Pain questions not leading to better control

Although more emphasis has been placed on charting patients' pain as a vital sign, recognition is growing that efforts are still needed to ensure action to relieve pain once it is measured.

"We should have known that [recording pain scores] would only be a starting point," said James N. Campbell, MD, a professor of neurosurgery at Johns Hopkins University School of Medicine in Baltimore and a strong supporter in the push to make pain a fifth vital sign.

Over the past decade, the Veterans Health Administration and the Joint Commission on Accreditation of Healthcare Organizations, among others, have instituted standards requiring that every patient be assessed for pain at every clinical encounter.

Several studies have found that the JCAHO standards have led to more satisfaction with pain management among hospitalized patients, but increases in full assessments of pain or more frequent treatment did not follow. In the outpatient setting, the impact has been similar. According to a paper in the June issue of the Journal of General Internal Medicine, the VHA's initiative also may not have translated to improved pain care.

Researchers from the Veterans Affairs Greater Los Angeles Healthcare System and Oregon's Portland VA Medical Center reviewed records of 600 patients before and after the initiative and found that, even though most patients were asked about pain levels, in many cases the patients' difficulties were not assessed further, nor were they prescribed medication to alleviate their discomfort. Even patients with significant pain still were likely to have it managed inadequately.

"Routinely measuring pain by the fifth vital sign did not increase the quality of pain management," wrote the authors.

Experts praised the paper for documenting what many long have suspected: It takes more than office staff routinely measuring pain along with other vital signs to improve pain care.

"I'm thrilled that the study was done," said Dr. Campbell, who is a former president of the American Pain Society. "The problem is that pain is not being treated as a vital sign. It's being treated as a nuisance piece of information."

Improving pain treatment has long been the focus of efforts by medical organizations and societies. The American Medical Association has several policies calling for increased physician education about pain issues, and the American Academy of Pain Medicine's consensus is that every physician has a responsibility to evaluate and treat those in pain.

Exploring the disconnect

This lack of impact of asking about pain appears to be, in part, explained by faulty connections between the person recording the pain score and the physician providing care. In informal discussions reported in the Journal of General Internal Medicine paper, physicians told the researchers that they were unaware that a pain score was available or did not receive the indicator until after they had met the patient.

"There cannot be a disconnection," said Dr. Campbell, also board chair of the American Pain Foundation.

The VHA National Pain Management Coordinating Committee is developing new tools to address this gap, but those who work with pain patients suggest that there may be more than systemic issues working against the goal of improved treatment. For instance, a pain score is subjective. A high one may not be taken as seriously as hypertension or fever. It also can take more time to address.

"Physicians easily see that high blood pressure or a high temperature is life threatening. Pain may not have the same impact that other vital signs have," said Gilbert Fanciullo, MD, director of the pain management center at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. "And pain takes way more time than anyone expects it to require."

The available pharmacologic interventions have baggage that can make physicians hesitant to use them. Opioids come with Drug Enforcement Administration regulation. And recent media reports have been filled with news about adverse events associated with nonsteroidal anti-inflammatory drugs, such as COX-2 inhibitors.

"The climate around analgesic therapy is not necessarily the most comfortable for any physician right now," said Martha Twaddle, MD, chief medical officer of the Midwest Palliative and Hospice CareCenter in Glenview, Ill.

Primary care physicians responded, though, that while they agree with the attention being paid to pain, this study validated their doubts about the value of it as a fifth vital sign, particularly in the outpatient setting.

Pain is the presenting complaint in the majority of clinical encounters outside the hospital. Thus, physicians say they don't have to ask every patient about it. Doing so also can change the focus of the visit to pain when the patient might have made the appointment for other reasons.

"My concern is that this could mean that physicians overfocus on pain and get off the issue that patients are there for," said Edward Bope, MD, program director of the Family Practice Residency Program at Riverside Methodist Hospital in Columbus, Ohio. "Maybe pain was not something they really wanted to discuss. It's forcing an agenda."

Pain outside of a hospital also can be caused by a combination of physical and psychosocial issues, making it a different animal than in the hospital, where it is more likely to be related to cancer or surgery.

"This study demonstrates that outpatient pain management is not nearly as simple as recording pain intensity as a vital sign," said Matthew Hollon, MD, MPH, a general internist and assistant professor of medicine at the University of Washington, Seattle. "It's not that it's wrong to do so or to encourage people to pay attention to complaints of pain. But in the outpatient setting, pain is a much more complex problem than is reflected in a score of pain intensity."