Fifteen years ago, The Joint Commission issued a standard for pain, often referred to — incorrectly — as the “fifth vital sign.” Those standards were developed because pain was undertreated. As the decade went on, and opioids began their upward climb of abuse and addiction, that pain standard came to be blamed for the epidemic. (The four vital signs are pulse, temperature, blood pressure and respiratory rate.)
But last month, David W. Baker, M.D., executive vice president for health care quality evaluation at The Joint Commission, explained that the pain standard was not connected to the epidemic at all. In fact, the increase in opioid prescriptions appears to have taken place during the decade preceding the epidemic, when the problem of untreated pain in hospital patients became clear.
First of all, the current standards do not require the use of drugs to manage pain, and do not specify which drugs should be used, according to the April 18 statement from Baker. From the statement:
“In the environment of today’s prescription opioid epidemic, everyone is looking for someone to blame. Often, The Joint Commission’s pain standards take that blame. We are encouraging our critics to look at our exact standards, along with the historical context of our standards, to fully understand what our accredited organizations are required to do with regard to pain.”
The standards are:
- The hospital educates all licensed independent practitioners on assessing and managing pain.
- The hospital respects the patient’s right to pain management.
- The hospital assesses and manages the patient’s pain.
Requirements for what should be addressed in organizations’ policies include:
- The hospital conducts a comprehensive pain assessment that is consistent with its scope of care, treatment and services, and the patient’s condition.
- The hospital uses methods to assess pain that are consistent with the patient’s age, condition and ability to understand.
- The hospital reassesses and responds to the patient’s pain, based on its reassessment criteria.
- The hospital either treats the patient’s pain or refers the patient for treatment.
The most common misperception is that The Joint Commission endorses pain as a vital sign. It doesn’t, said Baker. “The only time that The Joint Commission standards referenced the fifth vital sign was when The Joint Commission provided examples of what some organizations were doing to assess patient pain,” he said.
The initial requirement was that pain be assessed in all patients — this was eliminated in 2009 from all accreditation programs except behavioral health care accreditation, which were still required to conduct assessments because patients “were thought to be less able to bring up the fact that they were in pain and, therefore, required a more aggressive approach,” according to the Joint Commission statement. The current statement for hospitals and other programs says, “The hospital assesses and manages the patient’s pain.” Other misconceptions are that the standards require pain to be treated until it reaches “zero,” and that the standards urge clinicians to prescribe opioids. “We do not mention opioids at all,” said Baker. A note to the pain standard says: “Treatment strategies for pain may include pharmacologic and nonpharmacologic approaches. Strategies should reflect a patient-centered approach and consider the patient’s current presentation, the health care providers’ clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse.”
But perhaps the most serious misconception is that the pain standards caused a rise in opioid prescriptions at all. “This claim is completely contradicted by data from the National Institute on Drug Abuse,” said Baker, which found that the number of opioid prescriptions filled at commercial pharmacies in the United States from 1991 to 2013 shows the rate had been steadily increasing for 10 years prior to the standards’ release in 2001. “It is likely that the increase in opioid prescriptions began in response to the growing concerns in the U.S. about undertreatment of pain and efforts by pain management experts to allay physicians’ concerns about using opioids for non-malignant pain,” said Baker. “Moreover, the standards do not appear to have accelerated the trend in opioid prescribing. If there was an uptick in the rate of increase in opioid use, it appears to have occurred around 1997–1998, two years prior to release of the standards.”