The 5th Sign: Understanding the Root of the Opioid Epidemic in Order to Fix It

In his State of the Union Address last week President Trump discussed the need to take action against one of the most deadly crises our country is currently facing: the opioid epidemic.

Trump was very passionate about fixing this problem on the campaign trail back in 2016, but so far, we’ve seen little in the way of federal designation of funds to make a positive impact.

Last Tuesday night, however, he vowed to make putting an end to this national crisis — which killed 174 people a day in 2016 alone — a priority for his administration in the coming year.

But in order to even begin to fix this issue, it’s important to understand the root of the problem and how some medical professionals on the frontlines have been taking matters into their own hands in the meantime.

For many years now in the field of surgery, we have been indirectly conveying the message to our our patients that all pain is evil.

The 5th sign

We have created the illusion that all medical procedures should be pain free through a series of events that paved the way for federal guidelines, pharmaceutical companies and medical organizations to establish what we in the medical field refer to as “the 5th sign.”

Prior to the late 1990s, vital signs represented respiration, blood pressure, temperature and heart rate. But then the 5th sign appeared, which was pain scores.

The Joint Commission, which is the governing body of healthcare accreditation and certification in America, established standards for pain assessment in response to Americans reporting widespread undertreatment of chronic pain. Doctors began asking patients about their pain on a scale from 1 to 10 basically any time a patient landed in their hospital or office for an acute issue.

While the Joint Commission’s standards never explicitly required the use of narcotics for pain management, we’ve somehow ended up in a place where many patients are popping pills and doctor shopping to feed their addictions.

The effort to minimize pain in hospital settings has been one of the most underscored health initiatives that this country has ever seen. And what do we have to show for it? Well, overutilization of narcotics in medical settings for one, and the growing opioid epidemic that claims thousands of lives each year.

Now, it’s time to redefine pain and look at legitimate ways to treat it while creating reasonable expectations for our patients. It’s important for patients to understand that pain is a natural phenomenon created by the body when it is injured. If we numb a patient’s pain completely, how will they know whether or not they are over-exerting themselves only delaying the healing process, or worse, causing further injury?

For many years, the Centers for Medicare & Medicaid Services (CMS) included pain management in their nationally standardized survey used to measure patient perceptions of their hospital stay. But in 2017, the agency decided to drop pain management from their survey in an effort to address concerns from physicians and other healthcare providers that felt it was inadvertently contributing to the opioid crisis.

“While there is no empirical evidence of such an effect, we are finalizing the removal of the pain management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey for purposes of the Hospital Value-Based Purchasing Program to eliminate any financial pressure clinicians may feel to overprescribe medications,” CMS said in a press release.

Now, healthcare professionals and hospitals across the country who realize they may have been part of the problem are now figuring out ways to become part of the solution.

Reworking the system

WIthout much help from the federal government, some hospitals including Hackensack University Medical Center where I practice, have started to implement programs to mitigate the need for post-surgical narcotic pain medications.

As early adopters of a program called Enhanced Recovery After Surgery (ERAS) doctors here are learning to predict the functional outcomes of pain intervention in their patients before they even enter the operating room.

“We look at all phases of care including preoperative care to post-surgery to coordinate all the resources so that patients have a comfortable, faster recovery,” said Dr. Michael Block, director of obstetric anesthesiology at Hackensack University Medical Center in New Jersey. “It involves pain management, but it also involves nutrition, ambulation and smoking cessation.”

Not all patients qualify for ERAS based on their medical history and current condition, but those who do go through a period of prehabilitation before surgery to make sure they are entering the OR in the best condition possible.

Using minimally invasive surgical techniques and regional anesthetics are two other ways doctors can minimize or even eliminate the need for heavy narcotics during recovery.

Now I’m not advocating for narcotic-free hospitals, but with the emergence of the opioid epidemic, I think most doctors will agree we need to re-evaluate the way we’re treating pain.

“We as doctors shouldn’t cause or feed addiction, but certainly proper use of narcotics have their place in medicine — especially in the world of anesthesia,” said Dr. Mark Schlesinger, chairman of the department of anesthesiology at Hackensack University Medical Center. “The trend now is rather than pick one drug and give high doses of narcotics, if you treat pain with a little bit of a lot of things, it goes a long way.”

New moms recovering from c-sections at our hospital often receive non-narcotic pain medications on a scheduled basis to stay ahead of the pain so that they’re not getting to the point where they require something stronger.

This trend in pain management is common practice In many surgical departments outside the United States. Patients in many European countries, for example, are often sent home with ibuprofen and instructions to rest.

Changing our approach

Advances in modern medicine are allowing us to redefine how we view and treat pain and it all starts with patient education. It’s time to realize that 2018 procedures are not your grandmother’s surgery anymore.

Operating time has been significantly reduced and minimally invasive procedures are taking the place of complicated surgeries that required large incisions leading to shorter hospitals stays and faster recoveries. Modern surgery is changing rapidly, so it’s high time we change our approach to managing pain when it’s done.

We need federal funds designated to helping this problem starting on the frontlines: in our hospitals and doctors’ offices. We need more resources in the way of mental health facilities and rehabilitation centers equipped to deal with addiction. And finally, we need to revisit the laws surrounding the criminalization of drug addiction. By putting these people in jail and not helping them overcome their addictions, we’re creating a new marketplace and a bigger problem for society at large.

So, Mr. President, I’m hopeful that you’ll make 2018 the year we conquer this beast. It’s time to act, and act fast.