The pain scale has been harmful

[Emergent]

This article hits the nail on the head; the pain scale has contributed to the opioid crisis. The pain scale has been the centerpiece of the regulatory policies that are absolutely correlated to the growth of America's love affair with opioid drugs, contributing to the the current rate of overdose deaths at over 50,000 yearly! Over 20,000 Of the deaths result from prescription opioids, more than the 12,000 plus from heroin!

The pain scale shares the blame for the opioid crisis in America

...To help curb this crisis, we need to move away from "the pain scale," including the visual analog scale, and instead ask patients about their abilities to function at work, home and in other daily activities. This is the best way to assess chronic pain syndrome. We need to dive deeper into their physical capabilities, such as how their pain affects their job performance, if at all. We need to ask patients if they are able to hold their children or carry groceries to their car in order to assess the type of pain and how it truly affects their day-to-day lives. With nearly 100 people dying each day from opioid misuse, we must start making changes now. We cannot wait for the right piece of legislation or rely on law enforcement to crack down on every neighborhood. ...

[Nurse SMS, MSN, RN]

I feel so much emotional angst and ethical conflict inside over the current opioid crisis. There is little doubt that healthcare providers are part of the problem and that the impression of a pain-free life or full access to endless narcotics is the other part. At the same time though, people are hurting. I want to say that people just need to accept that pain is part of life and if you are unlucky enough to have severe Crohn's or arthritis or migraines or fibromyalgia or whatever the diagnosis is, that pain is going to be part of YOUR life. And then I put myself in those people's shoes and the compassion and sorrow for them is near to crippling. Sadly though, behaviorally I see these same populations often medicating in anticipation of pain rather than in treatment of it. And then they want benzos for that anxiety because benzos work AND potentiate the pain meds. And then they start to develop tolerance to both the benzos and the opioids, so then we send them to pain management, who enact a contract with them and manage high doses and/or dangerous prescriptions. And then the patient begins to hoard or hide meds and other "addictive" or "manipulative" behaviors begin.

I have family members with this problem. Genuine pain. Out of control need for meds combined with a sense of being entitled to them. Subsequent mistrust of any and everyone in the medical field because we try to put the brakes on the consumption of these meds. Manipulative behavior to get around having the brakes put on. That anxiety leading to increased need. If one is counting pills, hiding pills, searching for reasons to go to the doc to try to get more pills....there's a problem. A family member of mine recently ruined a family vacation with moodiness, sulking and angry behavior because they took too much of their pain meds (outside of the prescribed dosage and frequency), presumably because being active with family in a vacation scenario increased both pain and anxiety...and they thought they had what they referred to as their "emergency stash"...only to be unable to locate said stash, leading to an emotional breakdown that was both sad and and scary to witness. Nothing mattered beyond getting more pain meds. This was a young and otherwise healthy young person who has a minor surgical issue that isn't actually bad enough yet to qualify for surgery.

Round and round it goes. I don't know how to stop it. I feel cruel to say "Some people are going to have to live in pain". But right now, that seems to be what needs to happen. And that sucks. There has to be a middle ground. I need there to be a middle ground. And I don't see one.

[Oldmahubbard]

I am a Psych NP, worked as an RN back in the dark ages. But I vividly recall asking about pain, back in the day and some patients would absolutely deny it. But 5 minutes later, they would be talking about this ache, or that discomfort, or various other similar descriptors.

This was long enough ago that only cancer patients got narcotics. But it wasn't really that long ago. Strange.

[OldDude]

I called a cardio-thoracic surgeon one night for a patient's PAIN 10/10 (he was the only doctor on the case). He wasn't happy and told me "Well, Cardiacfreak, DON'T ASK HIM IF HE'S HAVING PAIN!"

He may just have a point. LOL

You know...this might be the answer. In elementary school nursing you never ask a question that has an end to it. Does your head hurt? Are you hungry? Dose your hair hurt? You can even ask them if their name is Daffy Duck and most of them will say, "yes." So you ask open ended questions like, "what's bothering you," "why are you here in my clinic," and you'll get the real reason.

Keeping this in mind...do you think "most" (of course there are exceptions to everything) patients would NOT tell you if they were hurting to the degree that they thought needed attention? So why not let them volunteer the information instead of giving them a free pass to say yes they are experiencing pain, 10 out of 10 of course.

Just a thought.

[OldDude]

I am a Psych NP, worked as an RN back in the dark ages. But I vividly recall asking about pain, back in the day and some patients would absolutely deny it. But 5 minutes later, they would be talking about this ache, or that discomfort, or various other similar descriptors.

This was long enough ago that only cancer patients got narcotics. But it wasn't really that long ago. Strange.

I believe we've gone to the opposite extreme due to the whole JCAHO mandate; trying to legislate interventions versus allowing health care professionals do individual in depth personal patient assessments.

[Tenebrae, BSN, RN]

I think its deeper than misuse of the pain scale.

(donning my flame proof undies)

I think the insurance based model and the move towards a strong customer service focus, combined with a highly litigous society where some health professionals are so worried about getting sued for random stupidity they are much more free and giving with stronger pain meds than perhaps is clinically indicated

I see my American colleagues talking about stuff and behaviours that would never be tolerated here. Sure, our system is not perfect and its moving more towards a customer service focus than I would like to see. However we would never have to deal with cases like Jahi McMath's corpse being kept alive indefinitely.

We had a patient doing their prunes over medication the other day. The problem was started by another service and we were left to pick up the pieces, the patient was effing and jeffing about how they were going to come back to the ward and break everything, assault staff etc. They were told that if they chose to take that path, the police would be called and they would be charged. One thing we do well is we have a zero tolerance policy towards abuse of staff members

[Rocknurse, MSN, APRN, NP]

I am of the opposite opinion, and in fact am seeing that nurses are feeling empowered to impose their own biases and beliefs onto patients in an exceedingly judgmental way. I've seen too many sanctimonious nurses insist that absolutely no one is in pain and take great pleasure in denying any kind of pain relief. It is not the nurses place to make those judgments and assume that every patient who is in pain is lying, and it angers me to see this kind of behavior amongst so-called professionals. The pain scale is an effective way for the patient to convey to the nurse the severity of the pain. I find it incorrigible that nurses will try to minimize a patient's pain on some misguided preconception because they think everyone is a drug seeker. In a hospital, you are going to see a lot of people in pain. Do not let the minority of true drug seekers cloud your judgment on patients in real pain. You hold a lot of power in this scenario...don't abuse it. Failure to address the very real issue of pain and disseminate it from addiction is failing the patient.

[Here.I.Stand, BSN, RN]

While I agree always offering Tylenol first is not appropriate for all levels or types of pain, I also feel offering up the entire menu of PRNs is going all the way in the opposite direction.

For example (and it might be a bad one, I admit), if a patient complains of constipation, do I let the PATIENT choose which med they want without any clinical considerations? No! I think about the quantity/consistency of any bowel movements they have had, the patient's normal bowel habits, what has caused it, fluid intake, acute/chronic, comorbidities, what has/has not worked in the past according to the patient, and the MOA of the meds in order to choose a PRN or recommend one to the provider.

Why would I treat pain medications any differently than I would a selection of PRN meds for for any other reason?

In my view, something like constipation can be more visually evaluated. We can see/feel a belly's increasing size and firmness. We can see documented the number of days with no BM. We can hear the characteristics or absence of bowel sounds. With pain, there are some who are more stoic than others. This can be cultural, or if the pt has chronic pain they may have developed coping methods (e.g. distraction... so the fact that they are laughing at the TV or talking on their phone tells me nothing.)

I do however, discuss options with other prns -- not just pain meds. In the laxative example, I will say something like "it's been 3 days since your last BM - let's try some MOM. If that doesn't work, they did write for a suppository or an enema." If they tell me that they are on daily Miralax at home (which they forgot to tell the PharmD about when doing their med rec) and that MOM never works, I will get the order for the Miralax and yes, skip the MOM.

Or with anti-emetics, say they have orders for both zofran and compazine. If the pt is c/o mild nausea, I'll probably start with 4 mg of Zofran, but tell them that we can increase the dose and/or try the Compazine if this isn't effective.

Most people who live in their own bodies know their bodies better than I do. I will look at their clinical picture yes, but also include the pt as a central part of their own treatment team.

On the flipside, if the pt is asking for the full mg of Dilaudid... but slurring his words and falling asleep as he's asking for it, I will explain why that isn't safe and why I won't be giving it right then. Reasonable people will understand that they don't want to stop breathing, and that Narcan will reverse not only their respiratory depression but also their pain relief. In my ICU setting, I've never had anyone argue with me on that point.

Side note -- I have never worked in the ED. When I worked on the floor, we did have a handful of pts who exhibited the "typical frequent flyer drug-seeking" behaviors. It was in their record that they would be admitted only with the approval of their primary team, that opioids/benzos could only be ordered by their primary team, and that their doses would not be increased without objective clinical justification (e.g. postop.) That's not the situation I was referring to in my other post.

[OldDude]

I am of the opposite opinion, and in fact am seeing that nurses are feeling empowered to impose their own biases and beliefs onto patients in an exceedingly judgmental way. I've seen too many sanctimonious nurses insist that absolutely no one is in pain and take great pleasure in denying any kind of pain relief. It is not the nurses place to make those judgments and assume that every patient who is in pain is lying, and it angers me to see this kind of behavior amongst so-called professionals. The pain scale is an effective way for the patient to convey to the nurse the severity of the pain. I find it incorrigible that nurses will try to minimize a patient's pain on some misguided preconception because they think everyone is a drug seeker. In a hospital, you are going to see a lot of people in pain. Do not let the minority of true drug seekers cloud your judgment on patients in real pain. You hold a lot of power in this scenario...don't abuse it. Failure to address the very real issue of pain and disseminate it from addiction is failing the patient.

Completely agree...pain assessment should be very specific and individualized for each patient. Here's a case for your point Rocknurse. My Sweet Petunia is a Home Health PT. She sees a lot of fresh knee and hip replacements. The key to successful rehab for these patients is movement. Historically she calls her joint patients about an hour before her planned arrival (all preplanned) to remind them to take their pain medication, and in so doing, they are able to make better progress with ROM exercises, and other physical torture she puts them through, during the therapy visit; hence, a faster recovery to independence. Joint replacement rehab is extremely painful. But, now that we are in the midst of the opiod crisis, she is seeing patients come home from the hospital with virtually ineffective pain control medication which greatly inhibits their rehab. Sad, very sad.

[Guest219794]

I am of the opposite opinion, and in fact am seeing that nurses are feeling empowered to impose their own biases and beliefs onto patients in an exceedingly judgmental way. I've seen too many sanctimonious nurses insist that absolutely no one is in pain and take great pleasure in denying any kind of pain relief. It is not the nurses place to make those judgments and assume that every patient who is in pain is lying, and it angers me to see this kind of behavior amongst so-called professionals. The pain scale is an effective way for the patient to convey to the nurse the severity of the pain. I find it incorrigible that nurses will try to minimize a patient's pain on some misguided preconception because they think everyone is a drug seeker. In a hospital, you are going to see a lot of people in pain. Do not let the minority of true drug seekers cloud your judgment on patients in real pain. You hold a lot of power in this scenario...don't abuse it. Failure to address the very real issue of pain and disseminate it from addiction is failing the patient.

How many sanctimonious nurses insisting that absolutely no one is in pain and taking great pleasure in denying any kind of pain relief have you seen?

I have never seen this.

Not once.

Seriously.

What kind of hell hole do you work in?

[JKL33]

I have never seen this.

Not once.

Seriously.

Ditto.

Not trying to be argumentative. I literally haven't seen it.

[Tenebrae, BSN, RN]

How many sanctimonious nurses insisting that absolutely no one is in pain and taking great pleasure in denying any kind of pain relief have you seen?

I have never seen this.

Not once.

Seriously.

What kind of hell hole do you work in?

I saw something similar when I was a student. My allocated patient had multiple arterial ulcers and in alot of pain from them.

Patient had morphine charted which worked well to dull the pain. One of those situations when the patients pain was adequately addressed he could sit up in bed, read, talk to his neighbour, when he was in pain, he was curled up under the bed covers in as tighter ball as possible.

Patient had a history of alcohol misuse.

Arriving on shift I saw patient was in pain, and went to get him some analgesia. The allocated nurse for the patient said "oh well he's an alcoholic".

My rational inner voice is going "what the hell does that have to do with ANYTHING"

My PC student side was going "he seems to be in pain. It would be good practice for me to draw up the meds, if you are busy I can ask the clinical tutor to check the meds out with me"

The nurse mumbled that she was happy for me to give the meds with the clinical tutor. The patient got their pain relief and within 15-20 minutes was able to sit up in bed and looked 150% relaxed

As a nurse, I dont see it often. Fortunately I work in an area that is big on effective palliative care and we dont often get nurses with that sort of attitude.

[Guest219794]

I saw something similar when I was a student. My allocated patient had multiple arterial ulcers and in alot of pain from them.

Patient had morphine charted which worked well to dull the pain. One of those situations when the patients pain was adequately addressed he could sit up in bed, read, talk to his neighbour, when he was in pain, he was curled up under the bed covers in as tighter ball as possible.

Patient had a history of alcohol misuse.

Arriving on shift I saw patient was in pain, and went to get him some analgesia. The allocated nurse for the patient said "oh well he's an alcoholic".

My rational inner voice is going "what the hell does that have to do with ANYTHING"

My PC student side was going "he seems to be in pain. It would be good practice for me to draw up the meds, if you are busy I can ask the clinical tutor to check the meds out with me"

The nurse mumbled that she was happy for me to give the meds with the clinical tutor. The patient got their pain relief and within 15-20 minutes was able to sit up in bed and looked 150% relaxed

As a nurse, I dont see it often. Fortunately I work in an area that is big on effective palliative care and we dont often get nurses with that sort of attitude.

Pain management specialists could answer this better than me, but in my anecdotal experience, it is very relevant. Issues include tolerance, inadequately controlled withdrawal, manipulation......

The patient has a particular diseases that effects all aspects of care.

So, that nurse may have been displaying either an understanding of these issues. Or, as your impression, complete ignorance. Or, maybe she was a judgmental jerk who allowed personal feelings to interfere with patient care.

But, she did not deny the existence of pain, and display glee at the opportunity to withhold medication.

" I've seen too many sanctimonious nurses insist that absolutely no one is in pain and take great pleasure in denying any kind of pain relief.