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The Fifth Vital Sign

Addiction, Facing Addiction in Indiana

As told to Colton LeTourneau

Since 1991, the U.S has seen a tremendous increase in opioid prescriptions, leading to an increase in deaths and overdoses bound to painkillers.

According to drugabuse.com: “The interaction between painkillers and specific opioid receptors results in activation of our ‘reward centers’ — a phenomenon that is brought on by the resultant surge of the neurotransmitter dopamine, which creates a feeling of euphoria and well-being. These effects, which are similar to those of heroin (another opioid), reinforce patterns of abuse and can quickly lead to addiction, as many users will continue to increase their doses to achieve these effects as their tolerance develops.”

Developing a tolerance can be dangerous and sometimes even deadly.

Some common opioids derived from painkillers are methadone, hydrocodone, codeine and meperidine. According to the National Institute of Drug Abuse, the numbers of prescriptions for opioids (like hydrocodone and oxycodone products) have escalated from around 76 million in 1991 to nearly 207 million in 2013. The United States is their biggest consumer globally.

Opioids account for the largest prescription-drug-abuse problems and are the most common drugs used in overdoses. According to the Center for Disease Control and Prevention (CDC), 91 Americans die each day from overdose of prescription painkillers (opioids) and heroin.

The assessment of pain by the Joint Commission, an independent, not-for-profit organization that certifies and accredits nearly 21,000 health organizations and programs in the U.S., has been a controversial topic for many years now. As the opioid crisis continues to affect almost every state in the U.S., advocates such as the American Medical Association are urging the Joint Commission and Centers for Medicare and Medicaid Services (CMS) to scrap policies that they say can lead to opioid over-prescribing.

Advocates are asking the Joint Commission to re-examine its Pain Management Standards, which previously identified pain as “the fifth vital sign.” In 2001, the Pain Management Standards required healthcare providers to ask what degree of pain the patient felt with the notion that, at the time, pain was undertreated.

According to an article called “Opioid Crisis: Scrap Pain as 5th Vital Sign?” in Medpage Today, “In a letter to Mark Chassin, MD, MPH, president and CEO of the Joint Commission, advocates ask the organization to re-examine those standards, which lead to overtreatment and overuse of opioids.”

The letter said that pain is merely a symptom. It is not a vital sign. Blood pressure, heart rate, respiratory rate and temperature — the four original vital signs — can be objectively measured, meaning it is the repetition of a unit that maintains its amount within an allowable range of error. Medical test results for each person will be different, but each of the four vital signs can be tested within a certain range to determine the patient’s condition.

Pain, on the other hand, cannot be measured objectively (or medically).

For many years, Dr. Thomas D. Gustavino, an orthopedic surgeon, would get calls from nurses telling him that his patient was in severe pain, and the pain had not been successfully controlled by the pain medication already ordered. He and other doctors would go through a series of checks: seeing what kind of pain medication had been given to the patient, determining if they had any allergies, identifying patient symptoms such as numbness and tingling, and even asking if they a had on a tight bandage.

Going through this series of checks, Gustavino said, “can make for an identifiable and correctable reason for the patient’s pain.” For example, it could just be a slight loosening of the bandage to release a little pressure and relieve the patient’s pain.

But ever since the inclusion of the “fifth vital sign,” Gustavino said hospitals are to be “more aggressive” when treating pain and are to follow new guidelines, which include utility of pain “scales,” which are as follows, according to the Universal Pain Screening as required by the Joint Commission:

  • Pain Free
  • Very Mild: hardly notice the pain at all
  • Discomforting: minor pain
  • Tolerable: very noticeable pain — like an accidental cut
  • Distressing: strong, deep pain — like an average toothache
  • Very Distressing: strong, deep, piercing pain — like a sprained ankle when you stand on it wrong
  • Intense: strong, deep, piercing pain — so strong it seems to partially dominate your senses
  • Very Intense: same as 6 except the pain completely dominates your senses
  • Horrible: pain so intense you can no longer think clearly
  • Excruciating: pain so intense you can no longer tolerate it and you demand painkillers or surgery right away
  • Unimaginable: pain so intense you will go unconscious shortly

Considering pain as the “fifth vital sign” has put many people at risk of becoming addicted to these opioid painkillers because it’s impossible to accurately test a patient’s pain. So doctors and nurses are required to give their patients something to stop the pain … but they cannot medically assess their patients’ degree of pain. In other words, the “fifth vital” is largely based on self-diagnosis.


This story originally appeared in Facing Addiction in East Central Indiana, a publication of The Facing Project that was organized by Dr. Adam Kuban and the Louis E. Ingelhart Scholars at Ball State University in Muncie, Indiana.

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