The Joint Commission Pain Standards: Five Misconceptions

Baker_David_275In the environment of today’s prescription opioid epidemic, everyone is looking for someone to blame. 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.

The Joint Commission first established standards for pain assessment and treatment in 2001 in response to the national outcry about the widespread problem of undertreatment of pain. The Joint Commission’s current standards require that organizations establish policies regarding pain assessment and treatment and conduct educational efforts to ensure compliance. 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.

Our foundational standards are quite simple. They are:

  • The hospital educates all licensed independent practitioners on assessing and managing pain.
  • The hospital respects the patient’s right to pain management.
  • The hospital assesses and manages the patient’s pain.

Requirements for what should be addressed in organizations’ policies include: 

  1. The hospital conducts a comprehensive pain assessment that is consistent with its scope of care, treatment, and services and the patient’s condition.
  2. The hospital uses methods to assess pain that are consistent with the patient’s age, condition, and ability to understand.
  3. The hospital reassesses and responds to the patient’s pain, based on its reassessment criteria.
  4. The hospital either treats the patient’s pain or refers the patient for treatment. Note: Treatment strategies for pain may include pharmacologic and nonpharmacologic approaches. Strategies should reflect a patient-centered approach and consider the patient’s current presentation, the health care providers’ clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse.

Despite the stability and simplicity of our standards, misconceptions persist, and I would like to take this opportunity to address the most common ones:

Misconception #1: The Joint Commission endorses pain as a vital sign

The Joint Commission does not endorse pain as a vital sign, and this is not part of our standards. Starting in 1990, pain experts started calling for pain to be “made visible.” Some organizations implemented programs to try to achieve this by making pain a vital sign. The original 2001 Joint Commission standards did not state that pain needed to be treated like a vital sign. The only time that The Joint Commission standards referenced the fifth vital sign was when The Joint Commission provided examples of what some organizations were doing to assess patient pain. In 2002, The Joint Commission addressed the problems in the use of the 5th vital sign concept by describing the unintended consequences of this approach to pain management and described how organizations had subsequently modified their processes.

Misconception #2: The Joint Commission requires pain assessment for all patients.

The original pain standards stated “Pain is assessed in all patients.” This was applicable to all accreditation programs (i.e., Hospital, Nursing Care Center, Behavioral Health Care, etc). This requirement was eliminated in 2009from all programs except Behavioral HealthCare Accreditation.  Patients in behavioral health care settings were thought to be less able to bring up the fact that they were in pain and, therefore, required a more aggressive approach. The current Behavioral Health Care Accreditation standard says, “The organization screens all patients for physical pain.”

The current version of the standard for hospitals and programs other than Behavioral Health says“The hospital assesses and manages the patient’s pain.” This standard allows organizations to set their own policies regarding which patients should have pain assessed based on the population served and the services delivered. Joint Commission surveyors determine whether such policies have been established, and whether there is evidence that the organization’s own policies are followed. Some organizations may still follow the old standard and require pain assessment of all patients.

Misconception #3: The Joint Commission requires that pain be treated until the pain score reaches zero.

There are several variations of this misconception, including that The Joint Commission requires that patients are treated by an algorithm according to their pain score. In fact, throughout our history we have advocated for an individualized patient-centric approach that does not require zero pain. The introduction to the “Care of Patients Functional Chapter” in 2001 started by saying that the goal of care is “to provide individualized care in settings responsive to specific patient needs.”

Misconception #4: The Joint Commission standards push doctors to prescribe opioids

As stated above, the current standards do not push clinicians to prescribe opioids. We do not mention opioids at all:

The note to the standard says: Treatment strategies for pain may include pharmacologic and nonpharmacologic approaches. Strategies should reflect a patient-centered approach and consider the patient’s current presentation, the health care providers’ clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse.

Misconception #5: The Joint Commission pain standards caused a sharp rise in opioid prescriptions.

This claim is completely contradicted by data from the National Institute on Drug Abuse Figure1Figure 1 – Opioid Prescriptions Dispensed by US Retail Pharmacies IMS Health, Vector One: National, years 1991-1996, Data Extracted 2011. IMS Health, National Prescription Audit, years 1997-2013, Data Extracted 2014.

The number of opioid prescriptions filled at commercial pharmacies in the United States from 1991 to 2013 shows the rate had been steadily increasing for ten years prior to the standards’ release in 2001. It is likely that the increase in opioid prescriptions began in response to the growing concerns in the U.S. about under treatment of pain and efforts by pain management experts to allay physicians’ concerns about using opioids for non-malignant pain. Moreover, the standards do not appear to have accelerated the trend in opioid prescribing. If there was an uptick in the rate of increase in opioid use, it appears to have occurred around 1997-1998, two years prior to release of the standards.

The Joint Commission pain standards were designed to address a serious, intractable problem in patient care that affected millions of people, including inadequate pain control for both acute and chronic conditions. The standards were designed to be part of the solution. We believe that our standards, when read thoroughly and correctly interpreted, continue to encourage organizations to establish education programs, training, policies, and procedures that improve the assessment and treatment of pain without promoting the unnecessary or inappropriate use of opioids.

The Joint Commission is committed to working to dispel these misunderstandings and welcomes dialogue with the dedicated individuals who are caring for patients in our accredited organizations.

David Baker, MD is Executive Vice President for Healthcare Quality Evaluation with the Joint Commission.


5 replies »

  1. The JC was part of the drumbeat that got us into this mess…carefully worded guidelines or not. When pain management is a “right”, what is the basis of withholding opiates? Hospitals fear the JC, so they are going to go above and beyond when it comes to any guidelines presented. Accept your portion of the blame, and then lets get on with the solution. Dr. P is right: we need way better treatment options for pain, and we need something to assist in the detection and determination of the severity of pain. (Not a subjective pain scale).

  2. We just don’t have a good answer with pain. Our present choices leave us with gastric bleeding, liver toxicity, and respiratory failure. Cox2 were disappointing. THC or derivatives? Elavil+compazine-like? Acupuncture? Hypnosis? Anti-seizure meds? Electrical devices? All pretty ineffective or problematic. Keep looking.

  3. Well the biggest problem is that abuse of prescription opioids puts you at a 19 fold risk for being a heroin user and the overdose death rate from heroin has tripled since 2010. Furthermore – there is no physician out there who can predict which of their patients will start abusing prescription opioids – at least when we discount the unrealistically low levels of addiction in survey studies and look at more realistic data.

  4. Pain is assessed in all patients IS a major problem.

    The following reference that is not available in online JAMA for some reason:

    1: Phillips DM. JCAHO pain management standards are unveiled. Joint Commission on
    Accreditation of Healthcare Organizations. JAMA. 2000 Jul 26;284(4):428-9. PubMed
    PMID: 10904487.

    If you read that reference you will find the following:

    This direct quote from Dennis O’Leary MD, then President of JCAHO: “Pain control has become a problem because of confusion as to who is responsible [for it], a general lack of knowledge about pain, and misconceptions about drug tolerance and addiction.”

    It seems to me that physicians in the 1990s, probably knew a lot more about drug tolerance and addiction than in the first 15 years of the 21st century.

    That was followed by the statement that JCAHO would change things in 4 ways:

    1. Make it a patient rights issue as well as an education and training issue.
    2. Emphasize the quantitative aspects of pain (placing it on a 10 point scale).
    3. Encouraging systematic assessment
    4. Emphasizing safe management.

    Unfortunately we are just starting to get a handle on items 3 and 4 today. Pain is obviously not quantitated.

    You can certainly post any number of graphics, but the ones I read show an inflection point in the very early 2000s in terms of overdose deaths.

    In politics it is rare to find a smoking gun, but at the very least the sentiment of the day was to liberalize prescription of opioids. I can’t imagine Americans seeking out advocacy for ibuprofen in a hospital setting. It is time to acknowledge that many mistakes are made when regulators and other entities repeatedly talk about physician deficiencies and come up with their own plans that subsequently backfire or that are part of the collective backfire..

  5. I remain to be convinced that–if pain was severely under treated in 1990 which basically everyone agrees it was–the trebling of opiod use by 2010 was such a bad thing. However I am damn sure that if we simply cut opiod availability and push patients in pain out the door, we will see a spike in heroin use. Why? Because it’s already happening.

    Can someone explain to me why opiods prescribed by doctors are worse for public health than heroin sold by drug dealers?