Dr. James Campbell addressed the American Pain Society in 1995, declaring that pain should be the fifth vital sign. This was soon adopted by the Veterans Administration and other regulatory agencies and became commonplace in hospitals and doctors’ offices. Hospital quality metrics were tied to improving compliance with measuring and treating pain.
A second front in the pain management dilemma was patient satisfaction surveys, which Press Ganey is well known. Governmental agencies collected and used patient satisfaction with hospital care and pain to assess compliance with pain control initiatives and eventually were tied to reimbursement levels. This was an incentive to improve the patient surveys, and one way was to increase pain treatment or at least the metrics being studied. This incentivized doctors to use and prescribe more opioids for pain.
When I went to medical school and residency, Fentanyl was limited to anesthesia and some cancer patients. Emergency department use was unknown or discouraged in the 1980s. In the 1990s, the new Emergency residents were taught to treat pain aggressively. Unfortunately, parenteral Fentanyl, 70-100 times more potent than morphine, was used in this and other settings and quickly became commonplace to treat pain. As Fentanyl became incorporated into mainstream medicine, different formulations, patches, lollipops, aerosols, and others became available. This widespread use may have contributed to the popularity of Fentanyl as a drug of abuse. Fentanyl has not been approved or manufactured as a pill or tablet, to my knowledge, in the U.S.
The argument can be made that the rise of the fifth vital sign of pain coincides with the increase in the abuse of opioids. This can also be correlated with regulations implemented to help treat pain more effectively, but with the unintended consequence of promoting the use of opioids.
