JAMA Surgery “Viewpoint” misrepresents Joint Commission’s role in the opioid epidemic

A “Viewpoint” published in JAMA Surgery in August 2019 perpetuated the falsehood that pressure from The Joint Commission in part led to the opioid epidemic.

As I see it, the author makes two major contentions related to The Joint Commission in “When a vital sign leads a country astray—the opioid epidemic.”¹ The first asserts that The Joint Commission pain standards that went into effect in 2001 resulted in a significant increase in opioid prescriptions, and the second is that The Joint Commission created the concept of “pain as a fifth vital sign.” Both assertions are incorrect. Let us look at the facts on both.

Did The Joint Commission 2001 pain standards cause a substantial increase in the prescription of opioid medication?

Total opioid prescriptions had been increasing in the U.S. for at least 10 years before The Joint Commission’s pain standards went into effect in 2001 (see Figure 1).² According to data gathered by the National Institute on Drug Abuse, the number of opioid prescriptions dispensed by U.S. pharmacies between 1991 and 1997 (well before the pain standards were released) increased from 76 million to 97 million.² Moreover, no incremental increase or change occurred in the rate of increase after the standards were released in 2001. To claim otherwise simply ignores these facts.

Figure 1. Opioid prescription trends

The increase in opioid prescribing actually dates back to the 1980s—perhaps in response to the health care industry’s past failure to adequately assess and treat pain.3 In 1990, then-president of the American Pain Society Mitchell Max, MD, penned an editorial in the Annals of Internal Medicine that spoke to the lack of improvement in those areas.³

In his editorial, Dr. Max offered the following recommendations:³

• Make pain “visible”
• Provide tools to the care team for better analgesic treatment
• Keep patients in the communication loop with their care team
• Hold physicians accountable for inadequate pain control

In response to the outcry over the widespread undertreatment of pain, The Joint Commission established standards for pain assessment and treatment in 2001. The 2001 standards required that hospitals and other health care facilities establish policies regarding pain assessment and treatment and that they educate their health care professionals to ensure compliance. The standards did not, however, require the use of drugs to manage a patient’s pain. If a pain drug was appropriate, the 2001 standards did not specify which drug should have been prescribed.

Thus, the authors are illogical in their conclusion that placing the responsibility for pain management on health care facilities is wrong or somehow contributed to today’s epidemic. It is analogous to suggesting that our emphasis on the management of sepsis with antibiotics has led to the development of bacterial resistance.

In accordance with its mission to continuously improve health care for the public, The Joint Commission revised its pain standards in 2016—with the revisions going into effect in 2018 across all of The Joint Commission’s accreditation programs.⁴

The process involved rigorous research, evaluation, and review, ultimately leading to new and revised pain assessment and management standards. Among the new requirements were the following:⁴

• Identify a leader or leadership team to be responsible for pain management and safe opioid prescription
• Engage patients to participate in the development of their treatment plans, while setting realistic expectations and measurable goals
• Improve access to drug monitoring tools and databases for care teams, as well as the availability of nonpharmacological therapy
• Educate patients on the addictive nature of opioids and how to properly dispose of unused medications to prevent drug diversion

From a surgeon’s perspective, I believe it is right to place emphasis on the appropriate treatment of postoperative pain using all the available methods—such as setting appropriate expectations, and managing anxiety and fear, among others—as is the development of assessment methods to determine the effectiveness of the treatment.

Did The Joint Commission create the concept of the “fifth vital sign?”

The “Viewpoint” published in JAMA Surgery also misrepresents The Joint Commission regarding the “fifth vital sign,” a concept that the American Pain Society developed and that gained the attention of the U.S. Department of Veterans Affairs (VA).

While The Joint Commission included the VA’s initiative in its “Examples of Implementation”—which was released in 2001 along with the pain standards—it was removed from the “Examples of Implementation” in 2002 when concerns about the fifth vital sign were raised.

The outlook moving forward

Good news is on the horizon. The Centers for Disease Control and Prevention states that drug overdose remains the leading cause of unintentional injury-associated death in the U.S.—with 24.2 percent of fatal drug overdoses in 2017 involving prescription opioids. However, the number of opioids prescriptions being dispensed has declined since 2013.^2,4

In the meantime, The Joint Commission will continue to do its part to address the opioid epidemic by striving to inspire the more than 22,000 health care institutions it accredits and certifies, as well as all health care professionals who work in those facilities, to provide the safest, highest-quality care to patients.

As surgeons, we must do our part by working with our patients, setting the right expectations, managing anxiety and fear, and using all the modalities available today to provide the most efficient and safe treatment to manage pain.

Disclaimer

The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

References

1. Chidgey BA, McGinigle KL, McNaull PP. Viewpoint: When a vital sign leads a country astray—the opioid epidemic. JAMA Surg. August 14, 2019 [Epub ahead of print].
2. National Institute on Drug Abuse. America’s addiction to opioids: Heroin and prescription drug abuse. May 14, 2014. Available at: https://archives.drugabuse.gov/testimonies/2014/americas-addiction-to-opioids-heroin-prescription-drug-abuse. Accessed September 30, 2019.
3. Baker DW. The Joint Commission’s pain standards: Origins and evolution. May 5, 2017. Available at: www.jointcommission.org/assets/1/6/Pain_Std_History_Web_Version_05122017.pdf. Accessed September 30, 2019.
4. García MC, Heilig CM, Lee SH, et al. Opioid prescribing rates in nonmetropolitan and metropolitan counties among primary care providers using an electronic health record system—United States, 2014–2017. Morb Mortal Wkly Rep. 2019;68(2):25-30.