This was the report that kicked off the current opioid crisis in earnest. The Joint Commission, an accrediting agency, suggested that hospitals take pain management more seriously, and tie rewards to patient satisfaction with pain management. PDF
The opening lines set the tone:
Despite ongoing, significant advances in treatment options, studies indicate that pain continues to be poorly managed and undertreated. The increase in clinical information related to pain management, as well as recent high-profile press coverage of individual cases of undertreatment, has resulted in heightened awareness among health care professionals and the public that this critical issue must be addressed.
This in itself isn’t bad. But in practice it led to the opioid epidemic, killing tens of thousands (maybe eventually hundreds of thousands) of people.
One of the visible elements of the shift was the use of the Wong-Baker FACES Scale
Some of the shift was based on surprisingly small studies. See Perils of a Small Study, Opioid Edition
JCAHO was at the core of the opioid epidemic. See JCAHO and the Opioid Epidemic