the unintended consequences were, in retrospect, predictable

JAMA just published an article on the history of the Joint Commission standards on pain and the lessons learned from the opioid crisis that followed.

The article describes the impetus for the increased attention to pain.

In 1990, Max² decried the lack of improvement in pain assessment and treatment over the previous 20 years and called for a different approach that included the following: make pain “visible”; give physicians and nurses bedside tools to guide use of analgesics; ensure patients a place in the communications loop; increase clinician accountability by developing quality assurance guidelines; improve care systems; assess patient satisfaction; and work with narcotics control authorities to encourage therapeutic opiate use. Max reiterated the conventional wisdom of the day that “therapeutic use of opiate analgesics rarely results in addiction,”² although this was based on a single publication from 1980 that lacked detail about the study methods.³

In 2000, The Joint Commission introduced standards for pain management and began referring to pain as “the fifth vital sign.”

However . . .

The Joint Commission standards raised concerns that requiring all patients to be screened for the presence of pain and raising pain treatment to a patients’ rights issue could lead to overreliance on opioids.

What were the real world consequences?

Signals appeared suggesting that some clinicians had become overzealous in treating pain. In a 2003 survey of 250 adults who had undergone surgical procedures, almost 90% of patients reported they were satisfied with their pain medications. Nevertheless, the authors concluded that “many patients continue to experience intense pain after surgery”7 and “[a]dditional efforts are required to improve patients’ postoperative pain experience.”7 Health care organizations implemented treatment policies and algorithms based on patients’ responses to numerical pain scales. Concerns about this practice increased after a report that the incidence of opioid oversedation increased from 11.0 to 24.5 per 100 000 inpatient hospital days after the hospitals implemented a numerical pain treatment algorithm.8 The ISMP linked overaggressive pain management to a substantial increase in oversedation and fatal respiratory depression events.

Is that a little too jargon-ey for you? How about this?

Here are their lessons learned:

Several conclusions from this history could serve as lessons for addressing the current prescription opioid epidemic. First, engage all stakeholders when creating standards and not just those who passionately favor action. Advocates may be less able to see the possible unintended consequences than other stakeholders. . . .

Second, try to anticipate unintended consequences and have monitoring programs in place from the start. Many of the unintended consequences of The Joint Commission standards were, in retrospect, predictable, and the need for changes may have been identified earlier if there had been prospective monitoring of adverse consequences. . . .

Third, pay close attention to what programs and procedures organizations implement to meet new requirements. For example, the algorithms organizations used to guide treatment based on numerical pain scores should have immediately raised concern. . . .

Finally, they share a lesson that I emphasize over and over about addiction treatment research.

Fourth, carefully review the primary literature on issues of critical importance and do not simply repeat the claims of experts in previous articles. The 1980 letter to the editor by Porter and Jick3 suggesting that addiction is rare in patients treated with narcotics has been cited almost 1000 times. Yet the report is so brief, methodologically vague, and unlikely to be generalizable to recent medical practice that its finding should never have been disseminated without cautionary notes and calls for research.

The article does close with a worthwhile reminder.

Concerns about unintended consequences should not serve as a deterrent from pursuing “noble” goals.

We should work hard to not pit the problems of pain patients and people with addict against each other.

We can attentively and compassionately treat pain and be mindful of the limitations and risks of the drugs involved for the patient and the community.