Yes, Assessing Pain Is Vital

imageYes, Assessing Pain Is Vital

I wrote in a blog last year that efforts to roll back pain as the fifth vital sign are likely to gain traction, despite inaccuracies and flawed thinking. That is precisely what has happened. A recent Medpage Today article titled “Opioid Crisis: Scrap Pain as 5th Vital Sign?” lays out similar flawed arguments touted by Physicians for Responsible Opioid Prescribing (PROP). At press time, the American Medical Association had been petitioned by its Illinois delegates to remove pain’s fifth-vital-sign status.

What are these flawed arguments? One is to falsely equate the Joint Commission standard to assess pain with a mandate to prescribe opioids. If anyone believes that administering opioids is the sole and automatic response to managing high pain levels, that in itself demonstrates a lack of education, knowledge and understanding. Such a perceived mandate would be a terrible misapplication.

The problem is not the Joint Commission standard but what happens afterward. This is where the system is failing with inadequate education about assessing and managing pain. Clinicians should assess and treat underlying disorders that cause pain, and they should work to eliminate the pain, but they should also understand that, for some patients with some types of pain, eradicating all underlying causes or the pain itself may not be possible. Yet pain must be prioritized and addressed. To do otherwise puts patients at risk for a host of complications, the most serious of which is the progression to pain as a chronic destructive pathology.


So, is pain, after all, a vital sign? I have argued in the past that it is. But the main point is that assessing pain is indeed vital, whether or not pain is a vital sign. Furthermore, assessing pain as often as vital signs are assessed would seem appropriate. We assess cognitive function, reflexes and laboratory values, none of which are vital signs but are clinically important signs nevertheless. Pain is a symptom; however, it can become a disease when the nervous system changes as a result of it, as the 2011 report on pain in America from the Institute of Medicine, now the Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering, and Medicine, clearly indicates (“Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.” Washington, D.C.: National Academies Press; 2011). It is better to assess pain often and regularly and treat it adequately while it is still a symptom, and before it can progress to the point of disease, at which point it will demand chronic management, much like diabetes.

Another flawed argument is that we as health care professionals would not use dangerous methods to treat pain if only we could remain ignorant that the pain exists. Incredible as it seems, this is indeed the argument. In a letter dated March 28, 2016, the American College of Emergency Physicians (ACEP) wrote to the secretary of the Department of Health and Human Services to claim that asking patients about their pain care could lead to opioid overprescribing. The fear, also expressed by the members of PROP, is that patients who seek opioids will give poor marks to hospitals that do not provide the drugs, thus driving down financial reimbursement through the Centers for Medicare & Medicaid Services (CMS). Like PROP, the ACEP asked the department to remove questions pertaining to pain control from the 32-question survey known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).

But increased reimbursement for improved health care results in a hospital is appropriate, and CMS should not deviate from the objective of creating incentives for better outcomes, particularly quality of pain control. The HCAHPS questions pertain to how often pain was well controlled and whether hospital staff did everything possible to help control the pain. These are quality improvement measures, and pain control is an important part of quality improvement.

Rational, compassionate in-hospital pain treatment would be better informed by considering the following points:
Quality pain control is a critical outcome that must be measured.
Quality pain control does not dictate prescribing opioids.
Patients should be involved in assessing the quality of their care. Asking patients about their quality of pain control does not dictate inappropriate care. What evidence there is indicates that satisfaction scores do not correlate with prescribing quantities.
Writing unnecessary opioid prescriptions in pursuit of greater financial reward is unethical.
If scores indicate poor outcomes for pain control, this may be an incentive to learn more about how to treat pain.

The HMD report addressed evidence of poorly managed pain by calling for more comprehensive assessment, and this is the direction in which medicine should move. Health care providers have a professional and ethical obligation to assess and reassess the pain of their patients, not to decide that assessing pain levels should no longer be part of routine care because CMS ties a small part of hospital payments to patient evaluations of how well their pain was treated. Patients often demand unnecessary antibiotics, but ethical physicians must learn when and how to refuse them, informed by the ethics of good care, not maximum reimbursement. Ethical, informed clinicians do not prescribe unnecessary medication for the sole purpose of gaining a high patient satisfaction rating.

The drive to end pain control assessment appears to come from the belief that people with substance abuse problems will complain if a practitioner fails to give them the drugs they seek. Thus, ignorance is deemed a better alternative to appropriate clinical judgment. But supporting evidence for this belief is lacking, as a top CMS official recently wrote in JAMA (2016 Mar 10. [Epub ahead of print]): “It has been alleged that, in pursuit of better patient responses and higher reimbursement, HCAHPS compels clinicians to prescribe prescription opioids. However, there is no empirical evidence that failing to prescribe opioids lowers a hospital’s HCAHPS scores. … On the other hand, good nurse and physician communication are strongly associated with better HCAHPS scores.”

Advocates in favor of eliminating pain assessments are attempting to benefit patients and society at large. The principles that not all pain can be relieved and that opioids are not always the answer are good and deserve wider dissemination. But there is nothing in assessing the quality of pain relief or in patient satisfaction surveys that says opioids must be administered, and if such is automatically happening, then education on pain assessment needs improvement. Pain treatment has never been, nor should it ever be, synonymous with opioid therapy. In its zeal to eliminate problems with opioids, society must not dismiss pain, whether that pain is a symptom or a disease.

Sadly, because of today’s opioid crisis, many patients are being denied humane treatment of their pain. There is no rational argument that appropriate in-hospital pain control contributes to the opioid crisis in our communities. This attack on our most vulnerable patients must stop. The problem isn’t that we ask our patients too many bothersome (to the clinician) questions. Neither does the solution to the opioid crisis lie in denying the majority of patients compassionate pain control.

Lynn R. Webster, MD, is a past president of the American Academy of Pain Medicine and author of “The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us.” Visit He also is a member of the Pain Medicine News editorial advisory board. He lives in Salt Lake City.


Guilty by association ?

Former suspects sue over DEA raid

INDIANAPOLIS — Former employees of medical clinics in Central Indiana that were raided two years ago by the Drug Enforcement Administration filed a lawsuit Wednesday alleging unlawful arrest.

In July 2014, local police and federal agents with the DEA arrested doctors and staff affiliated with the Drug Opiate Recovery Network (DORN) on charges of selling prescription painkillers to their patients, calling the operation a pill mill.

The defendants have maintained their innocence and questioned the validity of the accusations. Charges have since been dismissed against nine of the 12 suspects — everyone but three doctors.

In the lawsuit filed in U.S. District Court in Indianapolis, the former DORN staff members are seeking unspecified monetary damages from drug agents, police agencies and cities involved in the arrest. The former employees are Cassy Bratcher, Carmel; Jessica Callahan, Muncie; Andrew Dollard, Noblesville; Eric Ley, Noblesville; Joeseph Mackey, Howard County; Yvonne Morgan, Eaton, Ohio; Felicia Reid, Carmel; and Derek Tislow, Avon.

Many of the staff members, the lawsuit says, lost jobs, spent significant savings on legal defenses and bail, and are no longer employable due to the criminal charges and subsequent publicity.

The lawsuit alleges that DEA agents Gary Whisenand and Dennis Wichern, Hamilton County Drug Task Force Maj. Aaron Deitz, the Carmel Police Department, the Hendricks County Sheriff’s Office, the Johnson County Sheriff’s Office, the Howard County Sheriff’s Department, the city of Kokomo and the town of Cumberland performed false arrests and took part in malicious prosecution, negligence and defamation.

Carmel, Johnson County and the DEA had no comment on ongoing litigation. None of the other defendants could be reached Wednesday.

The lawsuit, filed by attorney Jeffrey S. McQuary of the firm Brown, Tompkins, Lory & Mastrian, based in Indianapolis, alleges the employees were not responsible for prescribing medication and were merely performing their jobs.

The lawsuit claims that prior to being arrested and charged, the staff members were performing often mundane clinical duties such as answering the phone, scheduling appointments, ordering drug screens, processing patients and physically handing prescriptions to patients.

“The employees had no reason to believe the doctors had done anything wrong,” McQuary said. “I don’t think the doctors did anything wrong, but even assuming for a second that a doctor was prescribing medication outside of the legitimate scope for doing so, how on earth would the employees have known that?”

The lawsuit alleges that one suspect was told by a DEA agent she was arrested in hopes she would testify against the doctors. McQuary said using the staff members for leverage in the prosecution of the doctors might be only plausible explanation for the arrest of staff members.

The drug case has stalled since authorities in a multijurisdiction drug task force announced on July 25, 2014, that they had uncovered an extensive drug ring after a nine-month investigation.

In charging documents, authorities accused the doctors of illegally providing patients prescriptions for Suboxone, a synthetic heroin substitute, in exchange for cash.

At the time, authorities said thousands of patients streamed into the clinics, and consultations would take minutes or less. Patients paid up to $160 to obtain prescriptions, authorities said, and doctors pocketed hundreds of thousands of dollars in legal fees.

Dr. Larry Ley, the former head of the clinic, faces charges in Hamilton County. Prosecutors there also are pursing charges against Dr. Ronald Vierk. Howard County is pursuing charges against Dr. Luella Bangura and Ley. Wayne County is pursuing charges against Vierk and Ley. All have maintained their innocence as the cases have progressed.

Hamilton County and Wayne County courts, however, dismissed charges against the staff members, essentially ruling staff members could not be held legally responsible for the prescriptions written by doctors.

One of the cleared suspects, Dollard, had asked the Indiana Disciplinary Commission to investigate and ultimately disbar five prosecutors for their roles in what he called one of the most corrupt, dishonest and unethical prosecutions in the history of the state.

Dollard was DORN’s attorney. He also is a former candidate for Hamilton County Council.

The commission declined to discipline any of the prosecutors.

Dollard also has filed a civil lawsuit accusing Current Publishing in Carmel of defamation for its news reporting in relation to the drug raid. A trial has been scheduled for 2017.

CVS says it has tightened its policies and procedures to help its pharmacists determine whether a prescription is legitimate

CVS to pay $3.5M to settle allegations of forged prescriptions

Could this mean that more CVS Pharmacist “not being comfortable” filling controlled meds ?

BOSTON (AP) — CVS Pharmacy has agreed to pay $3.5 million to settle allegations that dozens of its Massachusetts pharmacies violated federal law by filling forged prescriptions for addictive painkillers and other controlled substances.

U.S. Attorney Carmen Ortiz announced the settlement with the Woonsocket, Rhode Island-based drugstore chain Thursday.

 CVS says it entered into the agreement to avoid the expense and uncertainty of further legal proceedings.
 Ortiz’s office says the settlement resolves two investigations by the Drug Enforcement Administration after reports of forged oxycodone prescriptions. One involved hundreds of forged prescriptions at 40 CVS stores in Massachusetts and New Hampshire. The other involved 120 forged prescriptions at 10 CVS stores in and around Boston.

CVS says it has tightened its policies and procedures to help its pharmacists determine whether a prescription is legitimate.

There is always a hidden agenda ?

connectthedotsDEA: Heroin-related deaths tripled in four years

It really doesn’t matter when big business is involved.. be it for profit, non profit or governmental… You often have to wonder if what you see is the reality of it all or if there is some hidden agenda. If there is a hidden agenda, no one will every really know… unless legalities are involved and someone ends up getting caught with their hand in the cookie jar.

I have posted before about our judicial system’s apparent “addiction/dependency” on the 51 billion dollars that flow into the judicial system annually to fund the war on drugs.

I have posted about the fact that 43 % of the members of Congress are attorneys (170 House, 60 Senate) and how it would seem that – in general – will not do anything that will deprive the judicial system of any funding.. including failing to acknowledging what everyone considers how big a failure the war on drugs is in reality.

Sometimes, parts of a agenda can be intentionally or unintentionally hidden or can appear to have no association with the agenda at all. This is what could be happening right now. All of a sudden over the last few months there has seemingly been a “bum’s rush” to get a dose or two of Naloxone in as many pockets as possible. There seems to be no limit to the times that a substance abuser should or should not be revived. I have reports of a single person being revived TEN TIMES in one day.

There was a recent DEA report that opiate OD deaths have TRIPLED in FOUR YEARS.. There has been reports that acetylfentanyl from Mexico and China have been added/mixed with Heroin and since acetylfentanyl is 25 -40 times more potent than Heroin.. and as a result many people are dying from a overdose.

There has also been reports for tablets showing up on the west coast .. looking like Narco 10 (Hydrocodone/Acetaminophen 10/325) but in reality it is acetylfentanyl from Mexico or China or some mixture of Heroin and acetylfentanyl.. and more people are dying… Also reported that there has been tablets that appear to be Xanax (Alprazolam ) 2mg showing up on the west coast of Florida but also containing acetylfentanyl and/or mixed with Heroin and again people are dying.

Since the Harrison Narcotic Act of 1914 there has been an estimated 1%-2% of our population abusing some substance other than Alcohol and Nicotine.. the population of the USA back then was around 100 million as opposed to 330 million today.. It is now estimated that there are some 1.9-2.1 million serious substance abusers.. percent of the population has dropped dramatically since 1914 < 0.7 % and with the increased deaths from the acetylfentanyl and Heroin.. is the DEA/judicial system frighten that the serious substance abuser population could be dwindling ?

Does this help explain the “bum’s rush” to get a dose or two of Naloxone in as many pockets as possible ? Could this explain the change in the mindset of the politicians/bureaucrats that substance abuse is a “mental health issue” ? Could this explain the change in the nomenclature .. no more addicts.. no more junkies…just people who take opiates for whatever reason – both legal & illegal – are now being labeled as having a “opiate use disorder” ? And we no longer have accidental/unintentional drug OD’s… now we have deaths that are just a “opiate related death”. Doesn’t matter if their is a lethal amount of opiates in the toxicology report… any amount showing is enough to classify the death as “opiate related”

Then there is the CDC guidelines… wanting no one taking opiates longer than 90 days… with the estimated 106 million chronic pain pts.. there are going to be untold numbers – perhaps millions – that will be forced to go to “the street” to seek whatever pain relief that they can get.

Then there are proposed rule changes that will raise the number of Suboxone pts that a single prescriber can manage at any one time from 100 to 500.

Is it just me… or does it look like all those parties that are addict to the “war on drugs” money… are laying the ground work to make sure that the “substance abusers population” at least stays the same and possibly grows ?

At least 26 U.S. Senators are still dedicated to marijuana prohibition.

cryingeyevoteTop 26 marijuana opponents in the U.S. Senate

12 Senate seats currently occupied by Senators that are “hard-headed” opposed to the legalization/decriminalization of MJ.. ARE UP FOR RE-ELECTION this fall !


At least 26 U.S. Senators are still dedicated to marijuana prohibition.

A fair amount of attention has been paid to presidential candidates’ positions on marijuana legalization this election cycle. However, United States Congress member stances have received far less coverage.

Considering Congress can amend federal marijuana laws and block executive action in many cases, their positions on marijuana and drug policy will play significantly into the outcomes of reform efforts.

Recognizing this, the National Organization for the Reform of Marijuana Laws (NORML) has gathered Congressional voting records and relevant member statements and compiled “Scorecards” that assign letter grades “A” through “F” to all Congress members.

Twenty-six serving U.S. Senators received failing grades from NORML this year.

“Guest Speaker, Ed Coghlan from the National Pain Report

!cid_logo“Guest Speaker, Ed Coghlan from the National Pain Report on Wednesday, June 29th, 2016 at 9:00 PM EDT

Live interview with Ed Coghlan from the National Pain Report on June 29th, 2016 at 9:00 PM EDT.

During this special event, we will be discussing a wide range of topics, followed by a question and answer segment where you will be able to ask questions directly to Ed.

Goto to register for the live webinar


Drug Users Need Treatment,’ Says President Obama. Not So Fast, Says Dr. Carl Hart

This confuses me… yes to decriminalize/legalize all drugs/medications… allow prescribers to treat/maintain all people who need or abuse opiates.. provide pharmaceutical grade medications… Where do you draw the line between “education” and “talk therapy” or is there a “line “?

“For too long we’ve viewed drug addiction through the lens of criminal justice,” President Obama said yesterday at a conference in Atlanta. “The most important thing to do is reduce demand. And the only way to do that is to provide treatment—to see it as a public health problem and not a criminal problem.”

At least one expert totally disagrees. Earlier this month at South by Southwest Interactive (SXSWi), Columbia University neuropsychopharamacologist Carl Hart gave a talk called “Mythbusting the Drug War With Science” in which he explicitly made the case that the notion that “drug addiction is a health problem that requires treatment” is exactly the wrong way to look at the use of drugs in the United States.

“Politicians today, whether Republican or Democrat, are comfortable with saying that we don’t want to send people to jail for drugs; we will offer them treatment.” Hart said in Austin. But “the vast majority of people don’t need treatment. We need better public education, and more realistic education. And we’re not getting that.”

Why does he say most people don’t need treatment? Because—contrary to widespread perceptions—the vast majority of drug users aren’t addicts. “When I say drug abuse and drug addiction, I’m thinking of people whose psycho-social functioning is disrupted,” he said later in the talk. But for more than three-quarters of drug users (and we’re not just talking about marijuana here, either), that description doesn’t apply.

This overturns the conventional wisdom on drug addiction, but Hart thinks that’s a good thing. We’ve all been fed a diet of panic-inducing misinformation about what drugs actually do to our brains, he says.

Most of us were taught that drugs like cocaine are so addictive that a rat in a laboratory experiment will continue to press a lever to receive the substance—to the exclusion of all its other physical needs—until it actually dies. Hart said at first even he believed that finding to be true. But it turns out, those studies weren’t what they were cracked up to be.

“When you have the rat in a cage alone, and there’s nothing else for the rat to do, the rat will repeatedly choose to take cocaine,” he said. “That’s logical. If the only thing you had to do in your life was press a lever to receive cocaine, what are you doing? I hope you’re pressing for the cocaine.”

But if additional stimuli are introduced to the environment, the finding completely falls apart.

“When you enrich the rat’s environment such that you provide something like a sweet drink, or a sexually receptive mate, or some other alternative, the rat doesn’t repeatedly take cocaine,” he explained. “In fact, it’s difficult to get the rat to self-administer or press the lever to take cocaine if you provide the rat with food!”

When he tried to replicate the experiment with drug-addicted humans instead of rats, he found they too behaved logically, choosing, say, $20 in cash as opposed to a $10 hit of coke. “This ‘hijacking’ of the brain’s reward system, that’s a nice sexy metaphor,” he said. “But what we said was that cocaine addicts could not inhibit certain types of responses. They could not delay gratification. They had cognitive impairment such that they couldn’t engage in this long-term planning.” Yet repeatedly in tests, they did.

Once you realize that drugs don’t actually rewire people’s brains, making them unable to function, you can start to focus on things that matter more—like preventing overdoses. The way to do that, according to Hart, is through educational initiatives, not treatment programs.

“Now, if we are concerned about overdose deaths, we need to know how these people are dying,” he said. “The vast majority [75 percent] of people who die from a heroin-related overdose do so because they combine it with another sedative, like alcohol or benzodiazepines….The public health education message is simple: If you’re going to use heroin or another opioid, don’t combine it with another sedative.”

The message should obviously vary according to the substance in question and the population you’re trying to educate. When talking to young people about marijuana, for instance, we should teach them not to start out with large doses. “And if you do and you get anxious, be cool,” he said. “You’re going to be OK!”

The main problem with methamphetamines, meanwhile, is that they disrupt people’s sleep and reduce their food intake. “Sleep is probably the most important biological function. If you don’t get enough sleep, you can get psychiatric illnesses and all types of different illnesses,” he said. “So when I think about education with methamphetamines, you want to make sure people are sleeping. You want to make sure people are eating. You also want to make sure people understand the risks in terms of cardiovascular concerns: If you have a cardiovascular-compromised system, it’s probably not the drug for you.”

These are all examples of harm reduction, something Hart believes we need a whole lot more of. “We can help keep people safe,” he said. “We haven’t made much progress in this regard, but we’re pretending that we are more compassionate people…by saying that we’ll give them treatment.”



DEA: Heroin-related deaths tripled in four years

DEA: Heroin-related deaths tripled in four years

Maybe it is just a coincidence but Obama came to power in 2008 and Gov Scott & AG Bondi came to power in 2010… legal opiate Rxs peaked in 2012.. and the DEA has had an increasing war on prescribers/pts over the last 6 -7 yrs. There has been more Heroin deaths in the last FOUR YEARS than in the previous TWELVE YEARS. Maybe if we had a national policy to give proper treatment to those suffering from the mental health issue of addictive personality disorder we would have prevented tens of thousands unnecessary/preventable deaths. Over those four years we would have spend > 200 BILLION dollars fighting the war on drugs. Should Congress consider defunding the DEA’S war on drugs… if you believe this statistic … their failure is accelerating … do they even deserve a grade of F- ?

WASHINGTON – A new report from the U.S. Drug Enforcement Agency analyzing the nation’s ongoing heroin use health crisis says deaths involving heroin tripled between 2010 and 2014.

Other key facts in the report include:

– The number of people reporting current heroin use nearly tripled between 2007 (161,000) and 2014 (435,000).
– Deaths due to synthetic opioids, such as fentanyl and its analogues, increased 79 percent from 2013 to 2014.

The DEA was especially concerned about the recent phenomenon of fentanyl disguised as prescription opiate pills. The pills have been connected to the deaths of 19 people in Florida and California during 2016’s first quarter. Traffickers are exploiting high consumer demand for illicit prescription painkillers by producing inexpensive counterfeits that contain the highly potent fentanyl. In Baton Rouge, one man was convicted of pressing heroin into counterfeit prescription pill form in a similar profit-driven drug trafficking move.

“We tend to overuse words such as ‘unprecedented’ and ‘horrific,’ but the death and destruction connected to heroin and opioids is indeed unprecedented and horrific,” said DEA Acting Administrator Chuck Rosenberg. “The problem is enormous and growing, and all of our citizens need to wake up to these facts.”

The DEA says the number of users, treatment admissions, overdose deaths and seizures related to the drugs increased over last year’s summary. Heroin was the greatest drug threat reported by 45 percent (up from 38 percent last year and 7 percent in 2007) of state, local and tribal law enforcement agencies that responded to a 2016 survey. Law enforcement agencies across the country reported seizing larger than usual quantities of heroin in 2016. An 80 percent increase of heroin seizures has been reported over the past five years.

The entire 2016 National Heroin Threat Assessment Summary can be viewed online.