The “Fifth Vital Sign”

You and your clinician colleagues in primary care have no difficulty recognizing pain when your patients present with it. But accurately diagnosing the cause of that pain and treating it appropriately presents much more of a challenge.

In addition to gathering as much information from a detailed history and physical examination and ordering the relevant laboratory and radiographic diagnostic tests, you must appraise each patient’s subjective description of their level of discomfort before determining which pharmacotherapeutic approach—if any—is the best one.

What’s more, today’s charged social and political climate surrounding narcotic painkillers, with frequent media reports of “pill mill” busts, high-profile cases of celebrities with prescription painkiller addiction, and the documented increase in narcotic abuse and overdose among the general public, has many prescribers looking over their shoulder with every pain medication prescription they write. It’s small wonder that so many health care providers tend overlook pain as a primary concern among their patients, even though that pain very likely is what prompted them to seek care in the first place.

To help with this dilemma, we’ve put together this special pain management supplement to Consultant, including the timely, practical article on prescribing opioids for pain in primary care, by Christopher Kolker, MD. The straightforward question-and-answer format offers a sensible approach to bridging the gap between the physiology and psychology of your patients’ pain to help you craft a pain-management plan that not only improves patients’ quality of life and satisfaction, but also steers wide of the many thorny therapeutic and medicolegal pitfalls associated with prescribing narcotic painkillers. Careful and meticulous documentation in the health record is critical to this dual goal.

But while it is important that primary care providers not be afraid to properly prescribe oral opioid analgesics for patients who will benefit from them, it’s also important to view these potent painkillers as just one weapon in the pain-management armamentarium, along with nonnarcotic pain medications, mind-body techniques, physical therapy, and even surgical approaches in some cases.

“Emphasize to patients that narcotics are one aspect of a comprehensive pain treatment protocol,” Dr Kolker writes. “Doing so addresses any unrealistic expectations about the ability of narcotics to control pain.”

Share your personal clinical experiences with pain management with Consultant and your colleagues by posting a comment at Or send a note to, or call me at (800) 237-7285, ext. 4396.


Michael Gerchufsky, ELS, CMPP
Managing Editor, Consultant