Commentary
The fifth vital sign revisited
James N. Campbell
he Topical Review by Sullivan and Ballantyne6 identifies the
T frequent dilemma faced in treating patients with chronic pain
where nothing seems to work. They raise a provocative question
as to whether assessing the intensity of pain should be
deprioritized. They suggest that focusing on the rating of pain
intensity in the clinical setting sets the wrong goal, and may lead
to misguided interventions, in particular treatment with opioids.
The intent of the “pain the fifth vital sign” campaign (Presidential
Address to the American Pain Society, 1996, Campbell) was to
encourage doctors and nurses to listen to their patients and
assess their pain. This was because health care professionals
often ignored patients’ suffering from pain. There was no intent to
have everyone take an opioid. The hope really was that by this
time, now nearly 20 years later, we would be able to talk about
other innovations in pain care rather than still focusing on the use
of opioids. When this initiative was launched we were in a world
where the principles of palliative care were first being articulated,
where postoperative pain was often ignored, and where many
patients died with severe pain from cancer. We have moved
forward by leaps and bounds. Hospital ratings of quality of care by
patients in part relates to how well pain is treated. The authors
acknowledge these monumental gains, but worry that there may
now be an overemphasis on pain ratings, and that this
overemphasis may lead to overzealous efforts to control chronic
pain with opioids. Although this logic may apply in some
instances, there is a danger that we end up simply being less
sensitive to our patients. In a medically refractive patient with
hypertension, should we just stop measuring the blood pressure?
A singular focus on reducing pain intensity without considering
the patient’s overall quality of life is clearly misguided. However, it is
equally self-evident that if we can reduce pain effectively and safely,
we should. Defocusing the assessment of pain intensity has risks of
being paternalistic. Pain care is largely empirical. Ideally we try
different interventions in a tiered proportional manner aimed at
balancing risk and benefit and quality of life. The assessment of
pain intensity is an important component of the patient-doctor
dialogue. It is not the unitary focus. It may be helpful in many
circumstances to try to help a patient defocus on pain and to
engage in other rehabilitative measures. But unfortunately, the
quality of life may not be improved by these interventions alone.
The authors pose a clinical problem where a patient complains
of intense low back pain. The patient takes an opioid which initially
helped, but has stopped being effective. The patient had imaging
studies, which indicate the presence of degenerative disk disease
Sponsorships or competing interests that may be relevant to content are disclosed
at the end of this article.
Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
PAIN 157 (2016) 3–4
© 2015 International Association for the Study of Pain
http://dx.doi.org/10.1097/j.pain.0000000000000413
January 2016
· Volume 157
· Number 1
Copyright Ó 2015 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
at a single level, not particularly striking in its severity. The pain
seems out of proportion to the underlying disease. In such
instances, a patient’s pain may be magnified by psychological
factors (eg, depression, anxiety, or pain catastrophizing). If this is
the case, pain interventions (eg, surgery, implanted drug pump,
spinal cord stimulation) may be ineffective. Training in psycho-
logical strategies, guided exercise to increase activity, or even no
treatment at all may be best. Low back pain could be part of
a “central sensitization” or fibromyalgia syndrome in which case
the range of effective treatment options might be very limited.
However, we should be cautious in thinking that a magnetic
resonance imaging scan necessarily tells us how much pain
a patient feels. There are too many variables from the process of
transmission of physical energy, to neural transduction, to
nociceptive processing, to the report of pain before we even
get to the richness of the myriad of psychological variables.
It is instructive to consider that there is often a disconnection
between x-rays and reports of pain in areas of the body other than
the lumbar spine. For the hip, the knee, the shoulder, and other
examples, the level of disease and the level of pain are only weakly
correlated.1 A small tear of the rotator cuff may be very painful
whereas large tears may be associated with no pain. Often our
failure to understand the pathophysiology of a disease affects our
attitudes about the symptoms. Back pain problems dominate
pain clinics. It is possible that the greater anatomical complexity of
the lumbar spine makes pain management much harder from the
perspective of biomechanics. We have to be careful about how
our limited ability to treat and understand a painful condition
translates to believing our patients. Surgery for chronic hip pain is
highly successful overall.5 Patients with chronic pain associated
with osteoarthritis of the hip typically do not make their way to pain
clinics. Our attitudes about chronic pain are influenced by
whether we understand the underlying disease.
A major point in the Sullivan and Ballantyne article is that asking
a patient to rate his or her pain intensity may have the unintended
consequence of fostering the overuse of opioids leading to
greater harm. There undoubtedly are many cases where this is
the case. The converse likely also applies, where patients who
might benefit from the skillful use of opioids are denied care. In the
absence of much needed data, the use of opioids is a polarizing
emotional issue for the public, for doctors, and for our patients.
Obviously we need much more research to understand how to
use this very important class of medications to its best advantage,
given the spectrum of treatments presently available. So called
“titration to effect” where the dose of an opioid continues to be
increased may backfire. “More” may not be better and opioid-
induced hyperalgesia may be an issue. One lesson in taking care
of patients is the role of personalized medicine, acknowledging
that each patient responds differently.
The assessment of pain intensity should go beyond thinking
about whether to write a prescription for an opioid. The authors
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J.N. Campbell 157 (2016) 3–4
paint a pessimistic picture of what can be offered to a patient in
chronic pain. Initially, a decision might be made to help a patient
try to defocus on pain intensity as a therapeutic strategy. If the
patient’s quality of life improves sufficiently, then this option
should be pursued. However, the patient may continue to have
a poor quality of life because of pain. The patient both alone and, if
possible, together with the family, need to be brought into
a careful consideration of the treatment alternatives. In time, one
option may be a trial with opioids. By some accounts, favorable
outcomes may be achieved with surgery in particular for single-
level disk disease such as that described in the clinical vignette.2,3
In recent years, spinal cord stimulation technology also has
advanced to the point that in at least some patients, axial pain (in
addition to radicular pain) can be helped.4
Teaching doctors that in the context of chronic pain, the
assessment of pain intensity should be deprioritized threatens to
send the wrong message. In the beginning part of my career, I
became aware of the often devastating consequences of chronic
serious pain. It was clear that many individuals were underserved
because doctors were too busy to assess their patients’ pain and
because they believed that persistent pain was a relatively
unimportant health problem. Converging lines of evidence,
however, now demonstrate that persistent pain (as measured
by intensity) is an important health care problem. Now, hospitals
and doctors in hospitals are judged in part on how well they care
for conditions such as postoperative pain. We have witnessed
a surge of growth in pain medicine and a shift of attitudes such
that it is now clearly unacceptable to ignore a patient’s pain and
suffering, whether it is acute or chronic. In describing pain as the
fifth vital sign, the message is that pain assessment is a priority.
Assessment should not equate to giving a patient an opioid.
Assessment also does not mean that we cannot work with
strategies to help patients adapt and to try to focus their lives
away from pain. Assessment, however, does mean that we care,
that we empathize, and that short of evidence to the contrary we
Copyright Ó 2015 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
PAIN®
believe the patient’s report of pain. Belief offers hope to our
patients, and belief motivates us, the doctors, the nurses, and the
scientists, to continue to search for better ways to enhance the
quality of our patients’ lives.
Conflict of interest statement
J. N. Campbell serves as President, and Chief Scientific Officer of
Centrexion Therapeutics, a company aimed at the development
of new therapeutics for the treatment of pain.
Article history:
Received 12 September 2015
Accepted 2 November 2015
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