Pain is not the “5th vital sign”

By Skeptical Scalpel

No, contrary to what you may have heard, pain is not the 5th vital sign. It’s not a sign at all.

Vital signs are the following: heart rate; blood pressure; respiratory rate; temperature.

What do those four signs have in common?

They can be measured.

A sign is defined as something that can be measured. On the other hand, pain is subjective. It can be felt by a patient. Despite efforts to quantify it with numbers and scales using smiley and frown faces, it is highly subjective. Pain is a symptom. Pain is not a vital sign, nor is it a disease.

How did pain come to be known as the 5th vital sign?

The concept originated in the VA hospital system in the late 1990s and became a Joint Commission standard in 2001 because pain was allegedly being undertreated. Hospitals were forced to emphasize the assessment of pain for all patients on every shift with the (mistaken) idea that all pain must be closely monitored and treated .

This is based on the (mistaken) idea that pain medication is capable of rendering patients completely pain free. This has now become an expectation of many patients who are incredulous and disappointed when that expectation is not met.

Talk about unintended consequences. The emphasis on pain, pain, pain has resulted in the following.

Diseases have been discovered that have no signs with pain as the only symptom.

Pain management clinics have sprung up all over the place.

People are dying. In 2010, 16,665 people died from opioid-related overdoses, a four-fold increase from 1999 when only 4,030 such deaths occurred. And the number of opioid prescriptions written has doubled from 109 million in 1998 to 219 million in 2011.

Meanwhile in the 10 years from 2000 to 2010, the population of the US increased by less than 10% from 281 million to 308 million.

Doctors are caught in the middle. If we don’t alleviate pain, we are criticized. If we believe what patients tell us—that they are having uncontrolled severe pain—and we prescribe opioids, we can be sanctioned by a state medical board or even arrested and tried.

Some states now have websites where a doctor can search to see if a patient has been “doctor shopping.” I once saw a patient with abdominal pain in an emergency room. After looking up her history on the prescription drug website, I noted that she had received 240 Vicodin tablets from various doctors in the four weeks preceding her visit.

That’s a lot of Vicodin, not to mention a toxic amount of acetaminophen if she had taken them all herself during that month.

What is the solution to this problem?

I don’t know, but as long as pain is touted as the fifth vital sign, I do not see it getting any better.


5 thoughts on “Pain is not the “5th vital sign”

  1. Michael,

    You are mistaken. Pain can be measured!

    I suggest you investigate some of the recent fMRI research which can measure pain by those experiencing it.

    “What is the solution to this problem” = more research and understanding of pain and more effective treatments.

    This “problem” as you point out won’t improve if those responsible for its management ignore and disregard its existence.

  2. Dave, thanks for commenting.

    The study you referred to showed that fMRI could distinguish physical pain from warmth and “social pain.” But it should not be used to rule out pain as “There are many conditions in which pain does not seem to directly stem from nociceptive —potentially tissue-damaging — stimulation,” [the lead author of the study] said, “and there are reasons to believe the current signature could fail to detect pain in these conditions, despite the fact that patients are truly in pain. []

    In addition, it would be rather impractical and prohibitively expensive to do fMRI studies on all of the millions of people who receive opioid prescriptions every year.

    No one is ignoring patients’ pain. That would be impossible and cruel.

  3. Skeptical Scalpel’s article is thought provoking. As I read through it, I was reminded of the words of Chris Pasero, MS, RN-BC, FAAN, Pain Management Educator and Clinical Consultant, who cautioned about a focus on hospitals achieving better patient satisfaction in ensuring patients are “pain free” at the possible risk to patient safety – “When someone has some mild pain, we give them opioids. They have a little more pain, we give them more opioids. They have severe pain, we give more opioids. And, of course, at the top of this pyramid is where we see adverse events including patient deaths. What’s happening nation-wide is a focus on opioid-only treatment plans. This is problematic.” (

  4. Pain is indeed the fifth vital sign and is very much measurable. We have been using validated visual pain scales to assess our patient’s pain level for quite some time and with success. This 10 point scale with visual faces that a patient can articulate or point to is how we determine if the narcotic is working to relieve the pain, or we need to adjust or change narcotic.

    Unrelieved pain affects other vital signs adversely and the patient becomes in distress -this is not the positive outcome we want to achieve and often call in a pain team to determine what is most appropriate for that specific patient. We have to chart in our notes the pain level patient is reporting and if it is relieved after the narcotic takes effect.

    Pain that is not well controlled makes the patient immobile when we want them to move, perform exercises and go to the bathroom on their own. If the patient is immobilized with pain we increase the potential for DVT, pneumonia or respiratory compromise and skin pressure areas. All of which we do not want to occur and prevent at all costs.

    TJC specifically looks intensely at our pain management or lack of for our patients we are caring for while hospitalized. The review our use of the pain scale and the associated documentation as well as interview our patients. This is a standard that has been in place for a while and in order to maintain our accreditation we must comply but more importantly do this for our patients under our care.

    CMS also plays an intrical role and assesses that we are supplying appropriate pain management and achieve our pain relief goals with and for the Medicare patient population.

    I know pain will remain the fifth vital sign in health care and one that is measurable as Joan McCaffery RN, Nurse Leader research and published on this topic of “Pain is what the patient report it to be and we must maintain objectivity and relieve the pain in order for patients to heal and progress.” I have been a professional nurse for 29 years and have always promoted the best practice in pain management protocols,policies/procedures and what we can do to improve the pain’s comfort level. This should be done all the time, no exceptions.

    Best regards Lynn Razzano RN, MSN, ONCC Clinical Nurse Consultant for PPAHS

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