The Joint Commission seeks to clarify 'misperceptions' of its pain standards

The Joint Commission’s pain standards are unfairly blamed for the current prescription opioid epidemic because of “misperceptions” of what it requires hospitals and other accredited institutions to do, says David Baker, M.D., The Joint Commission’s executive vice president for health care quality evaluation.

Baker on April 18 issued a statement to dispel what he said are five “key misconceptions” about The Joint Commission’s standards for treating pain in hospitals and other institutions.  The statement came five days after the Physicians for Responsible Opioid Prescribing – a group of state health officials, doctors and consumer advocates – asked The Joint Commission in an April 13 letter to reexamine its pain management standards due to concerns that they contribute to the current prescription opioid epidemic.

For Baker, clarification of the standards is critical for the independent, non-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States.

Baker’s statement “encourages our critics to look at our exact standards, along with the historical context of our standards, to fully understand what our accredited organizations are required to do with regard to pain.” 

“The standards do not require the use of drugs to manage a patient’s pain; and when a drug is appropriate, the standards do not specify which drug should be prescribed,” Baker said.

Baker takes aim at what he says are enduring fallacies: The Joint Commission endorses pain as a vital sign – measured like heart rate, blood pressure, respiratory rate, and temperature; requires pain assessment for all hospital patients; and requires hospitals to treat a patient’s pain (on a 0-to- 10 scale of pain intensity) until the level of pain reaches zero.  

He also takes issue with critics who contend the agency’s pain standards push doctors to prescribe opioids and contribute to the sharp rise in – and misuse of – opioid prescriptions. Deaths linked to misuse and abuse of prescription opioids increased to nearly 19,000 in 2014, the highest figure on record, according to the Center for Disease Control and Prevention.

“These misconceptions have been around for a long time,” Baker said. He said some date back to when The Joint Commission first issued its pain standards in 2001, amid concerns that too many doctors and nurses were neglecting pain. Baker noted that when he was an internist at a California teaching hospital in the early 1990s, he saw a patient with metastatic cancer who wasn’t receiving pain medication because no one asked him about his pain levels, which were high.

“We stand by these standards,” Baker said. “We think it’s important that we don’t backslide back into the days of poor pain control.”

Since 2009, The Joint Commission has not required hospitals to conduct a pain assessment of all patients – the requirement remains only for behavioral health care programs, according to Baker. He says the standard allows hospitals to “set their own policies regarding which patients should have pain assessed based on the population served and the services delivered.” What The Joint Commission’s surveyors want to know is whether the hospital is adhering to the assessment policies it put in place, he said.

Baker is “perplexed” that many believe The Joint Commission requires hospitals and other accredited organizations to treat pain until the pain score reaches zero. “It may be that some organizations started to do this before our standards were in place and people may have conflated [different organizations’ standards] in their minds,” he said. “But it is certainly not anything we have ever endorsed. The idea that you would be able to treat some of these pains to zero is just clinically absurd.”

In doing what is best for each patient, Baker cites the example of his mother, who died of metastatic breast cancer and endured significant pain in her final weeks.  “But when the grandkids came around, she did not want to take her medicine because she wanted to be awake so she could interact, and boy the minute they left and the door closed, she wanted her medication,” he said. “That’s the type of patient-centered assessment and treatment plan we need to have.”  

Baker hopes his recent statement clarifying The Joint Commissions pain standards will help debunk some persistent misconceptions. But he said setting the record straight will take “an aggressive communications campaign to clarify the standards” and working with hospital associations and physician and nursing organizations.

“We want to move forward,” he said. “We want to identify what we can do to improve pain management and address the misuse of prescription opioids, but here we are still talking about standards that were first written 15 years ago.”