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Pain as the Sixth Vital Sign

Doctors, remember that pain is subjective and may not fall easily into a grading system, writes Dr. Irina Litvin, a rheumatology fellow at SUNY Downstate in Brooklyn, N.Y.

We measure blood pressure, respiratory and heart rate, oxygenation and temperature at every patient encounter. We’ve learned to put our trust into these five beautifully packaged, all-encompassing, omnipotent vital signs - vital signs. Let that sink in for a minute. Realize that our ability to interpret these numbers is our window into the physical bodies we treat.

Pain is commonly referred to as the sixth vital sign. Each exam room has a picture of ranging emotions, smiling to frowning, that we ask our patients to identify. Unfortunately, pain is not something that can be objectified. Some patients can have horrific rheumatic hand deformities with severe limitations, and get away with occasional Tylenol. Those with fibromyalgia may have a heightened sense of stimuli, leaving them supremely sensitive to the lightest touch. Both patients will come to their follow-up appointments, and request something to make them more comfortable with their daily activities. The question is - with pain being a supremely subjective entity, how do we decide who gets what, and how much? Depending on where you did your residency training, your answer will differ. For some, a common motto is “start low, go slow”. Others are more aggressive with their treatment strategy. The unifying theme here is unearthing who will indeed benefit from medications such as opiates.

In an effort to combat the nation’s addiction, strict opioid guidelines have emerged. These guidelines enforce a seven-day policy for new prescriptions, do not allow phone-in renewals, and require a patient to be seen every 90 days for as long as they require the medications. These policies have caused quite a stir amongst the chronic pain population. When you’re not the one dealing with a constant ache, the new changes may come across as “no big deal.” But when you’re on the front lines, it’s yet another barrier that needs to be overcome.

The whole conglomeration of changes further underlines the importance of a good rapport between physician and patient. Practicing rheumatology in an inner city area gives me the chance to interpret red herrings, see extremely rare cases, and intertwine myself deeply into the lives of my patients. Weeding out who legitimately needs the opioids becomes a difficult task to undertake. Lines of communication should always stay open between both parties. Doctors, remember that pain is subjective and may not fall easily into a grading system. 



Irina Litvin, D.O., is a physician and rheumatology fellow at SUNY Downstate in Brooklyn, N.Y.