Quote from verene
I'm not sure how the pain scale contributes to addiction. While patients could certainly use more education around pain and the use of the pain scale. It does allow a metric to show improvement or lack of improvement in a pain rating. If rattled off quickly and given with out any reference points, yes it is meaningless, but this is where active listening, patient education and clinical judgement come in.
It is important to talk through the scale as it relates to function, providing patients with a reference for how impact and the scale line up. For example a 1-2 score is generally minimal pain that you don't feel unless focusing on the pain, a 3 or a 4 is pain that is always present but only minimally impacts your activities, a 5 or 6 is pain is pain that can't be blocked out and forces one to give up or avoid activities, etc.
Use of the pain scale can actually be beneficial to showing patients why they don't need opioids and setting realistic goals around pain management. A patient may say that they are still having pain, but when you talk to them about how Tylenol has helped dropped their pain from a 6 to their current score of 2 it helps to re-calibrate awareness. As can normalizing pain as part of the injury/illness and healing process, and showing how a little pain can actually be beneficial (e.g. if your foot hurts when you step on it it's a good reminder to limit how much walking you are doing while it heals, and maybe it is time to prop it up again for a little while).
Furthermore addiction is a separate issue from pain. Addiction is a psychological issue - a person seeking a substance or activity because it triggers positive feelings in the brain. And these positive feeling are not the stereotypical "high" but a feeling of "normal" or of avoiding the "terrible" of physiological withdrawal.
Rather than making talking about pain even more convoluted, it is important to both 1) set reasonable expectations around pain management with patients, and 2) examine the underlying factors that motivate addiction. What is going wrong in a persons life or neurochemistry that is prompting the need for addictive substances (or even substances which are not routinely thought of as addictive, but which may be to an individual)? Frequently addiction is rooted in historic and current life traumas, and treating addiction requires treating those underlying psychological factors in order to be successful.
I whole heartedly agree that opioid addiction and abuse is a problem in this country, that we don't do a good job of managing pain or education patients about it, and that addiction is a serious issued. I just don't think you can conflate the existence of the pain scale to causal factor of opioid overdose deaths.
"I'm not sure how the pain scale contributes to addiction."
It plays a small role in a bad system in which we set unreasonable expectations. When we fail to meet those expectations, we get poor satisfaction ratings. There are some pretty good links between striving for good ratings and sub optimal prescribing.
If I ask you what your pain is, and you tell me it is 9/10, you have reasonable expectation that I will do something to lower this number. Why else would I ask? Chances are excellent that I will actually not do anything that causes you to give me a lower number. Let's say I give you some Toradol. Then, I come back in a half hour, and it is still 9/10. or 8/10, or maybe it has gone up to 13/10, and you tell me that you have an incredibly high pain tolerance, and when Dr Feelgood is on, you always get........... I have now failed to meet your expectation twice. Somehow, despite having pain worse than a guest at the Hotel Guantanamo , you muster the strength to fill out a customer satisfaction survey.
In truth, I never even cared what your numeric pain rating is. The pain scale is one of many tools I have at my disposal, and I do find it helpful in a subset of patients. I only asked the above PT about pain scale because if I don't tick enough boxes on my computer, I have go to my boss's office. Again. I might just buy my own chair for that place.
Some examples of PT's for whom I find pain scale helpful:
- Cancer PTs
- Many actual trauma PTs
- Post surgical/procedure PTs
- High functioning chronic pain PT's- people with jobs, family responsibilities, etc....
Some examples where I tend use other assessment skills:
- HX drug abuse
- HX frequent narcotic RXs
- Multiple non-narcotic allergies
- Many chronic pain PTs
As a nurse, it is my job to do a good assessment and advocate in the best interest of my PT. I don't count checking a box on a computer screen as doing my job.
I see one of the problems with the pain scale is that it has, for some, become a substitute for actually assessing and managing pain. And doing a poor job managing pain has definitely been a contributor to the opioid crisis.
So while the pain scale did not cause this crisis, it is a ubiquitous component of a failed system that has resulted in a national health crisis. As such, it is certainly worth questioning.
Your response is both well written and well informed. It focuses on education. And, I think this is a great approach to those open to education. There is a huge number of patients with pain who are looking to minimize recovery time and maximize functionality. I can see good pain scale education being effective with these folks. And it would be great to meet more of them. But in my ER, they are definitely in the minority.
We live in a culture in which the equation problem = pill
has become a reality. millions of people experience pain when their body revolts against the garbage they put into it. The solution? PPI. I know I am predisposed to diabetes, but OMG, have you even tasted the new Sweet BBQ Bacon With Buttermilk Crispy Chicken? It's to die for. Seriously. So, about that metformin.....
There are countless medical problems for which the approach you advocate- motivation and education- is effective. In fact most of them. But, because of the minute number of willing participants in their own health, the "solution" is chemical rather than behavioral.
Our chemical approach to general medical management is, by some measures, effective. For example, it is working great for Eli Lilly and crowd who have invested their profits into the best legislators money can buy.
But when it comes to pain management, the idea that all problems have a chemical solution, has proven to be a huge failure.
A hammer is a handy tool for a homeowner. Very useful in some situations, useless in others. The same can be said for the numeric pain scale. While it can be of value in many situations, it can help make some problems worse. It should be used as an adjunct to sound clinical skills, good judgement and effective policy, not a substitue for them.