The Opioid Epidemic: What Was the Joint Commission’s Role?

The Opioid Epidemic: What Was the Joint Commission’s Role?
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Skeptical Scalpel

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 and tweets as @SkepticScalpel.


Skeptical Scalpel (click to view)

Skeptical Scalpel

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 and tweets as @SkepticScalpel.

"This set the tone for clinicians—patients are always to be trusted to report pain accurately."
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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 and tweets as @SkepticScalpel.


  1. Biggest problem is press ganey. Medicine is consultant work not customer service.

  2. Let’s not forget the pharmaceutical companies that are producing many times the number of opiate pills required by clinical practice. Who is buying them in bulk? Where are they going? How do they “leak” from the legitimate supply chain to the street market? Is it all “bad docs” in pill mills? I doubt it. Are they coming over our borders? Haven’t heard of it. Blame it on the Chinese? Come on. Hijacked shipments? Not on this scale. Busting low level dealers and users won’t put a dent in it.

    Efforts to curb the abuse need to look at the source of these “prescription pain killers”. If a bar tender can be held accountable for a car crash after serving an inebriated customer, why do the drug companies get away with supplying the massive illicit market – whether willingly or not? Where is their accountability?

  3. When physicians experience an unintended or adverse outcome or “sentinel event” the Joint Commission insists we perform a “root cause analysis” involving anyone who had any involvement, even peripheral, with that outcome. We are told to look deeply and transparently into systems, knowledge, behavior, equipment and protocols to fully understand the chain of events that lead to the undesired outcome. The fact that the Joint Commission has not engaged in a similar far reaching self examination to fully understand how that body may have contributed to a national iatrogenic epidemic that has brought death and misery to so many, is breathtaking in its hypocrisy. Any health care organization that reacted in such manner would be placed on probation, at a minimum, with a plan for remediation. I suggest the same for the Joint Commission.

    • Thank you for your comment. I agree 100%. Instead of owning up to their role, they deny any responsibility.

  4. Correction: I switched back and forth between number of overdose deaths per 100,000 Rxs and number of Rxs per overdose death above.

    The third paragraph should have ended with the sentence “Methadone is associated with 250 deaths per 100,000 prescriptions, oxycodone with about 15 per 100,000 Rxs, and hydrocodone with about 3.

    • My point was that the Joint Commission is not as innocent as it proclaimed. No one is hesitating to blame the doctors for this problem. I agree that we have some responsibility too, but we were pressured by entities such as the Joint Commission and its collaboration with the drug companies on the document I described in my post.

  5. I think the problem with the whole discussion is the assumption that the “Prescription drug overdose epidemic” is all about pain patients who innocently become addicted, then overdose and die.

    As outlined by Maia Szalavitz in a recent Scientific American Blog post ( ), 75% of all opioid misuse starts with people using drugs that were not prescribed to them. Multiple reviews, including a Cochrane meta analysis, found that the rate of addiction among those using pain medications per medical advice were 12% or below. Some found rates as low as 1 or 2%.

    The CDC reports that nearly half of the growth in overdose deaths over the last two decades can be attributed to a single drug, methadone, which has been recommended as first line therapy for pain patients by many Medicaid programs in spite of an idiosyncratic pharmacokinetic profile that leads patients to accidently overdose and die. Utah Department of Health data shows that Methadone is associated with one overdose death for every 400 prescriptions, vs about 15 for oxycodone and 2 -3 for hydrocodone. (

    Roughly half of the overdose deaths attributed to prescription painkillers are due to the poor pharmacokinetic properties of one exceptionally dangerous generic drug. Among the other half, as much as 75% may be completely attributable to recreational use of stolen drugs. Cocaine deaths doubled from 3000 in 1999 to 6000 in 2006 without a single Rx for cocaine being written.

    This is a complex problem, and simplistic solutions have consistently failed to date. Rather than pointing fingers at who is to blame for increased prescribing that may or may not be a root cause of the problem, we need to understand who is overdosing, the path that leads them there, and objectively assess where the best opportunities for intervention lie.


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