The Fifth Vital Sign

nutella, MSN, RN · Feb 13, 2016

It seems that I can rarely peruse the news in any fashion without reading about the 'epidemic' of opioid-related deaths. I know that we regularly see OD'd patients in ED.
Let's go ahead and say it: pain is *NOT* the fifth vital sign and this push to insist otherwise is a classic example of unintended consequences.
Rather than trying to confront the unfortunate truth that pain is something that we often need to learn to live with, we instead look to push the idea that every police officer should carry naloxone and a nasal atomizer. We're seeing Superbowl ads marketing medication to help treat another common narc side-effect that we see in the ED: severe constipation.
I'm sorry. Pain does suck (I speak as a chronc pain sufferer myself) and *limited* use of narcs can be helpful but let's put it in its place...
PAIN IS NOT A VITAL SIGN AND I REFUSE TO CONSIDER IT SUCH.

Very bold comment, basically yelling your opinion out into the world...

I do not think labeling pain assessment as a VS was intended to draw some attention to the fact that pain is often under treated or not treated sufficiently.

Of course there is pain and pain. But let me tell you that as a palliative and hospice nurse I see under treated pain all the time! Pain management is often not done well.

Of course pain is not a VS like BP - I think it is more of a metaphorical idea to illustrate the important of pain assessment.

What I do notice is that pain is addressed often too late and once out of control or severe hard to catch up on. Or insufficient amounts (in the community as well as the hospital).

I am not talking about drug abusers here - I am talking about pain that needs relief. Of course I am not all for PCP writing huge amount of narcotics for minor pain but narcotics have a very valid place in pain management.

calivianya, BSN, RN · Feb 13, 2016

I really do agree with you. I see over-treated pain more often than I see under-treated pain. I swear half of the rapid response patients I get from the floor are because somebody pushed too much drugs and the patient stopped breathing. And then, of course, the floor nurses usually wait until someone from rapid response gets there to push narcan and/or intubate, so then the patient has a preventable anoxic brain injury on top of whatever else was going on.

Most of the under-treated pain I see is because the family throws a royal fit if we try to give the patient pain medicine because they think the patient's too sleepy, and the physician goes the path of least resistance and D/Cs the pain medicine because of jerk family members.

KatieMI, BSN, MSN, RN · Feb 13, 2016

It seems that I can rarely peruse the news in any fashion without reading about the 'epidemic' of opioid-related deaths. I know that we regularly see OD'd patients in ED.
Let's go ahead and say it: pain is *NOT* the fifth vital sign and this push to insist otherwise is a classic example of unintended consequences.
Rather than trying to confront the unfortunate truth that pain is something that we often need to learn to live with, we instead look to push the idea that every police officer should carry naloxone and a nasal atomizer. We're seeing Superbowl ads marketing medication to help treat another common narc side-effect that we see in the ED: severe constipation.
I'm sorry. Pain does suck (I speak as a chronc pain sufferer myself) and *limited* use of narcs can be helpful but let's put it in its place...
PAIN IS NOT A VITAL SIGN AND I REFUSE TO CONSIDER IT SUCH.

OK, I got it. Now what?

The part of the problem is that pain management is much larger and much more complicated than pills and shots. Massage, hydrotherapy, PT, aquaPT, acupuncture, yoga, stretching all were shown to be just as or more effective and definitely more safe than opioids, for chronic low back pain, FBM and an array of other conditions. But I can tell you, finding a quality practitioner who knows how to do acupuncture is a quest which takes months and costs $$$$ out of pocket. Most of people just cannot afford it, plain and simple. There are not enough clinics offering holistic pain management. There are not enough qualufied providers (just to let you know, any MD right after any residency training is almost totally free to prescribe any amount of opioids he feels ok with. In order to become familiar with more advanced pain management options, he has to go through 2 to 4 more years of grueling training in fellowships, which is not available everywhere and for everyone. For example, internal medicine physician cannot freely join pain management fellowship, he needs to go through anesthesia or physical medicine residency for that, although he can prescribe narcs in any amount).

Second thing is that we, as a society, demand immediate results doesn't matter what. If I tore my back yet another time moving yet another 500+ lbs body, I will not be able to stay home for couple of weeks recovering. I will have to do something to be back there next understaffed shift. Same is about every store clerk, construction worker, etc. This is not what I or all these people choose to do, but what our employers force us into, and we all got bills to pay and kids to feed. What people are supposed to do, especially if most of them have bad insurances if any at all, and no knowledge, and no way to get help they really need except for urgent care visit, where they will be happily given 10 pills of Vicodin for $20 copay?

IMH (umble)O, we need to solve these two problems before starting to teach people to suck it up and live with it. As right now, everything a proverbial Joe the Plumber who pulled his back three months ago while cleaning the toilet in your house can get for his now officially chronic low back pain of 6-7/10 is that Vicodin script from your ER.

calivianya, BSN, RN · Feb 13, 2016

I will add - the other round of under-treatment of pain I see is from people who are on insane amounts of home narcs. It is just about impossible for people who take megatons of Opana and methadone to get a good amount of pain relief on the IV stuff, and many are NPO for me. I have run a dilaudid drip at 10mg/hr and still had the patient screaming, and the physicians are usually too afraid to run dilaudid drips at those sorts of levels for long.

I have literally had patients that nobody would write transfer orders for because of the amount of IV narcotics the patient was receiving, which is a RIDICULOUS reason to keep someone in critical care. I'd try to call report when I did get transfer orders, I'd mention a dilaudid/fentanyl drip running at really high levels, and get the "Hold on, let me talk to my charge real fast, I'll call you back," and before you know it, the transfer would be cancelled.

I had a patient we literally killed from aspiration pneumonia because the Opana was the only thing that kept her pain under control, so even though she couldn't swallow anything, not even pudding thick liquids, without aspirating - they made sure she got her PO controlled release Opana because nothing else worked. One of the five rounds of pneumonia she had in the hospital with us finally got her septic enough to kill her. We had talked to her about it multiple times, but she said she realized she would probably die of pneumonia if she kept taking the Opana, but she'd rather die than be in that much pain, so she and her family were okay with risking it.

I know people do need pain relief, but these people getting on these huge amounts of narcs legally is INSANE, and somebody needs to pull the licenses of these prescribers who are getting people hooked on these ridiculous amounts of drugs. As KatieMI mentioned, we need more options. Narcs are not always the answer.

nutella, MSN, RN · Feb 13, 2016

I really do agree with you. I see over-treated pain more often than I see under-treated pain. I swear half of the rapid response patients I get from the floor are because somebody pushed too much drugs and the patient stopped breathing. And then, of course, the floor nurses usually wait until someone from rapid response gets there to push narcan and/or intubate, so then the patient has a preventable anoxic brain injury on top of whatever else was going on.
Most of the under-treated pain I see is because the family throws a royal fit if we try to give the patient pain medicine because they think the patient's too sleepy, and the physician goes the path of least resistance and D/Cs the pain medicine because of jerk family members.

You make it sounds like every second pat gets rapid response because the nurses push too many drugs lol

Perhaps it also depends on the area - in the area I where I work providers are very careful about prescribing narcotics plus they a lot of them lack the knowledge to prescribe the right amount. As a result of skimpy pain management or PCP trying to switch pain regimens (and not working) I see patients in the hospital who are definitely under managed.

But you are also right in that relatives sometimes do not want the pat to get enough pain meds because it may lead to tiredness .

twozer0, NP · Feb 13, 2016

Its also worth noting that pain is subjective whereas all the other signs are objective. We can quantify pain with scales but it is really hard to determine an exact estimate like other things. Like most subjective anotations, it is hard to treat without being in total control or no control at all.

Rexie · Feb 13, 2016

It's been my experience that a lot of people really don't understand the pain scale. I've had people that I don't believe were drug seeking tell me they had 8/10 pain but their body language and demeanor would say otherwise. It's possible that they have learned to live with chronic pain but in these particular cases, I think they truly did not understand. I can hardly blame them. There have been times when I've been in pain and have stopped to think about what number I'd give it, and it's hard to come up with a number. Perception depends on so many factors, including how stressed I am a the moment (making it worse) or how busy I am (distraction).

It wasn't all that long ago, I recall being told that there was no need for people to live in chronic pain and that they would not become addicted to opioids. Obviously, that was not true. I can only hope that the pendulum does not swing too far in the other direction, leaving people who have pain, either acute or chronic, with insufficient relief.

MunoRN, RN · Feb 13, 2016

"Pain is the fifth vital sign" was an initiative of the American Pain Foundation, a group which dissolved after a Senate investigation was launched and found that it was front for a group of pharmaceutical company marketing departments. Pain scale based opiate dosing all came from this group.

https://www.washingtonpost.com/national/health-science/senate-panel-investigates-drug-companies-ties-to-pain-groups/2012/05/08/gIQA2X4qBU_story.html?hpid=z4

https://www.propublica.org/article/senate-panel-investigates-drug-company-ties-to-pain-groups

Was the Pain as a 5th Vital Signâ€ campaign in part a marketing ploy? | The Poison Review

The money and influence behind Pain as the Fifth Vital Signâ€ | The Poison Review

So yes, "pain is the fifth vital sign" was literally a scam, but we should also be careful to not go in the opposite direction and be indifferent to pain. While opiates for chronic pain are clearly overused, acute condition pain control is totally reasonable and produces beneficial health outcomes. Proactive pain control has been shown to actually reduce the total opiates required for the same level of pain control, so thorough pain assessments and reassessments is important not just for comfort but for avoiding the adverse effects of excessive opiates.

calivianya, BSN, RN · Feb 13, 2016

You make it sounds like every second pat gets rapid response because the nurses push too many drugs lol
Perhaps it also depends on the area - in the area I where I work providers are very careful about prescribing narcotics plus they a lot of them lack the knowledge to prescribe the right amount. As a result of skimpy pain management or PCP trying to switch pain regimens (and not working) I see patients in the hospital who are definitely under managed.
But you are also right in that relatives sometimes do not want the pat to get enough pain meds because it may lead to tiredness .

It's not all the time, but at least 3-4 times a week, and it's at least half of rapid response calls. Especially if the patient is having a COPD exacerbation and is already having trouble getting rid of CO2 when somebody slams in an opiate and drops his/her respiratory rate.

I don't know why people don't advocate for some Toradol or something when somebody teetering on the edge of buying himself a tube because of high CO2 complains of pain.

RunnerNurse09, BSN, RN · Feb 13, 2016

I agree with the OP. Yes pain management is important to patient care, but I remember reading some statistic that stated that the US used like 90% of the world's opiates? I am someone who has had herniated disks since I was 15(I am 39), and so I know what pain is. I also am a former marathon runner who ran the last 8 miles of one with an injured foot, and currently does crossfit and olympic weightlifting, so I know how to push through pain as well. Some docs are way to in-discriminant with prescribing pain meds. Case in point, sending my husband home who was complaining of MILD calf/achilles pain with VICODIN (which he never used). God forbid he was one of those people that decided to "take what the Dr said I should take " and became addicted. On the flip side when I worked in the ER I had a Dr refuse to give a very sick patient pain meds because "hes addicted". The man was on his last leg. When I have my back pain I literally have to be in agony before even considering narcotics (the last time I had percocet for it was probably 10 years ago). The wrong mentality is thinking you shouldnt have ANY pain. Yes, in some cases narcotics are needed, but the least extreme meds should be considered first, and in the words of another ER nurse, some people need to just "suck it up, buttercup."

RunnerNurse09, BSN, RN · Feb 13, 2016

Yoga definitely has been proven in studies to help with back pain. Mine has improved tremendously with yoga stretches.