1/5/2024 0 Comments Pdf signer googlThe net effect has been a serious deficit in clinical skills for the evaluation and management of the patient in pain. Pain education starting in medical school and through post-graduate training usually involves piecemeal incorporation of pain topics into existing curricula or clinical rotations, without devoted stand-alone class-time. Many clinicians do not know what the appropriate response is because they lack adequate education in the approach, examination, and management of patients in pain and do not know that prescribing opioids may be an incomplete response. Guided by pain as the 5 th vital sign mandates, patients report pain and expect their providers to respond. Why would clinician opioid prescriptions increase so significantly? Guided by the Hippocratic Oath, the intention is to do good, not harm. 3 This significant increase has been associated with serious consequences including an estimated 40 deaths per day due to prescription opioids. Dispensing opioids has almost doubled according to National Health and Nutrition Examination Survey data showing that from 1988–1994, 3.2 percent of Americans reported using opioids for pain while from 2005–2008, 5.7 percent reported use. This has led to an increase in opioid medication prescribing when acetaminophen and NSAIDS fail. How may clinicians have responded to the information they see at every patient encounter regarding the presence of pain? Having the knowledge that their patients are in pain, would often prompt clinicians to react with a response to treat the pain. In all inpatient settings, pain scores are used as a quality measure especially in Hospital Consumer Assessment of Healthcare Providers reports. Given the influence of both of these organizations it is not surprising that clinics and hospitals across the country now assess pain routinely. 2 JCAHO recommended that pain be assessed in all patients (JCAHO Standard PE1.4, 2000). The VHA created an extensive tool kit to implement pain assessment and management in all their patients. This idea rapidly caught on nationally and has been adopted by the Veterans Health Administration (VHA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, now called simply The Joint Commission). 1 By elevating it to the level of essential information he hoped it would be properly evaluated and managed. James Campbell in his 1995 Presidential Address to the American Pain Society, presented the idea of evaluating pain as a vital sign. With the concern for the under management of pain, Dr. INTRODUCTION OF PAIN AS THE 5 TH VITAL SIGN AND CLINICIAN RESPONSE Attention must move beyond the focus of pain as a 5 th vital sign to a focus on education and training in the evaluation, examination, and management of the patient’s pain report. Expanding pain education and training is critical to remedying these problems. Pain evaluation and management is further complicated in the older adult who requires a different approach to take into account comorbidities, including dementia, and increased adverse consequences of prescription medications. This is likely to result in a suboptimal patient response, especially when managing chronic pain. When both patients and clinicians view pain as purely a sensory experience then management is necessarily limited to managing the sensation (and the increased prescription of pain medications). Pain education starting in medical school and through postgraduate training usually involves piecemeal incorporation of pain topics into existing curricula or clinical rotations, without devoted stand-alone class-time. Many clinicians do not know what the appropriate response is because they lack adequate education in the approach, examination, and management of patients in pain. Associated with the national push to adequately manage patients in pain has been a rise in prescription opioids as well as a rise in opioid related death. It has also had some serious consequences which were never intended. In clinical practice pain as the 5 th vital sign has proven to be more complex to assess, evaluate, and manage than originally anticipated.
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