{JM Test Article 2} Pain as the 5th vital sign: Paving Malaysia’s own path to success

The 3^rd National Pain Free Conference 2018, which was held in Putrajaya recently, saw the gathering of healthcare professionals from both private and government settings. The conference, themed ‘Reshaping the Landscape of Pain Management in Malaysia,’ saw representatives from various specialties cover various topics on pain management across the healthcare spectrum from primary to palliative care.

One of the highlights of the conference was the panel discussion titled ‘Pain as the 5^th Vital Sign (P5VS): Does it improve the Quality of Patient Management?’ the session saw the participation of panelists Professor Dr Ramani Vijayan Sannasi, Dr Ho Kok Yuen, Mr Yan Yang Wai, Dr Siti Salmah Ghazali and Dr Paa Mohamed Nazir Abdul Rahman. Dr Kavita Bhojwani and Dr Mohd Anizan Aziz moderated the discussion. The following are excerpts from the discussion centred around topics related to the challenges facing the Pain Free Programme (PFP).

Kavita, Consultant Anaesthesiologist at Raja Permaisuri Bainun Hospital, Ipoh, said the general consensus is that pain is definitely important as a vital sign but the situation in the US and Canada, where an ‘opioid epidemic’ is taking place, has brought some negative press towards the concept of P5VS. However, she said the opioid epidemic in those countries can’t be attributed to the onset of recognition of pain as a vital sign alone as “there are many things going on in the background.”

Ramani said the problem of pain is part and parcel of healthcare. For the longest time patients had to put up with excessive pain and unrelieved pain accounted for up to 70 percent of patients’ suffering. Therefore, recognizing P5VS is a way of making pain more visible, thereby increasing the awareness of healthcare workers and patients on the importance of treating pain. Ramani is Advisor of the Malaysian Association for the Study of Pain and Senior Honorary Consultant Anaesthesiologist and Pain Specialist at University of Malaya Specialist Centre, Kuala Lumpur.

Pain is something everyone wants to avoid, from an administrative point of view, said Nazir, Senior Deputy Director of Medical Care Quality Section, Medical Development Division, Ministry of Health (MOH). The framework, recognition and push for pain as a vital sign came about from the awareness that pain alleviation is one important aspect of patient safety. The MOH is supportive of the initiative and recently announced the establishment of pain support centres in all MOH health clinics (Klinik Kesihatan).  

In Singapore, efforts to recognize P5VS started around the same time as Malaysia, said Ho. Ho, Clinical Director of Pain Management Services, Mt Alvernia Medical Centre, Singapore, said in the early 2000’s his centre was seeking JCI (Joint Commission International) accreditation and measuring pain was an important component of the accreditation process. In time, measuring pain became part of their nursing guidelines as well. The consensus was that it is good to make pain visible and to raise awareness but “we were looking at pain in the point of view that it is just a sensory experience. So, they just looked at pain as a number to treat and forget there is an emotional component to the pain. Therefore, it is important to remember that pain assessment is a lot more comprehensive than just numbers.”

According to Yan, Consultant General Surgeon, Raja Permaisuri Bainun Hospital, Ipoh, surgeons are rather dogmatic people and are slow to move away from dogmas. “To me, the P5VS initiative is to change how people (like us) look at pain. In the past, when some patients come with pain, we don’t give analgesics because it will disturb the diagnosis.” Now, with the P5VS initiative, it is understood that pain should not be a part of the healing process and a patient’s pain should be recognized and dealt with. In my department, we are adapted to this concept (of P5VS) and even our medical students will tell us the pain score of a patient without prompting, thereby alluding to the success of P5VS. This initiative is something that’s here to stay and should be embraced.

Siti Salmah Ghazali, Consultant Anaesthesiologist at HKL and a Malaysian Society of Quality in Health surveyor, said pain can be subjective and is different from the other vital signs which are easily measurable. However, it cannot be denied that pain is important and by having it as the fifth vital sign, pain can be monitored and cannot be easily ignored.

In terms of programme expansion and future funding, Nazir said the government looks forward to having all specialists certified as pain-free experts by 2020. The ministry is also looking to provide as much funding as possible and won’t “leave the initiative in a lurch.”

Multidisciplinary approach in the management of pain, is it warranted?
The concept of treating pain from a multidisciplinary aspect is nothing new, said Ramani. Even in the 1950s it was noted that pain should be looked at holistically and not be treated in silos. Hence, Ramani noted the multidisciplinary approach to treating pain is definitely the correct way forward. Making pain the fifth vital sign was just merely making it more visible. With the increase in visibility and ability to score pain (on a pain scale), it became easier to put a number to pain and thus allowed for treatment targets.

Ho agreed with Ramani’s points, saying pain is already treated by multiple specialties eg, when a patient undergoes knee replacement surgery, the anaesthetist and pain team manages the pain and after that the surgeon takes over. “It’s just that there is no official protocol.” Going forward, many hospitals will probably put pain under a multidisciplinary care setting.  

With the push for more surgical procedures to be daycare, Yan said proper pain management is more important than ever. The PFP’s role in spearheading daycare surgery is therefore timely and important. The challenge comes when trying to persuade the entire surgical fraternity that daycare surgery is beneficial for all stakeholders—the doctor, patient, hospital and government.

As the Pain Free Hospital concept transitions to the PFP, Siti was asked about the factors required to make the PFP a success. She said the most important thing is to ensure all stakeholders receive sufficient training. Secondly, the equipment (or infrastructure) to support the programme should be made available to all institutions involved in the PFP. Additionally, Siti noted the need for data collection and utilization. Going forward, the PFP should also aim for certification as evidence of its achievements.

Kavita then brought up the recent American Medical Association’s statement that pain is not a vital sign and that US’s move to include P5VS is responsible for its current opioid crisis. In response to these claims, the panel gave their take on the US opioid crisis and how it differs from the situation in Malaysia:

1)      In the US, patient satisfaction was also factored in when deciding reimbursement levels for treatment, thus leading to an increase in opioid prescription (to appease patients)—this is probably the key factor contributing to the opioid crisis. 

2)      Culturally, Malaysia and US are different in their views of opioid use. Traditionally, Malaysia has a negative perception towards opioid use and try to minimize it, whereas US is more open to the use of opioids. Also, the Malaysian PFP’s main aim is to increase awareness of pain to the caregivers and to take it into account when deciding treatment.

3)      The lack of education (on pain assessment and treatment) and focus on treating numbers is probably the reason for opioid crisis. In addition, pharmaceutical companies can engage in direct marketing, and informed consumers ‘it’s your right to be pain-free,’ thus making patients feel empowered to demand stronger pain medication and thereby, exacerbating the opioid abuse crisis.

4)      We already have a good case study (the US) and can learn from their pitfalls to avoid taking the same path.

5)      The emphasis on multimodal analgesia is also important as it enables both doctor and patient to access non-opioid pain control strategies. The awareness of these multimodal pain control strategies should be taught in both medical and nursing schools.