When doctors labeled pain as a fifth vital sign in the 1990s, they intended to encourage their colleagues to better manage their patients’ pain.
In hindsight, local doctors say their predecessors may have inadvertently contributed to the heroin and opiate epidemic sweeping the nation today.
“I think the medical profession got so focused on pain as the fifth vital sign — and we’re in a world of patient satisfaction, so we were incentivized to prescribe opioids to manage pain,” said Dr. Ken Braman, a family medicine specialist for Cleveland Clinic Akron General Medical Center. “Now we know that if we can not even start someone on an opioid, we could be doing them a favor.”
Dr. Cindy Kelley, a family medicine specialist at Summa Health System, said doctors could not have anticipated what came next.
“There was a lot of push to treat pain, and we did, without maybe fully understanding the big picture,” she said. “This epidemic could be seen as an unintended consequence.”
Now they’re working to correct the mistakes of doctors past.
The opiate epidemic
Opiates — commonly known as prescription painkillers — are the most abused drug in the United States, according to the Centers for Disease Control and Prevention. They’re very addictive, doctors said, and they’re accessible because homes are overstocked with the drugs.
The most recent push to aggressively manage patients’ pain started in the 1990s, when doctors labeled pain as the fifth vital sign alongside body temperature, heart rate, respiratory rate and blood pressure.
“Patients started to see things like pain scales. If they were evaluated in the emergency room, they were asked to rate their pain from zero to 10,” said Summa’s Kelley. “They saw posters on the walls with a smiley face on one side and a frowny face on the other side.”
If doctors weren’t checking their patients’ pain levels and offering treatment, they could be penalized, she said.
Physicians who didn’t treat pain well also saw drops in patient satisfaction levels, which in turn reduced their pay. Insurers and federal government programs increasingly tie reimbursement to the quality of the care provided, including patient satisfaction ratings.
“We were getting measured by how well we treated pain,” she said.
According to the CDC, the sale of legitimately prescribed painkillers quadrupled from 1999 to 2010.
Almost 750 million doses of prescription painkillers were dispensed in Summit County in 2014, the most recent data available from the county Alcohol, Drug and Mental Health Board. That was enough painkillers to give 68 pills to every county resident, both child and adult. The number was dropping in 2015, but a full year’s data was not available.
Officials said as personal stocks of painkillers depleted, more and more people were turning to a cheaper, stronger opiate: heroin. As many as four-fifths of today’s heroin addicts first used prescription painkillers illegally, according to the U.S. Substance Abuse and Mental Health Services Administration.
Thus, an epidemic began. In Summit County alone, as many as 160 people died of accidental opiate overdoses in 2015 — a more-than 50 percent increase over 2014. Across the country, thousands are dying yearly of accidental opiate overdoses.
In the midst of the epidemic, doctors said they’re working to reduce the chance their patients will get addicted to opiates. Most prominent among the efforts is a push for alternative ways to manage pain, like acupuncture and physical therapy.
Mark Trimble, 59, of Kent, said he prefers acupuncture and other alternative therapies over opiates to treat his severe chronic back pain.
“I’ve gone through just about everything,” said Trimble, a patient at Akron General’s Spine and Pain Institute in Kent, where doctors specialize in alternative pain treatments. “But ever since starting these treatments, I feel like I’ve been able to live my life better.”
He said he’s tried opiates but didn’t like the way they made him feel.
“Opiates take you down a bad path,” he said. “They should be a last resort.”
Other options
Dr. Samer Narouze, chairman of the Center for Pain Medicine at Western Reserve Hospital in Cuyahoga Falls, agrees opiates should be a last resort for treating pain. He said sometimes doctors forget that pain is a symptom of underlying issues — not a condition on its own.
“The most important goal is not to relieve the pain — it’s to identify where the pain is coming from,” he said. “If you can pinpoint where the pain is coming from, you know what to do to stop the pain.”
Instead, Narouze said sometimes doctors prescribe medication for chronic pain without ever addressing the cause. This leads to addiction because patients are using the drug nonstop.
“No one is immune to addiction,” he said. “The profiling in the past that low socioeconomic people are most at risk of drug addiction is incorrect. Anyone can be addicted, and prevention is the most important feature of stopping it.”
Narouze advised the public to be wary of overusing painkillers if they’re prescribed.
“If you’re not working, if you’re not at school, if you’re not hurting, don’t take the drug. You can’t get addicted if you’re not taking it all the time, all around the clock,” he said. “But if you’re taking it every four or six hours, this is around-the-clock and you’re conditioning your brain — and that will lead to addiction.”
Fewer prescriptions
Narouze’s thoughts on opiates are becoming more common among doctors. Many hospitals — including Summa and the Cleveland Clinic — have established policies to encourage doctors to prescribe pills only when necessary.
Policies enacted by Akron General reduced the number of prescriptions written by 59 doctors in its Partners Physician Group by 21 percent in six months when compared to the year before.
Akron General’s Braman, the medical director for quality for the physicians group, said the hospital’s policy resulted from discussions about who’s most at risk of addiction.
Each patient fills out a 30-question survey asking them about family history of addiction and risk factors like depression and anxiety. In addition, patients are required to agree they won’t abuse their prescriptions and they’ll undergo drug screens when asked.
“But there are still a lot of people getting high-dose prescriptions,” Braman said. “One of my challenges as the chief medical officer is trying to monitor this for compliance.”
Nick Glunt can be reached at 330-996-3565 or nglunt@thebeaconjournal.com. Follow him on Twitter @NickGluntABJ.