Pain is a vital sign

Near the end of May, the New York Medical Society brought forward a resolution for the American Medical Association (AMA) House of Delegates to consider. The focus of Resolution 707 is the 2001 Joint Commission standard to assess pain as the fifth vital sign. The drafters of the resolution claim that this standard has led to “misguided” efforts by clinicians to eradicate all pain and an overreliance on opioid medications that have subsequently worked their way into society and caused addiction and overdose deaths. It encourages the AMA House of Delegates to pull support from the fifth vital sign standard, apparently with the goal of eradicating harm from opioid use.

This would be very poor policy, and it is important to speak up now to stop its forward motion. Granted, any state chapter can bring forth a resolution, and passage is far from assured.  But even if this resolution dies, the talk it generates could live on. It could get into the societal bloodstream, infecting the conversation and influencing policy creation going forward.

The resolution as written is factually inaccurate and further stigmatizes people in pain.   The New York society falsely equates the fifth vital sign designation as a mandate to prescribe opioids.  That in itself is preposterous.  But it goes further in suggesting that to measure pain as a vital sign puts the pressure on clinicians to eliminate all pain. This is neither true nor possible in many, many instances. Of course, any right-minded clinician prefers zero pain, but with current therapies, that goal is often unrealistic. Yet pain should still be prioritized and addressed. To do otherwise puts patients at risk for a host of pain-related complications, the most serious of which is the progression to pain as a chronic destructive pathology.

This brings up another misunderstanding that could grow out of the resolution: the statement that pain is rarely a disease.  There is danger here for the tens of millions of Americans with migraines, peripheral neuropathy, complex regional pain syndrome, rheumatoid arthritis and hundreds of other pain types that affect and change the nervous system. Already, these are people who are castigated as if their pain were  self inflicted and life would be fine if they would “get over it.”

Clinicians should assess for and treat underlying disorders that cause pain but also understand that, for some patients with some types of pain, eradicating all underlying causes is not possible although, of course, that should always be the goal. Furthermore, the 2011 report on pain in America from the Institute of Medicine (IOM) clearly indicates that pain can become a disease in itself: “Pain sensation, transmission, modulation, and interpretation are functions of the central nervous system, and when abnormalities in this process occur, pain can be a neurologic disease.” The people who suffer in this manner deserve a scientific understanding of pain as a disease and the toll it takes on human life.

The drafters of the resolution are attempting to benefit patients and society at large. The principles that not all pain can be relieved and that opioids are not always the answer are good. But there is nothing in the standard of pain as a vital sign that says opioids must be administered, and if such is automatically happening, then education on pain assessment needs improvement. Pain treatment has never been, nor should it ever be, synonymous with opioid therapy.

Problems with pain management certainly remain. The resolution discusses research showing that despite being assessed more often since the fifth vital sign effort, pain is no better managed. The IOM report addressed this problem and called for more comprehensive assessment. Medicine should move toward comprehensive pain care and away from automatic reliance on opioid medications. But the assessment itself does not need to cease. To call for such action borders on lunacy or at least denigration of people with severe disabling conditions. Healthcare professionals have a professional and ethical obligation to assess and re-assess the pain of patients. The resolution proposed for AMA House of Delegates consideration is short sighted and should be denied.


  1. Anonymous on June 23, 2015 at 8:21 pm

    Thank you so much for your continued and vehement defense of pain patients.

    I’ve been told countless times, even by well-meaning doctors, that “opioids are bad for you”. I’m never given a clear reason for this besides potential addiction, which hasn’t happened in the 20 years I’ve been taking them.

    They never told me that letting pain continue unabated could permanently damage my nervous system and lead to “Centralized Pain”. I had to learn this through my own research. From what I’ve heard, too many in the medical profession still haven’t absorbed this reality. They are still unconvinced that pain can persist without a clear cause, and assume that it must be of mental origin.

    When a professional in any capacity cannot, or does not, keep up with their field they become too easily swayed by public opinion and media hype.

    Politicians and self-appointed experts are promoting the fear that opioids “cause” addiction, which is like saying alcohol causes car crashes and guns cause murders. Drugs, alcohol, and guns are instruments of destruction only when used by the wrong people for the wrong reasons.

    Instead of relying on scientific research and training, too many politicians, law enforcement personnel, and even some doctors, are allowing their judgements to be swayed by the media hype and political grandstanding around opioids these days.

    Heartbreaking stories of addiction are being used to promote all kinds of non-medical legislative limits on opioids, to establish more punitive measures for addicts, and to fill the coffers of the lucrative and unregulated Recovery Industry.

    Despite the ubiquity and devastation of chronic pain, its treatment don’t seem high on anyone’s training or expenditure priorities these days.

    Pain is extremely difficult to treat, so it’s more expedient to label patients seeking medication for pain relief as drug-seekers. Instead of helping us, our “healthcare providers” make the simplistic assumption that our problem is addiction, pack us off to some dismal institute for “detox” and “recovery”, and then leave us to be tortured by our pain, permanent companion until death do us part.

  2. Emily Ullrich on July 23, 2015 at 1:03 am

    First off, before the concept of pain as the “Fifth Vital Sign” is overridden or retracted, I would like to see it actually BE APPLIED! As a chronic pain patient for the past eight years, and an acute pain patient numerous times over those years (during which time the AMA had declared pain “The Fifth Vital Sign.”) I have NEVER ONCE seen, heard, or been treated as though pain was a vital sign. Over the past year, I have been hospitalized four times. During those times, more than once my pain was so intense that my entire body was trembling, I was sweating, my voice quivering, tears streaming down my face, and vomiting. Still, doctors refused to increase my pain medication. All the while, a sign on the wall taunted my pain, stating that the hospital’s “Goal” was to “adequately control my pain,” and that “If my pain was not reduced within 20 minutes,” I should “Call my nurse.” I of course did call my nurse. And the charge nurse. And up and up the chain of command, all of whom differred to doctors under-trained in pain treatment, who were too cowardly to talk to me in person, and who allowed me to suffer in agony rather than risk questioning by thier peers and superiors. Now, that pain has become chronic.

    In fact, as an Ambassador for the US Pain Foundation, and Delegate for the Power of Pain Foundation, as well as all around pain advocate, I have never heard of anyone being treated according to this theory. Since we know that acute pain left untreated or undertreated can create permanent pain pathways which then create chronic pain, and we know that pain (acute or chronic) can cause elevated blood pressure, which as we know can lead to a plethora of comorbidities and intractable illnesses, we know that chronic pain leads to depression and permanent brain changes, and we know that people heal better from surgery or injury if pain is controlled, it makes complete sense that pain be considered a vital sign. It IS a vital sign, a sign from your body that something is wrong, and it SHOULD NOT EVEN BE DEBATED that we should (as a society) assign even LESS gravity to this serious health concern. It is the intimidation from the DEA, politicians, media, and society, NOT medical science, which is moving this proposal forward. As we know, the average MD has fewer hours of training in pain medicine than a vetranarian, and more hours in being taught how to profile and be suspicious of patients. I would like to know who to contact to attempt to persuade this movement against the “Fifth Vital Sign” to be redirected.

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