The fifth vital sign: Has this concept gone too far?

Is the overwhelming problem of too many opioid and narcotic pain prescriptions related to the identification of ‘pain’ as the ‘fifth vital sign’?  Was the intention for the designation, the ‘fifth vital sign’, an expectation that individuals would be pain free during hospital stays, eg, after a surgical procedure, or after visiting ambulatory centers for an injury? While there is a definite need to manage pain, we must ask the question: Has the pendulum swung too far to the left making opioid pain prescriptions the treatment of choice for care rather than other non-prescription measures? Indeed, post-operative pain must be managed, but should anyone expect to be completely pain free postoperatively? That is not a realistic expectation. The nature of a surgical procedure alone, results in post-operative discomfort. However, have we mislabeled this expected discomfort, as pain, that can only be managed with opioid prescriptions?

Codeine continues to be prescribed despite Black Box warnings

The Clinical Brief by Ms. Zimlich, entitled, Children still prescribed postop codeine despite warnings, discusses a study published in Pediatrics, by authors Chua, Shrime, and Conti (2017) who investigated prescribing practices for tonsillectomy postoperative pain management. The study revealed, that despite US Food and Drug Administration Black Box warnings against administration of codeine in children aged younger than 12 years, 5% of the children received a prescription for codeine. Chua et al. proposed considering alternative treatments for pain management including over-the-counter medications and alternative noncodeine agents. 

Discomfort versus Pain

A major role of nurses and all healthcare providers is to discuss the ‘discomforts’ that are expected during the post-operative period. Perhaps we need to do a better job communicating with children and their families about what to expect and ways to manage discomforts associated with, not only postop procedures, but in everyday life events. How many children see their parents taking pills on a regular basis for a headache, backache, and minor injuries?  From a child’s viewpoint, if it is acceptable for the parent, then it must be acceptable for the child to take medications for anything identified as pain.

Pain assessment

As pediatric nurses, we use pediatric pain assessment tools to assess the degree of pain a child or adolescent is experiencing and make decisions for administering pain medications based on the results of the assessment. Have we continued this practice as nurse practitioners? It makes sense to do so. Think alternative treatments first. Ice is a friend. Ice reduces inflammation, bleeding, and discomforts (pain). Ice collars work very well for children and adolescents during the tonsillectomy postoperative period. Distraction therapy also works well for children.  Evidence-based complementary therapies also should be considered for management of discomforts and pain eg, tens, massage therapy.

Treatment plans without prescription pain medications

In my first year as a pediatric nurse practitioner, a physician and I were seeing an adolescent together who presented with dysmenorrhea. She was requesting pain medication and a note to stay home from school 2 to 3 days each month. While speaking together with the adolescent, I quickly realized that the physician and I had absolutely different viewpoints on managing adolescents presenting with this complaint. He was empathic and spoke kindly to her and left the room in about 3 minutes. I assumed he left the room so I could speak privately with her about menstruation and dysmenorrhea. I discussed recognizing her pre-symptoms, managing these symptoms without medications, and the value of attending school regularly. We agreed on a plan and she was to return to the office following her next menstrual cycle, for a re-evaluation of the treatment plan. As I was leaving the room, I noticed that the physician had written a note on the paper chart (those were the days!) and left a prescription for a narcotic. Later in the day, I mentioned to the physician my plan for the adolescent. I left the prescription on her chart as she had expressed an interest in trying my plan which did not include pain medication, now that she knew what to expect each month, what was within the norm of menstrual pain, management strategies, and healthcare providers who were just a phone call away, if the plan was not working and needed some ‘tweaking’. The outcome for this adolescent was very positive. She did not need or ask for pain medication, made some lifestyle changes including no more absences from school, and was comfortable with the idea of having someone available to talk with, if needed.

Quality improvement to the rescue

Chau et al. (2017) recommended quality improvements leaders take an active role in efforts to eliminate inappropriate use of codeine [and all opioids] during the postoperative period. I could not agree more!