When Pain Became a Vital Sign: How a Healthcare Slogan Helped Fuel an Opioid Crisis

Pain is real. I know that clinically, but I also know it personally.

For years, I dealt with intense lower back pain. It became part of my daily operating system. I worked around it, compensated for it, stretched carefully, sat differently, stood differently, and wondered if this was just what my body was going to feel like from now on. At one point, I saw an orthopedic surgeon who recommended surgery. Other providers recommended medication. Or physical therapy. Or injections. I understood why those options were offered, and I am not suggesting they were inappropriate. But I didn’t choose any of those paths.

During that same stretch of life, I was pushing through my bachelor’s, master’s, and doctoral degrees. That meant years of school layered on top of work (…12 hour shifts, upwards of 50/hours per week), family responsibilities (newborn to toddler years…eekkk), limited sleep (4 hours a night, max), constant deadlines (schoolwork, certifications, CEUs…), and the kind of stress that slowly becomes background noise. You do not always realize how much your body is carrying until it finally gets permission to stop carrying it.

Then something interesting happened. After I finished school, I started sleeping more, getting back on a structured exercise routine, eating nourishing meals. My stress level dropped. My nervous system seemed to downshift. And without surgery, without a new medication, and without any dramatic treatment plan, the back pain essentially went away.

That experience (nearly a decade of time) changed the way I think about pain. Not because the pain was “in my head,” and not because it was fake. It was very real. But it was also connected to more than my spine. It was connected to stress, sleep, workload, tension, and the way my body was trying to survive a long season of overload. That is the part healthcare often struggles with. Pain can be real and still be complicated.

Anyone who has worked in healthcare knows pain can dominate a patient’s attention, limit mobility, worsen anxiety, delay recovery, and turn an already frightening medical experience into something even harder. Patients deserve to have their pain believed, assessed, and treated. But pain was never a vital sign.

A vital sign is supposed to reflect a physiologic measurement. Something objective. A patients’ temperature, pulse, respirations, blood pressure, oxygen saturation. These are not perfect measures, but they are objective enough to trend, compare, and respond to clinically. Pain is different. Pain is subjective, personal, emotional, neurologic, cultural, psychological, and situational. That does not make it less important. It makes it more complex. And healthcare made a dangerous mistake when it tried to turn that complexity into a number.

The phrase “pain as the fifth vital sign” is commonly traced to the American Pain Society in the mid-1990s¹. The stated goal was understandable: pain was often undertreated, and patients were suffering. The Veterans Health Administration later adopted a “Pain as the 5th Vital Sign” strategy as part of a broader national pain-management effort.

On paper, that sounds compassionate. In practice, it helped create a metric. Once pain became a number, healthcare systems began to treat that number as something to reduce. Nurses asked for a score. Patients gave a score. Clinicians documented the score. Hospitals tracked the score. And in a healthcare culture increasingly shaped by patient satisfaction, accreditation pressure, and quick measurable outcomes, lowering the pain number became a clinical and institutional priority.

And, as well-intentioned as it was, the creation of that single metric is where the story becomes much darker.

Pain as the fifth vital sign did not spread in isolation. It grew inside a professional and commercial ecosystem that opioid manufacturers helped fund, promote, and exploit. Court records filed by the California Attorney General allege that the American Pain Society, “with the support of Purdue,” (Purdue refers to Purdue Pharma, which at the time, was owned and operated by the Sackler Family) recommended treating pain as the fifth vital sign. The same complaint alleges that Purdue was “instrumental” in promoting the movement through grants, promotional materials, sales training, field implementation, and even registering 5thvitalsign.com (which, at the time of this writing is no longer in use)².

The Minnesota Attorney General’s complaint similarly alleges that Purdue helped “create and capitalize on” the medical community’s increased focus on pain treatment, while using third-party organizations to promote opioid-friendly messages under the appearance of neutrality³. The complaint also names Sackler family members as defendants and alleges that Sackler leadership helped drive Purdue’s broader opioid marketing strategy. I must point out here, that the aforementioned are allegations in legal complaints, not [necessarily] final judicial findings on every claim. But they are serious, documented, and consistent with the broader public record of Purdue’s opioid marketing practices.

Suffice to say, the official making pain a vital sign so practitioners would take it seriously is not the whole story. It may be the clean version. The version that says healthcare finally took pain seriously. However, tthe fuller story says healthcare took pain seriously [coincidentally] at the exact moment a powerful pharmaceutical company was aggressively promoting opioids as the answer.

And that, that is worth noting. Whether as a healthcare professional giving care, or a patient receiving care.

Purdue and the Sackler family did not need to invent pain. They did not need to invent suffering. What they did need, was a healthcare culture primed to believe that aggressive pain control was compassionate care, that opioids were safer than previously feared, and that a lower pain score represented better treatment. The “fifth vital sign” movement helped create that culture. It gave pain a number, and that number became clinically powerful, institutionally measurable, and commercially useful.

This doesn’t mean every prescription was wrong. They weren’t. It doesn’t mean opioids have no place in medicine. They do. Severe acute pain, trauma, surgery, cancer pain, palliative care, and selected clinical situations certainly justify opioid treatment. There is no debate on that. The problem was not treating pain. The problem was oversimplifying pain. Overmedicalizing the score. And allowing industry-funded messaging to push healthcare toward a dangerous default: pain number high, opioid solution fast.

That is not patient-centered care. That is metric-centered care dressed up as compassion.

Nurses lived inside this system. We were the ones asking the pain score, documenting the reassessment, paging the provider, dealing with dissatisfied patients, watching respiratory rates, giving naloxone, and trying to balance real suffering against real risk. We saw the tension firsthand. Pain mattered. But so did -and does- sedation, falls, constipation, dependence, withdrawal, overdose, diversion, and the quiet devastation that followed many patients long after discharge.

The lesson is not that pain should be ignored. The lesson is that pain should never again be flattened into a vital sign.

Pain is not simply a problem to eliminate. In many ways, pain is protective. It is the body’s warning system, telling us something is injured, inflamed, overloaded, irritated, or unsafe. Pain tells us to stop touching the hot stove, rest the sprained ankle, avoid the movement that worsens the injury, or pay attention to something that needs care. Of course, pain is not always perfectly accurate. Sometimes it becomes chronic, amplified, or disconnected from ongoing tissue damage. But even then, pain is still information. It deserves interpretation, not just suppression.

That is why the old “zero to ten” (Numeric Rating Score, NRS) mindset was never enough⁴. A number can tell us intensity, but it does not tell us meaning. It does not tell us function. It does not tell us risk. It does not tell us whether the goal should be comfort, mobility, sleep, breathing, wound healing, emotional support, diagnostic investigation, or simply helping the patient feel safe.

The future of pain care should shift from pain scores to pain function. Healthcare should stop treating pain intensity as a stand-alone quality metric and instead assess pain as part of a broader clinical picture: function, mobility, sleep, breathing, mood, safety, diagnosis, risk of harm, treatment response, and the patient’s actual goals.

That means asking better questions. What is the pain preventing you from doing? What do you think the pain is telling you? What level of pain is tolerable? What are we trying to improve: comfort, function, sleep, mobility, wound healing, breathing, dignity? What treatments carry the least harm? What risks does this patient have for opioid-related complications? What non-opioid and nonpharmacologic options are realistic, available, and appropriate?

Is that a harder ‘number’ to collect; yes. Is it a better model of care; also, yes.

I want to be very clear here; pain deserved assessment. Pain deserved compassion. Pain deserved serious clinical attention. But pain was never temperature. It was never pulse. It was never blood pressure. And when healthcare pretended otherwise, it created a simple metric that was vulnerable to manipulation by companies that had billions of dollars riding on the answer.

As pain treatment reform is ongoing, one thing should be wholly clear: retire pain as a vital sign completely, stop rewarding pain-score reduction as proof of quality, and build pain care around function, safety, informed consent, individualized goals, and the clinical meaning of pain itself.

In closing, as healthcare providers, we are certain of several things: pain is real. The slogan was dangerous. And, the metric failed. The future of pain care should be measured not by whether we made the number smaller, but by whether we understood the signal, reduced suffering safely, and helped the person live better and leave safer.

-Mitch