The role of bureaucratic enabling in the opioid crisis

Figure 1 – Opioid Prescriptions Dispensed by US Retail Pharmacies IMS Health, Vector One: National, years 1991-1996, Data Extracted 2011. IMS Health, National Prescription Audit, years 1997-2013, Data Extracted 2014.

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform.

The opioid crisis has been prominent in the news for the past several years. There is no question that the rising rates of opioid deaths, addictions, and disabilities have reached an epidemic level. At this point in time, adjustments need to be made to curtail the crisis and prevent any recurrence. Ultimately we must learn from any mistakes.

As a physician who has practiced medicine for nearly 40 years, it has impressed me that patients are not reluctant to complain about pain. As such, I was always perplexed by the movement in the early 1990s to make pain management a fundamental human right. In my experience, treating pain complaints has always been part of primary care management. However, there has always been some caution in the use of opioids because of a fear of addiction. In the early 1990s, some pain management specialists suggested that opioids could be more liberally used to treat chronic pain and that in this area they have a very low risk of addiction.

In 2001, the Joint Commission introduced a new requirement for all its accredited facilities that all patients needed to be screened for pain. Joint Commission accredited facilities can include hospitals, rehab facilities, nursing homes, imaging centers, home care agencies, sleep centers, and urgent care centers. Many physicians feel this mandate further fueled the increase in opioid prescriptions and subsequent abuse.

In defense of these allegations, in April 2016 the Joint Commission presented a statement entitled, “The Joint Commission Pain Standards: Five misconceptions.” Several of these proposed misconceptions are a bit difficult to swallow. Here are three of them:

Misconception #1: “The Joint Commission endorses pain as a vital sign.”
They state that the Joint Commission never endorsed pain as a vital sign. However, in December 2001, the Joint Commission together with the National Pharmaceutical Council presented a 101-page documented entitled, “Pain: Current understanding of assessment, management, and treatment.” They made the following statements on page 21.

“In 1996 the American Pain Society (APS) introduced the phrase ‘pain as the fifth vital sign’. This initiative emphasizes that pain assessment is as important as assessment of the standard four vital signs and clinicians need to take action when patients report pain. The Veterans Health Administration recognized the value of such an approach and included pain as the fifth vital sign in their national pain management strategy.”

Obviously, they appear to be condoning pain as the fifth vital sign, especially with the statement that the Veterans Health Administration recognized the value of pain as the fifth vital sign. Also, in its initial pain standards of 2001, pain needed to be assessed in all patients in all accredited facilities. That would imply that any warm, breathing body with a pulse and blood pressure needed to be assessed for pain. Ergo, pain was right in there with those vital signs.

Misconception # 2: The Joint Commission requires pain assessment for all patients.
It says “The original pain standards stated pain is assessed in all patients. This was applicable to all accreditation programs (i.e., hospital, nursing care center, behavioral health center, etc.). This requirement was eliminated in 2009 from all programs except Behavioral HealthCare.”

I am at a loss to perceive the misconception that existed from 2001 to 2009. Also, the effects of this mandate lingered for much longer. It was not until June of 2016 that the AMA rescinded its recommendation that pain be assessed as the fifth vital sign. To this day, pain assessment is still one of the quality metrics that CMS uses to calculate the stars rating for Medicare Advantage Health Plans.

Misconception # 5: The Joint Commission Pain standards caused a sharp rise in opioid prescriptions.
They argue that a graph from the National Institute on Drug Abuse “completely” contradicts this claim.

This graph (above) charts the number of opioid prescriptions that were filled in the United States from 1991 to 2013. A “complete” contradiction may be a bit of an overstatement. In 1991, 76 million opioid scripts were filled. This rose to 126 million scripts in 2000 which represented a 66 percent increase from the 1991 amount. From the end of 2000 through 2009, the first nine years after the Joint Commission Pain Standards took effect, that amount rose from 126 million scripts to 202 million scripts, which represented a 60 percent increase from the 2000 amount.

In essence, the sharp rise in opioid prescriptions in the 1990s, due to pain medication advocates, continued with a sharp rise after the Joint Commissions pain standards took effect. Perhaps, in 2000 when the Joint Commission proposed its pain standards, they should have taken a second look at that sharp rise in the 1990s. It may not have been advisable to encourage more patients to complain about pain. I would suggest that most of those patients would have been more than willing to tell the provider if they were having too much pain.

In 2007, an editorial appeared in the anesthesiology literature that was critical of a publication entitled, “Pain management: a fundamental human right.” They took exception with the article’s characterization of individuals who advocate against more liberal use of opioids as “opioidphobic and/or opoioignorant.” They also quoted several studies that documented the adverse effect of the liberal use of opioids on adverse hospital events, increased length of hospital stays, and increased hospital costs.

In addition, the editorial quoted literature that concluded the long-term use of opioids in non-cancer pain failed to improve the patients’ pain relief, quality of life, or functional capacity. It should be noted that this appeared two years before the Joint Commission decision in 2009 to limit mandatory pain assessment to only Behavioral Health centers.

After a careful review of the Joint Commission’s statements concerning the misconceptions relating to their 2001 Pain Standards, I am left with the impression that these are more the Joint Commission’s “mis-rationalizations” of their 2001 pain standards.

Perhaps, in addressing chronic pain, we need to emphasize that all pain is not bad. For the most part, pain receptors exist for a protective effect. When you lean your hand on a hot stove do you pull it off because you smell something burning or because you feel pain? How many diabetics who have lost sensation in their feet have subsequently had amputations of toes, feet, and limbs?

The concept of “feeling no pain” is not a good thing. Should you drive a car if you are “feeling no pain”? Some level of pain is necessary and any treatment of pain needs to use modalities that provide “some” relief of pain but at the same time maintain a level of physical and mental functionality.

Yes, these modalities may at times include judicious use of opioids, even in non-cancer pain.

Keith Aldinger, MD, is an internist practicing in Houston, Texas.