Have patient satisfaction surveys and accreditation standards inadvertently contributed to the ongoing opioid epidemic that’s killing tens of thousands of Americans a year? A group of doctors and other health care stakeholders thinks so, and they’re petitioning the organizations responsible to get them to change how patient pain is measured and treated.

Advocacy group Physicians for Responsible Opioid Prescribing — in conjunction with dozens of other provider organizations — sent separate letters to both the Joint Commission and Centers for Medicare & Medicaid Services Wednesday, asking them to change pain management requirements that they say help to “foster dangerous prescribing practices.”

The group of docs specifically wants CMS to quash three questions about pain that are included in patient satisfaction surveys, and it’s urging the Joint Commission, which accredits and certifies health care organizations, to re-examine its pain management standards. Hospitals and docs must set aside expectations that they need to get pain down to zero. The focus, instead, should be on quality of living and how much pain gets in the way of living a “rewarding and healthy life,” says Harry Chen, M.D., the commissioner of the Vermont Department of Health and one of the letters’ signees.

“We’ve equated aggressive pain management with quality and that’s not necessarily the case,” Chen told me by phone. “And so, we have to reset our expectations as a health care system and, frankly, as individuals that we can expect that every last drop of pain will eventually be gone, because we’re reaping the results of that right now.”

In the CMS letter, physicians say that questions on the HCAHPS survey have had the “unintended consequence of encouraging aggressive opioid use in hospitalized patients and upon discharge.” They believe those questions may set “unrealistic expectations” for pain relief and spell dissatisfaction with care when not met. They want CMS to remove three questions from those surveys to help recalibrate expectations — during your hospital stay: (1) Did you need medicine for pain? (2) How often was your pain well-controlled? and (3) How often did the hospital staff do everything they could to help with your pain?

Others, such as the American Hospital Association, expressed agreement with those sentiments Thursday. Nancy Foster, AHA vice president of patient and safety policy, said the trade group is concerned that HCAHPS questions tied to pain management might lead to patients expecting to receive opioids for pain. Questions need to be re-evaluated, and until then, they should be removed from patient surveys. “Hospitals should not be penalized for appropriately treating patients’ pain,” Foster said. 

The letter to Joint Commission CEO Mark Chassin, M.D., meanwhile, argues that there has been a “sharp rise” in prescriptions for opioids following the group’s introduction of “pain management standards” 15 years ago, a notion that the Joint Commission disputes. Some 200,000 Americans have died from accidental overdoses of prescription opioids in that decade and a half.

“The Pain Management Standards foster dangerous pain control practices, the endpoint of which is often the inappropriate provision of opioids with disastrous adverse consequences for individuals, families and communities. To help stem the opioid addiction epidemic, we request the TJC [Joint Commission] re-examine these standards immediately,” Physicians for Responsible Opioid Prescribing wrote.

For its part, the Joint Commission disputed the physician group’s letter in a strongly worded statement Wednesday. The accreditation org debunks what it says are five common misconceptions about its pain standards, including that it endorses pain as a vital sign, that it requires pain assessment for all patients (which was dropped in 2009), and that the commission requires pain to be treated until the score reaches zero.

“In the environment of today’s prescription opioid epidemic, everyone is looking for someone to blame,” David Baker, M.D., executive vice president of health care quality evaluation at the Joint Commission, wrote. “Often, the Joint Commission’s pain standards take that blame. We are encouraging 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.”

In an interview Thursday, Andrew Kolodny, M.D., executive director of PROP, said concerns about pain management standards have been an ongoing chorus from its membership. He stressed that the group doesn’t believe such requirements from CMS and the Joint Commission caused the opioid epidemic, but they have exacerbated the problem. Kolodny said they don’t want to see pain management standards thrown out, but rather, he hopes that pain assessment can be much more targeted to each individual. He also hopes that CMS will launch a federal docket tied to PROP’s request, and urges hospital leaders to share their questions and concerns with the feds.

“I think hospitals are going to strongly endorse our requested changes,” he said. “In the meantime, I think their leaders have to recognize that there is overprescribing of opioids to hospitalized patients and upon discharge, and that they should be doing everything they can to avoid unnecessarily exposing patients to opioids. There are many patients with pain who don’t require these drugs, and yet they are being reached for first.”