In medical school I learned to record four vital signs to assess my patients: blood pressure, heart rate, respiratory rate and temperature. Later, health regulators required the measurement of a “fifth vital sign” to determine pain. Patients were asked to rate their pain on a scale from 1 to 10. Once we knew the pain level, we treated the pain, often with opioids. This caused problems because pain is not a vital sign, pain is a symptom.
Pain cannot be objectively measured; any measurement is inherently unreliable. For example, a 91-year-old grandma may rate her pain a 4 out of 10, yet visibly be in severe pain. In the next room a burly lumberjack who is resting quietly may also rate his pain 4 out of 10. Are both patients in the same amount of pain? Do both patients need opioids? No, not necessarily.
The “fifth vital sign” was based on good intentions. However, the consequences of using this method as the treatment indicator led to the overprescribing of opioids, and their excessive availability and misuse.
Because of the widespread use of the pain scale, we have a rapidly growing opioid crisis that is especially bad in Utah. In 2015 Utah ranked second in the nation for overdose deaths due to prescription opioids. In 2016 almost 17,000 people died from overdoses of prescribed opioid medication in the United States. Current data from the CDC show that 115 Americans die every single day from a prescribed or an illicit opioid overdose. That is roughly the same number of deaths per year in the United States as breast cancer.
Many health care organizations in Utah are working hard to lower the morbidity and mortality caused by improper opioid use. They are promoting public awareness, physician education programs and better treatment options for opioid addiction. These steps are helpful and long overdue, but they are not enough.
One vital piece to solving the opioid crisis is missing. We must prevent the need for opioids at the very onset of pain. Often the need for opioids arises in the hospital after a medical procedure or surgery. In order to prevent the overexposure to opioids, non-opioid pain management options must be the initial therapy. Once those methods have been exhausted, opioids should then be considered to help manage pain.
Prevention is the key to controlling opioid misuse, addiction, tolerance and abuse. Benjamin Franklin stated, “An ounce of prevention is worth a pound of cure.” If we can prevent the use of opioids during the peri-operative period, then we will see fewer cases of acute pain converting to debilitating chronic pain.
Anesthesiologists are in a unique position to help prevent opioid addiction and tolerance. We use proven methods like multimodal analgesia protocols and regional anesthesia techniques that reduce the need for opioid use during surgery and for several days afterward.
Regional anesthesia techniques like peripheral nerve blocks, epidurals and spinals can numb specific areas of the body for up to five days, sharply reducing and often eliminating the need for opioids after major surgery. So instead of treating the entire body with opioids, anesthesiologists focus specifically on numbing the part of the body that hurts.
The time is long overdue for the medical community and the public to be proactive when it comes to opioids and their devastating side effects. I call on the Utah Legislature, the medical societies, physicians and health care systems throughout the state to promote regional anesthesia techniques to lessen the need for opioids. We need to limit the overprescribing of opioids by physicians and properly care for the opioid medications in our homes. If we don’t employ these measures, the problem of opioid-related deaths will continue to affect society for generations to come.
Reed Y. Nelson, M.D.
Reed Y. Nelson, M.D., St. George, is director of acute pain service at Dixie Regional Medical Center.