Pain: The Fifth Vital Sign
A medical visit includes essential measurements, height, weight and the so-called "vital signs," blood pressure, pulse, respiratory rate and temperature, which give an indication of health status. Lately, many medical practitioners have added another indicator, pain assessment, what some call the "fifth vital sign."
Since pain cannot be measured objectively, the patient is asked to rate any pain at the time of the visit on a scale from zero to 10. Children use a scale based on faces from a smile for no pain to a crying face to show how they feel. If blood pressure were never measured, physicians would be less able to identify those who need treatment. Similarly, with pain, if no one assesses it, many with pain will go untreated.
Pain can arise from injury to body structures through trauma, such as a fracture or burn or as a result of surgery or as a complication of disease, such as cancer, HIV, diabetes nerve damage, infection, arthritis and toxins. The causes of some pain syndromes are not well understood as in the case of complex regional pain syndrome, formerly called causalgia or reflex sympathetic dystrophy.
According to a 1999 Gallup survey, nine in 10 Americans regularly suffer from pain. Untreated, pain can lead to other medical complications depending on the cause of the pain. Pain causes long-term disability, short-term job absences and contributes to depression. Pain is often under treated for a variety of reasons. People with pain may not report it and doctors may not diagnose it or feel comfortable with treatment options.
With all the advertising for over-the-counter pain medications, it's hard to understand why only one in four people are receiving adequate treatment for their pain, according to the American Pain Foundation. Some people do not use medication effectively, either under dosing or using too long a dosing interval. Misunderstandings about medication safety or addiction potential also might contribute in addition to worries about drug interactions or side effects.
Physicians may not provide adequate treatment either. There are often misperceptions about side effects, addiction potential and malpractice and legal risks from the use of prescription pain medications. Many may not feel adequately trained to manage pain. All these issues can lead to inadequate assessment or under treatment of pain.
Pain treatments include medications and nonmedical therapies. Most people can use acetaminophen (Tylenol and others) safely as long as they do not drink alcohol heavily. One problem with acetaminophen is that many over-the-counter medications combine it with decongestants, antihistamines and so on. Some prescription pain medications also include acetaminophen. If one does not read the label, it is possible to exceed the maximum adult dose of 4,000 mg a day.
Various nonsteroidal anti-inflammatories are available with and without prescription. The most familiar over-the-counter varieties are ibuprofen (Motrin, Advil and others), naproxen (Aleve) and ketoprofen (Orudis). In addition to pain relief, these drugs also reduce inflammation that is often an additional contributor to pain. These, too, are often found in combination with cold medications and can be taken in greater than recommended doses if not careful.
Aspirin has been known as a pain reliever for more than a century, but it is not commonly used alone because of its high rate of stomach ulcers and bleeding complications. However, variations on aspirin are available and are safer for chronic pain treatment.
Prescription nonsteroidal anti-inflammatories include Naprosyn, Motrin, Relafen, Daypro, Feldene, Lodine, Indocin, Mobic, Celebrex, Bextra, Vioxx and others. Most people can take over-the-counter and prescription nonsteroidal anti-inflammatories without any problems, but some have the potential to cause stomach ulcers and bleeding, to raise blood pressure and to impair kidney function. More recently, researchers have determined that all of them have some tendency to raise the risk of blood clotting which could lead to a heart attack in people at risk for heart disease. For that reason, Vioxx and Bextra have been removed from the market, although many physicians believe they can be prescribed safely in properly selected people.
Narcotics, also called "opioids" since they are derived from opium, are often the mainstay for management of both acute and chronic pain. Available narcotics include codeine, hydrocodone, oxycodone, meperidine, morphine, hydromorphone and fentanyl. Several products have been developed that work like narcotics but have a lower addiction potential, although some physicians debate the latter claim. All narcotics cause sedation and can cause nausea, constipation and confusion. Narcotics can be administered orally, by injection and through the skin.
Risk of addiction is frequently misunderstood by both patients and physicians. Tolerance occurs with chronic narcotic use. It results from the adaptation of the brain's pain centers to chronic narcotic administration such that higher doses are needed to achieve pain control. Dependence means that the body has adapted to chronic use so that abrupt discontinuation or reduction in dose causes symptoms of withdrawal. These two problems are manageable and should not limit the use of narcotics when needed.
Addiction is an entirely different problem. In addiction, the drug is sought and used for pleasurable effects, not for pain control. It happens only in people genetically predisposed to addiction. The chance of causing a new addiction by appropriate use of narcotic pain medication is quite low. This fear should never interfere with the proper treatment of pain, although it is a potential concern in a person with a history of substance abuse.
Pain can be treated in other ways. Physical therapy and massage therapy are useful in treatment of pain from injuries, arthritis, surgery and more. Local anesthetics applied to the skin are often effective for painful conditions caused by nerve irritation. Other topical treatments reduce pain sensitivity or provide a distraction from the pain. Nerve stimulators help many types of pain. Exercise is very beneficial in many painful medical conditions, even arthritis.
Use of adjunctive treatments can reduce the need for narcotics. Such therapies include anti-seizure medications and antidepressants. Sometimes they are prescribed alone. In conjunction with pain medications, these can reduce the dose of narcotic needed reducing the risk of side effects. Nerve blocks may be appropriate in some cases as are injections of cortisone into the area of pain or into the area around the spinal cord. In very severe cases, the painful nerve can be cut surgically.
There is much that can be done for acute and chronic pain, although in some cases, the pain is too severe to eliminate totally without unacceptable side effects or risk. Counseling is a useful adjunct when residual pain must be tolerated.
When pain exists, treatment is possible. Since pain is typically not visible, it is important to tell one's physician about it. When treatment is prescribed, ask how it is expected to work, what dosing schedule is recommended and what to do about side effects or inadequate relief. Don't let fear of addiction stand in the way of needed treatment.
By John Messmer
Penn State Family & Community Medicine
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine