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. ...

[OldDude]

I too have never met a nurse or other healthcare professional that derives pleasure from withholding pain medication. I've run across bitter skeptics who grudgingly follow the MD order and complain about it but otherwise that's it.

I still think the pain scale, in and of itself, is certainly a communication tool but should not be used exclusively. Governmental bureaucracy's telling healthcare professionals that the patient's pain is what the patient tells you it is, is laughable, and I think it's from this that the pain scale attachment for blame for contributing to the opiod crisis arises. As I've said, pain assessment is an individual, in-depth, examination of many factors; objective and subjective.

Unfortunately, the backlash of the opiod crisis is that prescribers are being more conservative and not facilitating the use of medications that properly control pain...the pendulum seems to never stop in the middle.

[Nurse SMS, MSN, RN]

I have seen, to be honest, many attempting to stop in the middle by prescribing sensible pain medication regimes. Unfortunately though, some of these patients are accustomed to having more, either dosage or frequency or refills or even number of physicians willing to write them scripts....

Now with this crackdown they cannot get early refills, pharmacies are monitoring for multiple prescriptions, patients are being required to sign pain contracts and there are state databases that actually get checked for prescriptions, medications and doctor shopping. When these patients get admitted, the reasonable meds prescribed for bedside pain control are not adequate, because the patients are actually accustomed to a higher dose than their real prescriptions state. So they are not adequately treated, because admitting they don't follow their regime appropriately means they admit they are not using pain meds appropriately and are in violation of their contract. Therefore pain control is inadequate and a "sensible" dosing amount and schedule no longer looks or feels sensible in their case.

It is so disheartening and demoralizing, both for the patient and for the healthcare workers. I have genuine moral distress over the subject. There just doesn't seem to be any good answers. Sadly, a lot of the patients upset about this have been taking such high levels of these drugs for so long that any cut in supply is going to seem "unreasonable". That doesn't mean it isn't, but it does make me wonder where the line ought to be drawn. There is no doubt there has to be a line somewhere, because people are dying in droves.

[Susie2310]

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.

As you pointed out, it is important to include the patient in their care as they know their own body best. Patients are supposed to be included in decisions about their care, not just have our treatment decisions imposed on them.

[Tenebrae, BSN, RN]

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 patients drug of choice was alcohol, not morphine. Patient had never abused any other drugs, both prescribed or illegal

As for managing with drawl, the patient had been undergoing regular monitoring for signs of DTs and administration of meds to address the symptoms

The bigger issue, was that the patient wasn't asking for pain relief. And yes it could be argued that the patient was not in pain, however as I've learned in my six years since graduation, a patients non verbal language often says more about their symptoms than their verbal language. And the non verbal language indicated that the patient had severe pain. The wound specialist also was pretty adamant that arterial ulcers are incredibly painful and the patient needs to have adequate pain relief on board at all times.

Like I said, the patients presentation when their pain was adequately addressed was very different than when it wasnt.

When the patient's pain was controlled, they were able to sit up in bed, read their book actually eat some food. When the patients pain wasnt addressed, they didnt eat, hardly slept and spent most of the day curled up in as small ball as possible

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

Never said she overtly denied pain relief, however I'd put money on that if I hadnt of pushed and offered to do it with my then clinical instructor it the patient wouldnt have gotten their pain relief

[K9lover, ASN, RN]

Patients with chronic pain have been thrown under a very big bus all in the interest of what? Most heroin addicts never had a legit Rx. This is why I do not work as a hospital nurse anymore; we were all told pain is what the patient says it is, pain is 5th vital sign etc...and now pendulum has swung so far pain is not being treated at all. This is like telling a restaurant patron they may not have a 2nd glass of wine because other people abuse alcohol. That and we do not have a prescription opiate 'crisis'. What we have is a law enforcement agency (DEA) dictating doctor-patient relationship in treating pain.

We even renamed it 'opiate use disorder' just for white people, isn't that special? As with the 1980s 'war on drugs' part one we have plenty of jails for all the non-white, inner city addicts...