Last month the Joint Commission issued a statement written by its Executive VP for Healthcare Quality Evaluation Dr. David W. Baker explaining why it was not to blame for the opioid epidemic. If you haven’t already read it, you should. Here is the first paragraph of that document:
“In the environment of today’s prescription opioid epidemic, everyone is looking for someone to blame. Often, The Joint Commission’s pain standards take that blame. We are encouraging our critics to look at our exact standards, along with the historical context of our standards, to fully understand what our accredited organizations are required to do with regard to pain.”
With the help of an anonymous colleague, I looked at some of the historical context.
In December 2001, the Joint Commission and the National Pharmaceutical Council (founded in 1953 and supported by the nation’s major research-based biopharmaceutical companies) combined to issue a 101-page monograph entitled “Pain: Current understanding of assessment, management, and treatments.”
Here in italics are some excerpts from it. My emphasis is added in bold.
Page 4: In 1968, McCaffery defined pain as “whatever the experiencing person says it is, existing whenever s/he says it does. This definition emphasizes that pain is a subjective experience with no objective measures. It also stresses that the patient, not clinician, is the authority on the pain and that his or her self-report is the most reliable indicator of pain.
This set the tone for clinicians—i.e., patients are always to be trusted to report pain accurately.
Page 16: For example, some clinicians incorrectly assume that exposure to an addictive drug usually results in addiction. Table 6: Common misconceptions about pain: Use of opioids in patients with pain will cause them to become addicted. Page 17: In general, patients in pain do not become addicted to opioids. Although the actual risk of addiction is unknown, it is thought to be quite low.
We now know that everything in the paragraph above is untrue.
Page 38: Long-acting and sustained-release opioids are useful for patients with continuous pain, as they lessen the severity of end-of-dose pain and often allow the patient to sleep through the night. Page 67: Table 38. Administer opioids primarily via oral or transdermal routes, using long-acting medications when possible.
We now know that long-acting pain medications often do not last as long as they are supposed to, and the use of long-acting drugs may create more addicts.
The recent Joint Commission statement says it never endorsed the concept of pain as a vital sign. While an explicit endorsement of pain as the 5th vital sign is not contained in the JC/NPC monograph, it is mentioned five times.
Page 21: In 1996, the American Pain Society introduced the phrase “pain as the 5th vital sign.” This initiative emphasizes that pain assessment is as important as assessment of the standard four vital signs and that clinicians need to take action when patients report pain. Page 29: Reassessing pain with each evaluation of the vital signs (i.e., as a fifth vital sign) is useful in some clinical settings. Routine screening for pain with a pain rating scale provides a useful means of detecting unidentified or unrelieved pain.
I read these as strong recommendations to assess pain levels frequently in conjunction with the standard vital signs.
Dr. Baker alleges another misconception about the Joint Commission is that it said pain must be assessed for all patients. He wrote, “The original pain standards stated ‘Pain is assessed in all patients.’ This requirement was eliminated in 2009 from all programs except Behavioral Health Care Accreditation.”
Therefore, “pain is assessed in all patients” was a standard that existed for almost the entire first decade of this century, a time when opioid deaths were increasing with each passing year.
The Joint Commission deserves at least some of the blame for the opioid crisis.
And how about that cozy Joint Commission-National Pharmaceutical Council relationship?
Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and critical care and has re-certified in both several times. He blogs at SkepticalScalpel.blogspot.com and tweets as @SkepticScalpel.