I work in the ER, therefore encounter many people with opiate problems. A lot of them, frankly, are unsophisticated people with low levels of education. We use the pain scale because we are required to. Many of these folks have been working the system for years, and are conditioned, like Pavlov's dog, to give a number that will give a result they need. We play along because we are required to put a number in.
I think the whole system is mostly highly inaccurate and subjective. A 10 often means how much they want the drug. The pain scale has contributed to our national sense of entitlement to be pain free through drugs.
I do find the pain scale useful with cardiac pain, but by and large, for the opiate seeking population, it contributes to the nationwide drug problem we are facing.
The socioeconomic and educational level of my patients is pertinent. Less sophisticated people, with poor adaptive skills, are easily swayed by a healthcare system that doled out opiates the past 30 years like candy.
The healthcare system set these people up for this. Now there is a gnashing of teeth about addiction.
Enshrining the pain scale as sacred contributed, in my opinion. The most vulnerable members of society were like sheep to the slaughter, lacking coping skills.
So ... what alternative to the pain scale do you recommend?
Obviously the system is broken and abused, but the path of least resistance is to let it continue. I don't want to argue with Drugs Bunny every time he or she is angling for another dose of drugs. If the person isn't presenting as over-sedated or reacting adversely to the drug, I really don't see the point in trying to start something.
I generally am not in favor of one size fits all scales that are so popular these days.
But, what's wrong with mild, moderate, and severe as reported by pt? Then add the nurses observations of the pt's behavior and VS.
That's a good idea, at least for the ED which shouldn't be treating chronic pain anyway. My concern would be the behavioral aspects, even for acute pain. Too many of us are stuck in the narrow stereotype of how pain is "supposed" to look. That's not how it looked on me when I broke my wrist, mainly because of my personal history and cultural background. If it wasn't for the obvious severe deformity of my wrist and a sky-high blood pressure, I doubt that I would have been believed.
People having an acute episode of a chronic pain condition (migraineurs, sickle cell, trigeminal neuralgia) have often developed strategies for surviving severe pain until some relief is forthcoming. That would be reflected in their behavior, which sometimes can resemble that of a drug-seeking addict.
My main point, though, is that pain and addiction, although frequently intertwined, are actually two different problems that should not be conflated. Addiction behaviors often include lying about pain, but not all pain complaints are a lie. Complaints and ratings are actually only part of the data that needs to be considered - not the only thing. It's the oversimplification of assessments - probably necessary in the ED, but no excuse for it elsewhere - that's the problem, in my opinion.
You're right - there is no "one size fits all" solution.
Let's try to remember that this whole pain scale idea came about because doctors and nurses had been so imbued with the fear of addicting their patients that someone had to be literally dying before true pain relief was regarded as a right and not a privilege.
Of course, marketing long-acting drugs like MSContin and OxyContin also had something to do with it...but that's a whole 'nother can of worms.
As professionals, I think we need to stop thinking with our emotions, stop swinging back and forth between extremes, and start asking, What is the real problem and how do we address it without causing further harm?
My first comment to many of the posts would be, the ER is just not the place to address long-term, complex issues like addiction. You also see diabetics, hypertensives, and obese people who are actively hurting themselves by refusing to care for themselves the way they know they should, but I rarely hear the kind of anger and disgust routinely directed at addicts also being directed at these unhealthy people who aren't doing their very best. Addicts seem to bring out the worst in healthcare professionals, and I just don't understand it. They are sick, just like anyone else, and they learn the lying, sneaky, manipulative behavior they often (though not always--not all addicts are liars or manipulators) display because they know how healthcare professionals look down on them, judge them, despise them. You wouldn't try to find ways to deny a diabetic in ketoacidosis his insulin--why do you feel you should try to deny a suffering addict in withdrawal his "medication?"
Again, the ER isn't the place for complex behavior modification. You tell the non-compliant diabetic the possible consequences of his behavior, highlight what he needs to do to care for himself better, and maybe try to hook him up with an educator, a support group, or some other resource where long-term needs can be better-addressed. How about doing the same for the addict? Be fair--next time, instead of fuming about how the addict is wasting your time, or giving him the evil eye while you push his morphine, treat him more like a patient and less like a pariah.
The problem being that the ED really is swamped with addicts seeking to score, so they have no choice but to address addiction behavior. I actually agree that easy access to legal drugs thru the ED has contributed (but not caused) the spike in addictions. It's a tough nut to crack (pun intended ) The trick is to avoid enabling addicts as much as possible while staying responsive to people with real pain issues that need assessment and relief.
I've read that some facilities have had some success with "no-fly" lists and enhanced access to patients' prescription histories across pharmacies and hospitals. Of, course, you need docs and administrators able to stand firm when it's time to say no ... and junkies don't make it easy. Once word gets around, though, they tend to take their business elsewhere.
No, my thoughts are pain scales haven't caused addiction - people with little self control are the root of addiction.
There will always be pain in health care, which requires humane management. When I use a pain scale trying to get a feel for level of pain I give them verbal cues, such as, "If 0 was no pain at all, and 10 was being in a meat grinder, what level would your pain be?". Rarely do I get a 10/10 that I would doubt, but then again I'm not administering narcotics any more in my job - I do telephone triage now, so I help them decide what next to do (home care, appt in clinic, or ER/UC).
There has always been people who milk anything, which is unfortunate, because people who really are suffering many times keep right on suffering.
Yes, it probably has a small role in this disaster.
When you ask in those terms, and are told 8/10, it develops an expectation that you are going to do something to lower the pain rating. By "something", I mean give narcotics. When you re-asses, and it is still 7/10, the person has a reasonable expectation that you are going to do "something" more. I try to avoid re-assessing when I know we aren't going to give more narcotics.
As a nurse, providing appropriate pain control is important to me. But, the 1-10 scale is only occasionally helpful, and often just a box to check. I might advocate for a gram of tylenol for a pt with 12/10 pain, and 2 mg of dilaudid for 3/10 pain. I use my judgement and experience, as well as developing a rapport with my pts.
The scale itself has lost meaning- it has fallen victim to inflation. We all know nobody walking/talking/eating has 90% of the pain possible. Dousing that person with gasoline and lighting it would easily double that pain, and taking a weed whacker to their head as they burned would bump it up even more.
I don't even know what number I would use if I wanted to get narcotics for pain for myself. The one time the issue came up was for an injury that was too painful for me to walk or move, so I ended up in an ambulance. Trying to get up to pee left me wincing, unable to move. At the time, I rated it 4/10. Not trying to be macho, I am just mathematically inclined. I believe that experiencing 50% of the pain possible would be agonizing.
But, when I hurt my back so badly I knew narcotics would be the only thing to help, I had to think "what number should I give to get narcotics."
So, as a one size fits all assessment tool, I think it has outlived it's useful life, and probably has a minute role in a colossal problem.
And on another note:
As nurses many of us want to help people. When you give a medicine to somebody, you either help them or hurt them. Many of us believe that providing narcotics to drug abusers, or narcotics that will be subsequently sold to abusers hurts them.
These threads always bring up the same themes about not being judgmental. Some folks will chime in on on how they experience pain differently, etc, etc. Outlier examples and cultural differences always come up. This is never what these OPs are originally about. We all get that somebody could be in agony, and not express it in a way we understand.
"How can you know how much pain......" Yup. We get it. Pain is an individual experience.
But- if, for example, you actually believe that somebody is allergic to NSAIDS and mild narcotics, but can tolerate mind altering, commonly abused drugs, then you are incredibly naive. Nursing requires good assessment tools and an ability to read people.
These threads are really about these PTs:
Common Characteristics of the Drug Abuser:
Unusual behavior in the waiting room;
Assertive personality, often demanding immediate action;
Unusual appearance - extremes of either slovenliness or being over-dressed
May show unusual knowledge of controlled substances and/or gives medical history with textbook symptoms OR gives evasive or vague answers to questions regarding medical history;
Reluctant or unwilling to provide reference information. Usually has no regular doctor and often no health insurance;
Will often request a specific controlled drug and is reluctant to try a different drug;
Generally has no interest in diagnosis - fails to keep appointments for further diagnostic tests or refuses to see another practitioner for consultation;
May exaggerate medical problems and/or simulate symptoms;
May exhibit mood disturbances, suicidal thoughts, lack of impulse control, thought disorders, and/or sexual dysfunction;
Cutaneous signs of drug abuse - skin tracks and related scars on the neck, axilla, forearm, wrist, foot and ankle. Such marks are usually multiple, hyper-pigmented and linear. New lesions may be inflamed. Shows signs of "pop" scars from subcutaneous injections.
Modus Operandi Often Used by the Drug-Seeking Patient Include:
Must be seen right away;
Wants an appointment toward end of office hours;
Calls or comes in after regular hours;
States he/she's traveling through town, visiting friends or relatives (not a permanent resident);
Feigns physical problems, such as abdominal or back pain, kidney stone, or migraine headache in an effort to obtain narcotic drugs;
Feigns psychological problems, such as anxiety, insomnia, fatigue or depression in an effort to obtain stimulants or depressants;
States that specific non-narcotic analgesics do not work or that he/she is allergic to them;
Contends to be a patient of a practitioner who is currently unavailable or will not give the name of a primary or reference physician;
States that a prescription has been lost or stolen and needs replacing;
Deceives the practitioner, such as by requesting refills more often than originally prescribed;
Pressures the practitioner by eliciting sympathy or guilt or by direct threats;
Utilizes a child or an elderly person when seeking methylphenidate or pain medication.
A drugged up population does not rise up and implement radical change. I really believe this pain scale crap has been instituted by the government and/or big pharma (hello, lobbyists?!) in attempt to subdue the general populous.
Yes, it probably has a small role in this disaster.
When you ask in those terms, and are told 8/10, it develops an expectation that you are going to do something to lower the pain rating. By "something", I mean give narcotics. When you re-asses, and it is still 7/10, the person has a reasonable expectation that you are going to do "something" more. I try to avoid re-assessing when I know we aren't going to give more narcotics.
As a nurse, providing appropriate pain control is important to me. But, the 1-10 scale is only occasionally helpful, and often just a box to check. I might advocate for a gram of tylenol for a pt with 12/10 pain, and 2 mg of dilaudid for 3/10 pain. I use my judgement and experience, as well as developing a rapport with my pts.
The scale itself has lost meaning- it has fallen victim to inflation. We all know nobody walking/talking/eating has 90% of the pain possible. Dousing that person with gasoline and lighting it would easily double that pain, and taking a weed whacker to their head as they burned would bump it up even more.
I don't even know what number I would use if I wanted to get narcotics for pain for myself. The one time the issue came up was for an injury that was too painful for me to walk or move, so I ended up in an ambulance. Trying to get up to pee left me wincing, unable to move. At the time, I rated it 4/10. Not trying to be macho, I am just mathematically inclined. I believe that experiencing 50% of the pain possible would be agonizing.
But, when I hurt my back so badly I knew narcotics would be the only thing to help, I had to think "what number should I give to get narcotics."
So, as a one size fits all assessment tool, I think it has outlived it's useful life, and probably has a minute role in a colossal problem.
And on another note:
As nurses many of us want to help people. When you give a medicine to somebody, you either help them or hurt them. Many of us believe that providing narcotics to drug abusers, or narcotics that will be subsequently sold to abusers hurts them.
These threads always bring up the same themes about not being judgmental. Some folks will chime in on on how they experience pain differently, etc, etc. Outlier examples and cultural differences always come up. This is never what these OPs are originally about. We all get that somebody could be in agony, and not express it in a way we understand.
"How can you know how much pain......" Yup. We get it. Pain is an individual experience.
But- if, for example, you actually believe that somebody is allergic to NSAIDS and mild narcotics, but can tolerate mind altering, commonly abused drugs, then you are incredibly naive. Nursing requires good assessment tools and an ability to read people.
These threads are really about these PTs:
Common Characteristics of the Drug Abuser:
Unusual behavior in the waiting room;
Assertive personality, often demanding immediate action;
Unusual appearance - extremes of either slovenliness or being over-dressed
May show unusual knowledge of controlled substances and/or gives medical history with textbook symptoms OR gives evasive or vague answers to questions regarding medical history;
Reluctant or unwilling to provide reference information. Usually has no regular doctor and often no health insurance;
Will often request a specific controlled drug and is reluctant to try a different drug;
Generally has no interest in diagnosis - fails to keep appointments for further diagnostic tests or refuses to see another practitioner for consultation;
May exaggerate medical problems and/or simulate symptoms;
May exhibit mood disturbances, suicidal thoughts, lack of impulse control, thought disorders, and/or sexual dysfunction;
Cutaneous signs of drug abuse - skin tracks and related scars on the neck, axilla, forearm, wrist, foot and ankle. Such marks are usually multiple, hyper-pigmented and linear. New lesions may be inflamed. Shows signs of "pop" scars from subcutaneous injections.
Modus Operandi Often Used by the Drug-Seeking Patient Include:
Must be seen right away;
Wants an appointment toward end of office hours;
Calls or comes in after regular hours;
States he/she's traveling through town, visiting friends or relatives (not a permanent resident);
Feigns physical problems, such as abdominal or back pain, kidney stone, or migraine headache in an effort to obtain narcotic drugs;
Feigns psychological problems, such as anxiety, insomnia, fatigue or depression in an effort to obtain stimulants or depressants;
States that specific non-narcotic analgesics do not work or that he/she is allergic to them;
Contends to be a patient of a practitioner who is currently unavailable or will not give the name of a primary or reference physician;
States that a prescription has been lost or stolen and needs replacing;
Deceives the practitioner, such as by requesting refills more often than originally prescribed;
Pressures the practitioner by eliciting sympathy or guilt or by direct threats;
Utilizes a child or an elderly person when seeking methylphenidate or pain medication.
These threads may be about addicts, but they always conflate addiction with pain in ways that betray profound ignorance of both conditions. No excuse for it in my opinion, as the information about pain goes back before I had a license (44 years) and addiction almost as long.
To state what should be obvious, addicts most certainly use complaints of pain as a tactic, no one has contested that. That does not mean that everyone who complains of pain without displaying the distorted, stereotyped behaviors that are cited as "proof" that pain is real, is apriori an addict.
And, no ... the pain scale was not developed by or for the benefit of either drug companies (although they have certainly exploited it) or a government wanting a docile citizenry. We have alcohol, the entertainment industry and the sacrament of consumerism to do that.
Modern pain management grew out of the hospice movement and our evolving understanding of the morbidity and mortality associated with unrelieved pain. Yes - mortality ... depression is a common, almost universal, complication of long-term unrelieved pain, the end stage of which is suicide.
I'll say it again, it's not the pain rating that's the problem. It's the incompetent use of it that gives addicts their opening to game the system.
Specializes in Huntingtons, LTC, Ortho, Acute Care.
I always felt like we should have two pain scales.
subjective- patient states 9/10 aching throbbing deep pain to LLQ
objective- patient posture is relaxed, playing on phone, laughing with visitor in room. Or rigid posturing, tight jaw, watery eyes.
i think if we had a subjective and objective scales, that then added both segments and averaged them we could have a "true" pain score. Patients give high numbers cause they know anything less than 7or 8 will be Tylenol or toradol
I always felt like we should have two pain scales.
subjective- patient states 9/10 aching throbbing deep pain to LLQ
objective- patient posture is relaxed, playing on phone, laughing with visitor in room. Or rigid posturing, tight jaw, watery eyes.
i think if we had a subjective and objective scales, that then added both segments and averaged them we could have a "true" pain score. Patients give high numbers cause they know anything less than 7or 8 will be Tylenol or toradol
They already exist - two of 'em that I know of. The flacc scale and the PAINAD scale, both developed for the assessment of pain in non-verbal or demented patients.
While your suggestion is a good one (in fact, I know of one local hospice that uses something close in their assessments), it fails to take into account for the different behavioral characteristics of chronic pain. IOW, you are proposing the use of the same distorted behavioral stereotypes and assumptions we have been challenging.
) The trick is to avoid enabling addicts as much as possible while staying responsive to people with real pain issues that need assessment and relief.
heron, ASN, RN
4,710 Posts
So ... what alternative to the pain scale do you recommend?