Pain: "The Fifth Vital Sign"

By: Bram Riegel, M.D.




Pain is the most common reason that individuals seek medical attention.According to the American Pain Society, 50 million Americans are partially or totally disabled by pain, 45% of all Americans seek care for persistent pain at some point in their lives, (1). A recent study in the New England Journal of Medicine found that children dying of cancer are not given adequate treatment of pain, shortness of breath, fatigue, nausea, and other symptoms, (2). It can be concluded that pain is under treated, despite the availability of effective pharmacologic and non-pharmacologic treatments. Why? First, accordingly to the American Medical Association Counsel and Scientific Affairs, healthcare professionals may have inadequate knowledge of analgesic pharmacology and pain therapy, poor pain assessment practices, and unfounded concern about regulatory persecution and oversight, (3). They may also fear the side effects of opioid analgesics, in particular, tolerance and addiction. In addition, they may be more focused on curing the underlying disease process than on treating pain. Second, patients may contribute to the under treatment problem by their reluctance to both report pain and take pain medications. Last, too few healthcare systems currently prioritize, pain management and may also have inadequate or inappropriate provisions for reimbursement.

The Under Treatment Problem

Despite the ever growing list of treatment options for relieving pain, pain management has shown little improvement over the past several decades. Consequently, large percentages of hospitalized patients regardless of why they are admitted, still experience considerable pain, (1).

Pain: How large is the percentage of hospitalized patients?


Estimates say that the percentage of pain is anywhere from 50-80% of all hospitalized patients. In one study, nearly 50% of severely ill hospitalized patients reported pain, almost 15% of whom said they had moderately or extremely severe pain, at least half the time, (3). Another study reported that 50% of hospitalized patients had pain when they were interviewed, while 67% had experienced pain during the past 24 hours, (1). In a study of randomly selected hospitalized medical and surgical patients, 80% reported pain, with 45% describing it as excruciating, (5). According to the Institute of Medicine, a significant portion of dying patients and patients with advanced diseases experience serious pain, (6). Finally, the 1992 "Clinical Practice Guidelines for Acute Pain Management of the Agency for Healthcare Research and Quality" suggests that routine orders for IM injections of opioids as needed (PRN) leave more than half of post operative patients with unrelieved pain due to under treatment.

Hospitals are not the only settings in which patients experience significant pain. The American Geriatrics Society suggests that between 45-80% of long tem care residence have substantial under treated pain, (7). In one study, more than 70% of long tem care residence reported the pain problem. When asked to describe the pain, 66% of the residence described intermittent pain, while 34% had chronic pain. Major sources of pain include the lower back, arthritis previous fracture sites, and neuropathies, (8). One study found that approximately 40% of long term care residence with cancer experience daily pain, (9), and 25% do not receive analgesics, (2,9).

Pain, The Fifth Vital Sign

The American Pain Society has created the phrase Pain "the fifth vital sign" to elevate awareness of pain treatment among healthcare professionals. Different pain assessment techniques and management strategies will be appropriate depending on the population. Five general populations will be discussed: elderly (burn survivors), infants and children (burn survivors), cancer and AIDS patients, patients at the end of life, and patients who have difficulty communicating (burn survivors).


There are five things a doctor and patient should be aware of to improve pain assessment and treatment:

  • 1. Consider pain "the fifth vital sign" and assess patients for pain for every time you check for pulse, blood pressure, temperature and respiration.
  • 2. Doctors should take their patients complaints of pain seriously. Remind them not to put patients in the position of asking for a favor when they want pain relief.
  • 3. Doctors should inform patients that they deserve to have their pain evaluated and treated.
  • 4. Work to implement the American Pain Societies quality improvement guidelines to the treatment of acute pain and cancer pain in you own practice setting, (10).
  • 5. Wear your fifth vital sign button and create opportunities to explain the importance of pain evaluation and treatment to other healthcare professionals, patients and the public.
  • References

    1. American Pain Society, American Academy of Pain Medicine, Janssen Pharmaceutical: Chronic pain America: Roadblocks to relief. Study conducted by Roper Starch Worldwide, 1999.
    2. Wolfe J, et al. Symptoms and suffering at the end of life in children with cancer. New England Journal of Medicine 324(5):326-333, Feb 2000.
    3. Won A, et al. Correlates and management of nonmalignant pain in the nursing home. Journal of the American Geriatrics Society 47;936-942, 1999.
    4. Desbiens NA, et al. Pain and satisfaction with pain control in seriously ill hospitalized adults: Findings from the Support research investigations. Critical Care Medicine 24(12): 1953=1961, 1996.
    5. Donovan M. Dillon P, McGuire L. Incidence and characteristics of pain in a sample of medical-surgical inpatients. Pain 56:69-87, Jul 1987.
    6. Institute of Medicine, Approaching Death: Improving Car at the End of Life. Washington DC: National Academy Press, 1997, p.5.
    7. Lamberg, L. New guidelines on managing chronic pain in older persons. Journal of the American Medical Association 280(4):311, 1998.
    8. Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. Journal of the American Geriatric Society 38(4):409-414, 1990.
    9. Bernabei R, et al. Management of pain the elderly patients with cancer. Journal of the American Medical Association 279(23):1877-1882, Jun 17, 1998.
    10. Journal of the American Medical Association, 274, 1874-1880, 1999.