PAIN AS A VITAL SIGN
Pain is real and it robs quality of life from so many everyday. Many live with painful chronic conditions and face such high levels of pain each day they also battle thoughts of suicide to escape that pain. They, like my 85 year old mother deserve to have their pain addressed with respect and receive the best quality of care and life they can. However, is pain really a vital sign?
Pain is a reality for many who deserve to have their pain addressed but the AMA made a fatal error in adding pain as the fifth vital sign. Pain is not a vital sign.
People are capable of living very happy, healthy and productive lives without a pain measurement; not possible without a body temperature, pulse rate, respiration rate or blood pressure. These measures are called vital signs because they are quantifiable measurements which are vital for life. Loss of any single one of these four vital measurements can lead to or indicate loss of life. I have never heard of anyone who died because they had no measure of pain.
Pain cannot be quantifiably or objectively measured. Pain is a completely subjective symptom reported by unique individuals with far too many variables. We do need a measurement to relate pain but pain is not the equivalent of a vital sign.
It seems to me the majority of patients report pain rates of 6/10 to 10/10 which in my opinion, should require medical providers to pick up a phone and call 911 for those patients.
Pain is not a vital sign! Pain is entirely subjective! I woke up one morning with abdominal pain which I suspected was bowel related and thought I would eventually be fine. I tried to call my boss to tell her I was going to be late and to ask if she had something to relieve gas pain. When I couldn’t get her on the phone, I knew I had to get ready to go to work because she may have been depending on me to open the business. I was beginning to perspire due to my pain as I stepped into the shower. Where does perspiration due to pain rate on the chart?
On the way to work I realized I should not be driving; I knew I needed to go to the emergency room because something was really wrong but I couldn’t drive that far. I did make it to work and as I walked through the door my boss looked at me and said “You need to go home.” I said, “I need to go to the ER but you need to call an ambulance” as I walked past her on my way to the employee restroom where I stretched out a towel on the floor to lie on until EMS arrived.
On the way to the ER I began throwing up because of the pain I was experiencing. Where does throwing up rate on the chart of 0 to 10?
I could not lie still; I was constantly moving in an attempt to escape the pain by finding some position that was less painful. Was my pain 10/10? I’ve delivered two children; one with an epidural effective on only one side and another which I missed because they put me to sleep during an emergency cesarean. Were those deliveries 10/10? Did my pain relate to those in automobile accidents, those with broken bones, the gunshot or stabbing victims? I don’t know!!! Maybe, according to some. However, there are other things I’m certain are much more painful!
Upon arrival at the ER, after an ultrasound and CT scan, I was taken into emergency surgery because my appendix was completely distended and on the verge of rupturing.
Pain is a symptom which is COMPLETELY SUBJECTIVE and is NOT a QUANTIFIABLE MEASUREMENT or OBJECTIVE FINDING!
I cannot say my rate of pain that day or any other day has ever actually rated 10/10 by mine or anyone else’s subjective standards.
Pain Management Centers
Have you ever stopped and wondered when pain management as a specialty began to evolve? I’m sure someone far more educated than I can answer that question but I remember days when the dentist treated my teeth, the ophthalmologist took care of my eyes, the OB/GYN delivered the babies and treated my reproductive health, the cardiologist took care of my daughter’s heart, the psychiatrist and counselors provided care for Heather, and the family doctor treated everything else.
I remember days of grandparents and family working in the fields with and regardless of pain because they didn’t have any other choice. Then suddenly, there was such an abundance of people with chronic pain issues that pain management became a specialty, centers began opening and people were being approved for disability due to their pain. I don’t have a problem with that. As I said, pain is a very real condition that impacts individuals and families significantly and they deserve respect and help. My mother is one of those individuals. It just makes me wonder, are we becoming less immune to pain or is something causing us to experience more pain? In my mind that is a sensible and logical question.
After my daughter’s addiction and death, I found myself examining the pain management field and not entirely by my choice and will. (Those closest to me will understand that).
Based on my observations and research, it appears to me that far too many pain management centers are filled with healthcare providers who are more preoccupied with the numbers, daily patient quotas, dollar signs, billable services, and people pleasing than they are in actually managing the treatment of their patients’ care. Granted, businesses have to use common sense in evaluating the bottom line and being profitable but have you looked at the number of practices being fined, closed and providers imprisoned for fraudulent billing of services? Have you been to a providers office and waited for hours to get a hot two to three minutes with the provider? How many times have you left a provider’s office thinking: ‘Wow! I’m so impressed with the compassion of the staff and the care they provided me! Wow! They really do care about me!’?
Unfortunately, far too many overlook the management component of Pain Management. Yes! Pain management includes MANAGING care of patients by utilizing various risk assessments of each patient to determine potential risks of abuse and/or suicide, monitoring state reporting systems of prescribed controlled substances, urine drug screens, pill counts, and communicating with patients; all in an attempt to ensure patients are being responsible with their medications.
I spoke with a medical assistant last week who said her provider alone runs 50 to 54 patients through his clinic in South Carolina every single day. That’s outrageous!!!! Is he managing the care of his patients or is he just pushing pills into the hands of people who may or may not be using them responsibly? She admitted they’re not taking those risk measures mentioned to even attempt to know what’s going on with their patients.
Providers like this give pain management a bad reputation because they are those who are creating and contributing to an opioid epidemic, creating addicts and feeding their addictions which lead to death. Providers like these remind me of the pill millls I have heard about in the news and that infuriates me. They are licensed providers in a profession entrusted by the public to care for others but instead are willing to kill them for financial gain and greed.
Fortunately, due to the NC STOP ACT more and more pain management centers are starting to implement these risk measures as a means to better manage and ensure patients are being responsible with their medications. This is going to require educating patients. Let’s face it, responsibility of managing a patient’s care also falls onto the shoulders of the patient as well. Patients are going to have to not only expect these measures but respect their providers for investing that time and effort into providing that level of care.
Patients walk into physician’s offices by the droves daily to sit in a chair with their legs crossed looking all cool, calm and collect while reporting pain ratings of 7/10, 8/10, 9/10, 10/10 and even 12/10, 15/10 and 20/10!!!!!!! They report these levels of pain and expect care team members to take them seriously! If, in fact they did, they should be calling 911! Then these same patients get upset when care teams conduct risk assessments to determine if they may be at risk of committing suicide or abusing medications; collect their urine to ensure they’re taking their prescribed medications appropriately and not taking others; question them about controlled substances prescribed by other providers that were filled by a different pharmacy; count the pills to ensure they’re taking them as prescribed and not overtaking them, not only by intentionally abusing them but because some taking these medications can forget having taken them and take too many; and possibly overdose without being addicted. People are going to have to be educated, understand and respect that these measures are part of managing and providing exceptional care by providers who care.
It’s impossible to enlist and utilize these tools and measures to manage care of patients at a volume of 50 to 54 patients a day per provider.
What If Offices:
1. Established patient flow limits to ensure quality of care as opposed to quotas to ensure quantity of billable visits.
2. Developed written protocols for each provider to follow to ensure each patient’s care is truly being managed and medications are not being over prescribed.
3. Staffed providers who are also addiction specialists trained in recognizing and treating addiction; because they want to be able to recognize the signs of addiction; because they are willing to confront the issue to treat or at least refer their patients to an another specialist or counselor who can help because they realize addiction is much more significantly life threatening than pain.
4. Staffed providers who acknowledge, respect and implement treatment options in addition to or other than medication through various stages of care.
Chiropractic, massage, acupuncture, therapeutic modalities, physical therapy, intramuscular injections, joint injections, epidural steroid injections and surgeries are all potentially effective methods of treating and reducing pain with medications when necessary through acute and corrective stages; and with or without medications in addition to establishing some realistic expectations regarding quality of life afterwards during maintenance care.
In addition to present tools available I believe offices should:
1. post charts of relative descriptions of pain ratings in every exam room to help educate patients in order to encourage more realistic reporting by patients. Because if a patient is in an office and is truly experiencing pain at a rate of 9/10 or 10/10, shouldn’t a responsible care team be required to call 911? If I went to my PCP’s office that day with my abdominal pain, reported a rate of pain of 9/10, was prescribed a medication and sent home, would my PCP and his team be liable when my appendix ruptured and I became septic and died? I’m just saying, maybe we need to change the way we communicate with patients, rate pain, respond to ratings of pain or at least try to better educate patients.
2. post information to educate patients of the signs and risks of addiction and encouraging them to ask for help in each and every medical providers exam room. Are staff properly trained how to respond in such a scenario?
3. post emergency numbers to addiction treatment referral sources in each exam room.
4. pharmaceutical reps should provide Narcan samples, coupons and lunches as freely and willingly as they do their other drug samples, coupons and lunches.
I mean, really, what if pain management centers employed providers who specialize in addiction who they could ever so discretely refer their patients whom they believe may be in trouble to see?
What if pain management centers also employed or at least established referral relationships with mental health providers and substance abuse counselors to refer patients to? Let’s face it! Pain, addiction and mental health are all closely connected. No! I’m not saying every patient who has pain is mentally ill but most who suffer from substance use disorders also suffer from some form of mental illness and many of their addictions began in a doctor’s office instead of a back alley or party as stigmatization would suggest.
I would love to see a comprehensive pain management practice that was truly comprehensive in implementing all of the above suggestions. Such a model would surely rotate the earth on its axis!
No One Wants To Deprive Care To Anyone Living With Chronic Pain
My mother is eighty-five years old with severe osteoporosis and spinal compression fractures. She doesn’t have to do anything to experience extreme pain from compression fractures, nerve pain, muscle spasms, etc. She deserves to live the best quality of life she can while being as comfortable as possible. However, even she realizes her pain management provider has implemented measures to ensure she is safe and being responsible with her medications. Not only does she realize it, she respects and appreciates it.
No one wants to prevent anyone from receiving the care and treatment they need to obtain the maximum quality of life possible. However, people need to be more like my mother and respect their providers for investing the time and measures to identify signs of potential problems; appreciate and respect the willingness of their provider to attempt to pull them from the fire when they see warning flags; and understand and respect the fact that whether they themselves may not be at risk of abuse or addiction, there are those who are and their provider and provider’s care team are doing their best to evaluate each of their patients every single day to not only help them with their pain but to save people’s lives. My provider said it best; “Prescribing that medication is like putting a weapon in their hand. I need to make sure they’re responsible with it or I need to take it away from them. I don’t want them to kill them self or someone else with a weapon I gave them.”
LOOK FOR PROVIDERS LIKE HER!!!! SEEK PROVIDERS WHO CARE AND SHOW THEM THE RESPECT AND APPRECIATION THEY DESERVE!!!
The future of pain management and their role in the opioid crisis is dependent on us, their patients, and the level of care we’re willing to accept. We should all want the highest standard of care possible. I want the assurance of knowing each of my medical providers actually care as much about my health as they do how much reimbursement they’re receiving from my visit.