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The 5th Vital Sign & America’s Painkiller Epidemic

posted on Thu, Oct 15 2015 11:53 am by Will Humble

The U.S. healthcare system has become much more aggressive in treating pain over the last 15 years. Just as with any medical intervention, there have been side-effects, and the U.S. is in the middle of an epidemic of painkiller misuse and abuse that’s killing large numbers of people. In fact, misuse and abuse of opiate prescription painkillers takes out more people every year than car crashes. 

How did we get here? What’s being done to address the issue, and are we developing responses that are capable of turning the tide?

One of the contributing factors to the epidemic began on November 11, 1996. In his presidential address, James Campbell of the American Pain Society introduced the phrase, “Pain as the 5th Vital Sign.” He emphasized the importance of including pain as part of the four traditional vital signs: body temperature, blood pressure, heart rate, and respiratory rate. The speech resonated. 

Shortly thereafter, the Veteran’s Health Administration included pain as the 5th Vital Sign in their national pain management strategy. Two years later, the Joint Commission on Accreditation of Healthcare Organizations released Standards Related to the Assessment and Treatment of Pain. The institutionalization of pain by these respected entities was motivated by their interest in delivering comprehensive and appropriate pain care—but it also sparked an opioid wildfire.

In the years since pain was institutionalized as the 5th Vital Sign, the misuse and abuse of prescription drugs has become the leading cause of injury death in the U.S. For example, in 2004 there were approximately 600,000 ED visits tied to prescription drugs in the U.S. By 2010 it had more than doubled to 1.4 million. Prescription opioids are now the leading cause of drug overdose deaths in most states.

The good news is that public health and health care officials are increasingly aware of the epidemic and there are a number of interventions underway nationally and in many states to stem the tide. 

In 2012, the Joint Commission issued a new Sentinel Event Alert recommending that health care organizations improve their response to and reporting of prescription drug misuse and abuse including. The CDC recently recommended a number of strategies states can implement including: 1) electronic Prescription Drug Monitoring; 2) monitoring prescriptions via state Medicaid programs; 3) implementing health care provider accountability programs; 4) enacting state laws to prevent doctor shopping and “pill mills”; and 5) providing affordable, comprehensive, and meaningful substance abuse treatment programs.

In 2013, the Centers for Medicare & Medicaid Services implemented new requirements (in Medicare Part D) to ensure that plan sponsors establish drug utilization management programs to prevent overutilization of opiates. 

As is the case with many of the public health challenges we face, prevention needs to be a key component in any solution. The Institute of Medicine set the stage for this case for prevention with their 2011 publication entitled Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The Blueprint emphasized steps individuals, providers, and communities can take to prevent pain from occurring in the first place.

The misuse and abuse of prescription drugs is real. It kills people, even children. Making pain the 5th Vital Sign may have kicked off what has become a complex population health epidemic, but responses that have been developed in response to the epidemic have given birth to policies that are likely having an impact. 

The policy question that few people are asking is whether it’s time to go back to 4 Vital Signs. What do you think?

This guest post was prepared by Will Humble, M.P.H., the Director of the Division of Health Policy & Program Evaluation for the Center for Population Science and Discovery, Arizona Health Sciences Center, at the University of Arizona, and the former director of the Arizona Department of Health Services. 

The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.

Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not necessarily represent the views of, and should not be attributed to, RWJF.

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