No need for pain

A Comprehensive Assessment of The Eight Vital Signs

The term “vital sign” has been assigned to various phenomena with the presumptive intent to emphasize their importance in health care resulting in the emergence of eight vital signs with multiple designations and overlapping terms. This review developed a case definition for vital signs and identified and described the fifth through eighth vital signs. PubMed/Medline, Google and biographical databases were searched using the individual Medical Subject Headings (MeSH) terms, vital sign and fifth, vital sign and sixth, vital sign and seventh, and vital sign eighth. The search was limited to human clinical studies written in English literature from 1957 up until November 30, 2021. Excluded were articles containing the term vital sign if used alone without the qualifier fifth, sixth, seventh, or eighth or about temperature, blood pressure, pulse, and respiratory rate. One hundred ninety-six articles (122 for the fifth vital sign, 71 for the sixth vital sign, two for the seventh vital sign, and one for the eighth vital sign) constituted the final dataset. The vital signs consisted of 35 terms, classified into 17 categories compromising 186 unique papers for each primary authored article with redundant numbered vital signs for glucose, weight, body mass index, and medication compliance. Eleven terms have been named the fifth vital sign, 25 the sixth vital sign, three the seventh, and one as the eighth vital sign. There are four time-honored vital signs based on the case definition, and they represent an objective bedside measurement obtained noninvasively that is essential for life. Based on this case definition, pulse oximetry qualifies as the fifth while end-tidal CO2 and cardiac output as the sixth. Thus, these terms have been misappropriated 31 times. Although important to emphasize in patient care, the remainder are not vital signs and should not be construed in this manner.

National trends in long-term use of prescription opioids

PURPOSE

This study examined recent trends and correlates of prescription opioid use and long-term use in the United States.

METHODS

Data were from 47 356 adult participants of National Health and Nutrition Survey from 1999-2000 to 2013-2014. Participants were asked about prescription medications used in the past 30 days. Long-term use of prescription opioids was defined by use for 90 days or longer.

RESULTS

The prevalence of prescription opioid use increased from 4.1% of US adults in 1999-2000 to 6.8% in 2013-2014 (odds ratio [OR] = 1.38, 95% confidence interval [CI] = 1.10-1.75, P = .007). This trend was driven by a sharp increase in long-term use which increased from 1.8% to 5.4% (OR = 2.22, 95% CI = 1.65-3.00, P < .001). Of all opioid users in 2013-2014, 79.4% were long-term users compared with 45.1% in 1999-2000. Long-term use was associated with poorer physical health, concurrent benzodiazepine use, and history of heroin use.

CONCLUSIONS

The findings highlight the need for research on potential benefits and harms of long-term use of opioids and efforts to restrict long-term use to patients for whom the benefits outweigh the risks.

Assessment of intraoperative pain during Mohs micrographic surgery (MMS): An opportunity for improved patient care

BACKGROUND

Intraoperative pain during Mohs micrographic surgery (MMS) has not been characterized. However, many patients report postoperative pain on the day of MMS.

OBJECTIVE

We sought to determine if patients experience pain during their MMS visit.

METHODS

In phase I of this study, patients were asked to report intraoperative pain level using the verbal numerical rating scale (0-10) at discharge. In phase II, pain levels were assessed before each Mohs layer and at discharge, to determine whether pain was experienced throughout the day.

RESULTS

Pain was reported at some point during the MMS day for 32.8% of patients (n = 98). The mean pain number reported was 3.7 (range 1-8) out of 10. Pain was more commonly reported by patients who spent a longer time in the office, had 3 or more Mohs layers, and had a flap or graft repair. Patients most frequently reported pain with surgical sites of the periorbital area and nose.

LIMITATIONS

Time between Mohs layers was not measured. There was nonstandardized use of intraoperative local anesthesia volume and oral pain medications.

CONCLUSION

Some patients experience pain during MMS. However, the majority of patients report a low level of pain. Additional preventative measures could be considered in patients at higher risk.

Natural history of opioid dosage escalation post-injury: a cohort study of injured workers in the State of Louisiana

OBJECTIVE

To determine the relationship between opioid dosage and claim duration.

METHODS

Closure rates and morphine-equivalent dose were analyzed over a 7-year period for 11,394 lost-time claims filed with the Louisiana Workers' Compensation Corporation.

RESULTS

The percentage of claims in which opioids were ever prescribed increased from 43.3% in year 1 to 80.8% in year 7 post-injury. The percentage of claims in which individuals were prescribed long-acting (LA) opioids increased from 5.2% to 29.6%, and the percentage of claims in which individuals were prescribed only short-acting (SA) opioids increased from 38.1% to 51.2%. Morphine-equivalent dose increased from 10.0 mg/day (year 1) to 143.2 mg/day (year 7) for claims in which individuals were prescribed LA opioids. The average claim duration for claims in which individuals were prescribed no opioids, only SA opioids, and LA opioids was 415, 930, and 2025 days, respectively.

CONCLUSION

Opioid dosage escalates as claims mature.

Trends in long-term opioid therapy for chronic non-cancer pain

OBJECTIVE

To report trends and characteristics of long-term opioid use for non-cancer pain.

METHODS

CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult enrollees of two health plans serving over 1 per cent of the US population. Using automated data, we constructed episodes of opioid use between 1997 and 2005. We estimated age-sex standardized rates of opioid use episodes beginning in each year (incident) and on-going in each year (prevalent), and the per cent change in rates annualized (PCA) over the 9-year period. Long-term episodes were defined as > 90 days with 120+ days supply or 10+ opioid prescriptions in a given year.

RESULTS

Over the study period, incident long-term use increased from 8.5 to 12.1 per 1000 at Group Health (GH) (6.0% PCA), and 6.3 to 8.6 per 1000 at Kaiser Permanente of Northern California (KPNC) (5.5% PCA). Prevalent long-term use doubled from 23.9 to 46.8 per 1000 at GH (8.5% PCA), and 21.5 to 39.2 per 1000 at KPNC (8.1% PCA). Non-Schedule II opioids were the most commonly used opioid among patients engaged in long-term opioid therapy, particularly at KPNC. Long-term use of Schedule II opioids also increased substantially at both health plans. Among prevalent long-term users in 2005, 28.6% at GH and 30.2% at KPNC were also regular users of sedative hypnotics.

CONCLUSION

Long-term opioid therapy for non-cancer pain is increasingly prevalent, but the benefits and risks associated with such therapy are inadequately understood. Concurrent use of opioids and sedative-hypnotics was unexpectedly common and deserves further study.

Epidemiology of regular prescribed opioid use: results from a national, population-based survey

Chronic pain occurs commonly and accounts for significant suffering and costs. Although use of opioids for treatment of chronic pain is increasing, little is known about patients who use opioids regularly. We report data from the second wave of the Healthcare for Communities survey (2000-2001), a large, nationally representative household survey. We compared regular users of prescription opioids to nonusers of opioids and calculated the percentage of individuals within a given demographic or disease state that reported chronic opioid use. Approximately 2% of the 7,909 survey respondents reported use of opioid medications for at least a month, which the Healthcare for Communities survey defined as "regular use." Opioid users were more likely than nonusers to report high levels of pain interference with their daily lives and to rate their health as fair or poor. Arthritis and back pain were the most prevalent chronic, physical health conditions among users of opioids, with 63% of regular users of opioids reporting arthritis and 59% reporting back pain. The majority of regular users of opioids had multiple pain conditions (mean=1.9 pain conditions). Regular opioid users appear to have an overall lower level of health status and to have multiple, chronic physical health disorders.

Patient Satisfaction and Pain Management

The importance of assessing and managing pain has become paramount in today's hospital environment. Poor pain management is associated with impaired health, decreased patient satisfaction, and increased healthcare costs. This quality improvement project on an internal medicine unit at an urban teaching hospital examined the impact of pain education on patient satisfaction with pain management. Although pain scores did not improve, there were improvements made with respect to patient assessment, patient satisfaction, and nursing knowledge.

Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000

The treatment of pain has received increasing attention over the past decade promoted by national guidelines, the 'pain as the 5th vital sign' campaign and direct-to-consumer advertising. We examined national trends in office visits and analgesic treatment for musculoskeletal pain in the office setting, comparing data from 1980 and 2000. We analysed the National Ambulatory Medical Care Survey (NAMCS)--a nationally representative survey of visits to office-based physicians--using data from 1980-81 (n=89,000 visits) and 1999-2000 (n=45,000 visits). During this time, NSAID prescriptions increased for both acute (19 vs. 33%, RR=1.74; 95% CI, 1.52-1.95) and chronic (25 vs. 29%, RR=1.16; 95% CI, 0.97-1.35) musculoskeletal pain visits. In 2000, one-third of the NSAID prescriptions were for COX II agents. Opioids increased for acute pain (8 vs. 11%, RR=1.38; 95% CI, 0.92-1.83) and doubled for chronic pain (8 vs. 16%, RR=2.0; 95% CI, 1.52-2.48). The use of more potent opioids (hydrocodone, oxycodone, morphine) for chronic musculoskeletal pain increased from 2 to 9% of visits (RR=4.5; 95% CI, 2.18-6.87). This corresponds to 5.9 million visits where potent opioids were prescribed in 2000--an increase of 4.6 million visits from 1980 (assuming the total number of outpatient visits was constant at the 2000 level). In spite of the increased attention to pain treatment, there has not been an increase in office visits for musculoskeletal pain complaints. The threshold for prescribing NSAIDS and opioids, however, has dropped.

The Hawthorne effect in the assessment of pain by house staff

Internal medicine residents are one component of the healthcare delivery team in the hospital setting. Their ability to assess and treat pain should be considered in quality improvement efforts. We surveyed our residents, using a 0 to 10 scale to determine how well they assessed their patients' level of pain. We then asked half of these residents to write down their patients' pain score as a fifth vital sign in the medical record. We repeated the house staff survey three weeks later. The residents improved their assessment as a whole, with the nonintervention group faring better on the follow-up surveys. We believe that the residents' improvement can be attributed to the Hawthorne effect, in which a group that is singled out for special study or consideration has its performance positively affected. The residents' ability to accurately rate patients with moderate and severe pain is still an area for further development. Improvements in our palliative care curriculum have been implemented to enhance our residents' education and performance in this area.

A multidisciplinary approach for improving outcomes

The healthcare environment has been impacted tremendously by higher patient acuity, cost-cutting measures, an increase in litigation, and increased expectations by an educated generation of healthcare consumers. This has led to the need to continually measure, assess, and improve quality. These activities must consider not only patient clinical outcomes, but also customer service ratings and financial outcomes. Quality improvement requires a collaborative approach to succeed, and the need to build a cohesive and effective multidisciplinary team is critical for positive outcomes. Strategies to build a culture of teamwork include incorporating total quality management principles into every level of the organization, seeking participation from every discipline and level of the organization, and recognizing employees for their efforts. Infusion nurses have an excellent opportunity to contribute their expertise to any multidisciplinary team that impacts the outcomes of infusion patients. In addition, team-building and quality improvement may prove to be excellent career moves for infusion nurses looking to further specialize their practice.