consequence of the pain scale and opioid prescribing guidelines. Further intrusion by the same groups who created the crisis is unlikely to solve the problem but is likely to create additional problems such as the undertreatment of patients with severe pain. As I write this on the ides of March it may be appropriate to paraphrase a line from Julius Cesar, “The fault lies not in our doctors but in our regulators”.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Anson P. AMA drops pain as vital sign. Pain News Network. June 16, 2016. Available at: https://www.painnewsnetwork.org/stories/2016/6/16/ama-drops-pain-as-vital-sign (accessed 3/2/17).
2. Lowes R. Drop pain as the fifth vital sign, AAFP says. Medscape Medical News. September 22, 2016. Available at: http://www.medscape.com/viewarticle/869169 (accessed 3/2/17).
3. Ault A. Many physicians, nurses want pain removed as fifth vital sign. Medscape Medical News. Medscape Medical News. February 21, 2017. Available at: http://www.medscape.com/viewarticle/875980?nlid=113119_3464&src=WNL_mdplsfeat_170228_mscpedit_ccmd&uac=9273DT&spon=32&impID=1299168&faf=1 (accessed 3/2/17).
4. Practice guidelines for acute pain management in the perioperative setting. A report by the American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section. Anesthesiology. 1995 Apr;82(4):1071-81. [CrossRef] [PubMed]
5. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, Lipman AG, Bookbinder M, Sanders SH, Turk DC, Carr DB. American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med. 2005 Jul 25;165(14):1574-80. [CrossRef] [PubMed]
6. National Pain Management Coordinating Committee. Pain as the 5Th vital sign toolkit. Department of Veterans Affairs. October 2000. Available at: https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf (accessed 3/2/17).
7. Baker DW. History of The Joint Commission's Pain Standards: Lessons for Today's Prescription Opioid Epidemic. JAMA. 2017 Mar 21;317(11):1117-8. [CrossRef] [PubMed]
8. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-540. [CrossRef] [PubMed]
9. Moghe S. Opioid history: From 'wonder drug' to abuse epidemic. CNN. October 14, 2016. Available at: http://www.cnn.com/2016/05/12/health/opioid-addiction-history/ (accessed 3/2/17).
10. Vila H Jr, Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesth Analg. 2005;101(2):474-480. [CrossRef] [PubMed]
11. Institute for Safe Medication Practices. Pain scales don’t weigh every risk. July 24, 2002. Available at: https://www.ismp.org/newsletters/acutecare/articles/20020724.asp (accessed 3/2/17).
12. Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006 Jun;21(6):607-12. [CrossRef] [PubMed] 
13. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016 Dec 16;65. Published on-line. [CrossRef] [PubMed]
14. Cha AE. The drug industry’s answer to opioid addiction: More pills. Washington Post. October 16, 2016. Available at: https://www.washingtonpost.com/national/the-drug-industrys-answer-to-opioid-addiction-more-pills/2016/10/15/181a529c-8ae4-11e6-bff0-d53f592f176e_story.html?utm_term=.36c5992fa62f (accessed 3/2/17).
15. Lowes R. CDC issues opioid guidelines for 'doctor-driven' epidemic. Medscape. March 15, 2016. Available at: http://www.medscape.com/viewarticle/860452 (accessed 3/2/17).

Cite as: Robbins RA. Pain scales and the opioid crisis. Southwest J Pulm Crit Care. 2017;14(3):119-22. doi: https://doi.org/10.13175/swjpcc033-17 PDF 

The Emperor Has No Clothes: The Accuracy of Hospital Performance Data

Several studies were announced within the past month dealing with performance measurement. One was the Joint Commission on the Accreditation of Healthcare Organizations (Joint Commission, JCAHO) 2012 annual report on Quality and Safety (1). This includes the JCAHO’s “best” hospital list. Ten hospitals from Arizona and New Mexico made the 2012 list (Table 1).

Table 1. JCAHO list of “best” hospitals in Arizona and New Mexico for 2011 and 2012.

This compares to 2011 when only six hospitals from Arizona and New Mexico were listed. Notably underrepresented are the large urban and academic medical centers. A quick perusal of the entire list reveals that this is true for most of the US, despite larger and academic medical centers generally having better outcomes (2,3).

This raises the question of what criteria are used to measure quality. The JCAHO criteria are listed in Appendix 2 at the end of their report. The JCAHO criteria are not outcome based but a series of surrogate markers. The Joint Commission calls their criteria “evidence-based” and indeed some are, but some are not (2). Furthermore, many of the Joint Commission’s criteria are bundled. In other words, failure to comply with one criterion is the same as failing to comply with them all. They are also not weighted, i.e., each criterion is judged to be as important as the other. An example where this might have an important effect on outcomes might be pneumonia. Administering an appropriate antibiotic to a patient with pneumonia is clearly evidence-based. However, administering the 23-polyvalent pneumococcal vaccine in adults is not effective (4-6). By the Joint Commission’s criteria administering pneumococcal vaccine is just as important as choosing the right antibiotic and failure to do either results in their judgment of noncompliance.

Previous studies have not shown that compliance with the JCAHO criteria improves outcomes (2,3). Examination of the US Health & Human Services Hospital Compare website is consistent with these results. None of the “best” hospitals in Arizona or New Mexico were better than the US average in readmissions, complications, or deaths (7).

A second announcement was the success of the Agency for Healthcare Quality and Research’s (AHRQ) program on central line associated bloodstream infections (CLABSI) (8). According to the press release the AHRQ program has prevented more than 2,000 CLABSIs, saving more than 500 lives and avoiding more than $34 million in health care costs. This is surprising since with the possible exception of using chlorhexidine instead of betadine, the bundled criteria are not evidence-based and have not correlated with outcomes (9). Examination of the press release reveals the reduction in mortality and the savings in healthcare costs were estimated from the hospital self-reported reduction in CLABSI.

A clue to the potential source of these discrepancies came from an article published in the Annals of Internal Medicine by Meddings and colleagues (10). These authors studied urinary tract infections which were self-reported by hospitals using claims data. According to Meddings, the data were “inaccurate” and “are not valid data sets for comparing hospital acquired catheter-associated urinary tract infection rates for the purpose of public reporting or imposing financial incentives or penalties”. The authors propose that the nonpayment by Medicare for “reasonably preventable” hospital-acquired complications resulted in this discrepancy. There is no reason to assume that data reported for CLABSI or ventilator associated pneumonia (VAP) is any more accurate.

These and other healthcare data seem to follow a trend of bundling weakly evidence-based, non-patient centered surrogate markers with legitimate performance measures. Under threat of financial penalty the hospitals are required to improve these surrogate markers, and not surprisingly, they do. The organization mandating compliance with their outcomes joyfully reports how they have improved healthcare saving both lives and money. These reports are often accompanied by estimates, but not measurement, of patient centered outcomes such as mortality, morbidity, length of stay, readmission or cost. The result is that there is no real effect on healthcare other than an increase in costs. Furthermore, there would seem to be little incentive to question the validity of the data. The organization that mandates the program would be politically embarrassed by an ineffective program and the hospital would be financially penalized for honest reporting.

Improvement begins with the establishment of guidelines that are truly evidence-based and have a reasonable expectation of improving patient centered outcomes. Surrogate markers should be replaced by patient-centered outcomes such as mortality, morbidity, length of stay, readmission, and/or cost. The recent "pay-for-performance" ACA provision on hospital readmissions that went into effect October 1 is a step in the right direction. The guidelines should not be bundled but weighted to their importance. Lastly, the validity of the data needs to be independently confirmed and penalties for systematically reporting fraudulent data should be severe. This approach is much more likely to result in improved, evidence-based healthcare rather than the present self-serving and inaccurate programs without any benefit to patients.

Richard A. Robbins, MD*

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Available at: http://www.jointcommission.org/assets/1/18/TJC_Annual_Report_2012.pdf (accessed 9/22/12).
2. Robbins RA, Gerkin R, Singarajah CU. Relationship between the Veterans Healthcare Administration hospital performance measures and outcomes. Southwest J Pulm Crit Care 2011;3:92-133.
3. Rosenthal GE, Harper DL, Quinn LM. Severity-adjusted mortality and length of stay in teaching and nonteaching hospitals. JAMA 1997;278:485-90.
4. Fine MJ, Smith MA, Carson CA, Meffe F, Sankey SS, Weissfeld LA, Detsky AS, Kapoor WN. Efficacy of pneumococcal vaccination in adults. A meta-analysis of randomized controlled trials. Arch Int Med 1994;154:2666-77.
5. Dear K, Holden J, Andrews R, Tatham D. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Sys Rev 2003:CD000422.
6. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ 2009;180:48-58.
7. http://www.hospitalcompare.hhs.gov/ (accessed 9/22/12).
8. http://www.ahrq.gov/news/press/pr2012/pspclabsipr.htm (accessed 9/22/12).
9. Hurley J, Garciaorr R, Luedy H, Jivcu C, Wissa E, Jewell J, Whiting T, Gerkin R, Singarajah CU, Robbins RA. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care 2012;4:163-73.
10. Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med 2012;157:305-12.

*The views expressed are those of the author and do not necessarily represent the views of the Arizona or New Mexico Thoracic Societies.

Reference as: Robbins RA. The emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care 2012;5:203-5. PDF