495366

research-article2013

FAIXXX10.1177/1071100713495366Foot & Ankle InternationalPinzur

FootForum Foot & Ankle International 34(11) 1605 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100713495366 fai.sagepub.com

The Fifth Vital Sign Michael S. Pinzur, MD1

A December 16, 2012, article in the Wall Street Journal highlighted a growing epidemic in the United States caused by our misdirected attempt to provide comfort to patients. In the mid-1980s, several prominent “paid” experts promoted expansion of the use of opioid drugs for the treatment of both acute and chronic pain. These experts claimed that the risk of addiction was less than 1%. The American Pain Society led the charge to make pain the “fifth vital sign.” It became mandated that we evaluate and document VAS (visual analogue scale) scores during every patient encounter. The use of opioids increased during the 1990s. An anesthesia subspecialty of perioperative pain management evolved. This led to an increase in the use of regional anesthesia, but also an increased use of opioids in the perioperative period. This practice coincided with the expansion of ambulatory surgery. Our anesthesia colleagues were often convinced that the use of opioids was necessary to move previously inpatient surgeries to the ambulatory surgery suite. Fast-forward to the present. Opioids are now responsible for more than 16 500 deaths per year in the United States.1 Over the past few years, it has been learned that many of these investigations were, at best, biased, or, at worst, simply fraudulent. Not surprisingly, many of the leading experts in the burgeoning field of pain management were highly pain consultants from many of the companies selling these very profitable expensive drugs.2,3 Acute pain is currently a presenting symptom in as high as 80% of physician visits. Chronic pain affects over 76 million Americans. The total cost to our economy is over $100 billion. The Hand and Foot Working Group of the recent American Academy of Orthopaedic Surgeons Patient Safety Summit has been charged with developing data to better understand our current prescribing practices and develop guidelines on “responsible prescribing of opioid drugs.” Parallel with the development of this pain management quandary is the “grading” of our care either in the hospital or in the office, based on patient satisfaction surveys. Going forward, reimbursement for either physician or hospital

services may well be rewarded or penalized, based on the patient satisfaction “grades” that we receive. None of us would argue that it is our responsibility to provide compassionate pain relief during the perioperative period. Many of the patients that seek our help simply want relief of pain. At the same time, none of us wish to create opioid dependence or other morbidity associated with overutilization of narcotic drugs. This quandary is evolving into one of our greatest challenges. We somehow need to find the appropriate balance between compassionate care and the creation of drug dependence. What is the appropriate balance? The FootForum is interested in your views on this difficult topic. To voice your opinion, or to provide insight, please contact the FootForum at [email protected]. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References 1.  Catan T, Perez E. The money and influence behind “pain as the fifth vital sign.” Wall Street Journal. December 16, 2012. 2. Lynch M. Pain as the fifth vital sign. J Interven Nurs. 2001;24:85-94. 3. Walid MS, Donahue SN, Darmohray DM, Hyer LA Jr, Robinson JS Jr. The fifth vital sign—what does it mean? Pain Pract. 2008;8:417-422.

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Loyola University Health System, Maywood, IL, USA

Corresponding Author: Michael S. Pinzur, MD, Loyola University Health System, Orthopaedic Surgery, 2160 South First Ave, Maywood, IL 60153, USA. Email: [email protected]

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The fifth vital sign.

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