ORLANDO, Florida — Physicians at the American Academy of Family Physicians (AAFP) 2016 Congress of Delegates voted this week to eliminate pain scores as the "fifth vital sign," partly in reaction to being seen as a scapegoat for the nation's opioid overdose epidemic.

Even Tom Frieden, MD, MPH, director of the Centers for Disease Control and Prevention, has called the epidemic "doctor-driven." But physicians in many specialties have explained that they feel pressure to overprescribe opioids, and do so to attain higher patient-satisfaction scores for themselves and their hospitals.

The fifth vital sign came into vogue several decades ago, when pain was more likely to be undertreated than overtreated. Many physicians blame the pharmaceutical industry for promoting opioid painkillers as a way to bring pain scores down.

When delegates discussed the resolution to drop pain as the fifth vital sign during a committee meeting the day before the vote, the outcome seemed to be a foregone conclusion. And as soon as the title of the resolution was announced, several hundred delegates in the room clapped and cheered.

This is a subjective measure put in an objective category.

"This is a subjective measure put in an objective category," said Mitzi Rubin, MD, president of the Georgia Academy of Family Physicians and a supporter of the resolution. One person might rate a pin prick 4 on a 10-point pain scale, whereas another might rate an identical prick 8.

And a patient who believes a physician did not do enough to lower his or her pain score has ways to get even, Dr Rubin pointed out. "There's plenty of room for patient dissatisfaction on the web," she said. "They can bash us on social media when we actually give very good care."

"No one is suggesting that controlling pain is unimportant," said Matt Burke, MD, from Virginia. However, the importance given to pain scores "is an uncomfortable distraction and promotes inappropriate patient expectations," he explained.

Several physicians pointed out that it makes more sense to measure functional status than pain. Can a patient work, walk, or take a bath without any assistance? One speaker recommended the Physical Functional Ability Questionnaire (FAQ5) as a measurement tool.

Cries of Pain Are Getting Some Results

The AAFP is not the first medical society to take a stance against the fifth vital sign. The House of Delegates of the American Medical Association did so a few months ago.

Cries of pain from organized medicine appear to be getting results. Consider, for example, the 32-question Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which is a controversial patient-satisfaction survey from the Centers for Medicare & Medicaid Services (CMS). HCAHPS is completed by patients after a hospital discharge. The first of three questions on pain management asks patients if they needed medicine for their pain. Critics of the HCAHPS argue that this wrongly equates pain management with the prescription of a painkiller.

The HCAHPS score is factored in when the CMS, using its hospital value-based purchasing (VBP) program, determines how much it should pay a hospital. This means there is a financial incentive for hospitals to achieve high marks from patients on the pain questions.

New and improved pain-management questions in development will "remove any potential ambiguity" about the survey, CMS reported in July. And to eliminate the financial pressure to overprescribe pain meds, the current pain questions will cease to be part of VBP calculations in 2018.

CMS has issued a warning to hospitals not to misuse HCAHPS data to evaluate or pay individual clinicians, on the basis of what it has heard from the field. Those practices are some of the very things that spurred AAFP delegates to vote for the end of the fifth vital sign.

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