The pain scale has been harmful

jaderook01, BSN, RN · Apr 7, 2018

I agree. I'm one of those nurses that will generally ask a patient how they're doing when I go in to do my first assessment. Nine times out of ten, they never complain of wanting pain meds when I do this. When they call out for pain meds is when I go to give them anything, and I will always start with offering their PRN Tylenol and will only go the next step if they already know about their other meds and/or insist on something else. If a patient has PRN dilaudid or morphine, I won't advertise it to them without reason. I'm heartily sick of the faux 10/10 pain folks. In fact, I've called doctors and had PRN morphine and dilaudid DC'd more than once.

verene, MSN · Apr 7, 2018

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.

AJJKRN · Apr 7, 2018

Well it looks like CMS is trying to cover their tracks in role that HCAHPS plays....

https://www.qualityreportingcenter.com/wp-content/uploads/2016/01/IQR-VBP_HCAHPS-and-Pain-Management_20160128_vFINAL508.pdf

Emergent, RN · Apr 7, 2018

Well it looks like CMS is trying to cover their tracks in role that HCAHPS plays....
https://www.qualityreportingcenter.com/wp-content/uploads/2016/01/IQR-VBP_HCAHPS-and-Pain-Management_20160128_vFINAL508.pdf

What an utter load of desk jockey BS!

Buckeye.nurse · Apr 7, 2018

My employer recently introduced the Defense and Veterans pain scale. There's a link to the graphic embedded in our flowsheet that we can show patients. I like the additional questions on the back, because it allows us to examine how pain affects our patients' quality of life, and gives a better understanding of individual responses to pain beyond just a number.

I especially like the statements that correspond to each pain number. I've worked in various practice settings. One (general med-surg) had patients we all love to complain about who rated pain 10/10 while texting on the phone and ordering take-out. However, in several of my practice settings (pediatrics, and now hematology-oncology), my patients often *underrate* their pain. The Veterans scale helps tease out when another call to the physician or a consult to palliative might be warranted.

Here's a link to the Defense and Veterns center for integrative pain management. It's well worth a look! Defense & Veterans Pain Rating Scale (DVPRS)

JKL33 · Apr 7, 2018

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.
....
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.

verene,

You make legitimate points about some of the underpinnings of addition and about how we can better assess pain.

That the pain scale single-handedly causes opioid overdose deaths wasn't the claim made in the title of this post, the opening lines, nor in the blog post referenced.

There are many, many relevant factors - each playing a little part in the progression of this problem. Of course there is nothing inherently wrong with the pain scale as a basic tool. There's nothing wrong with understanding that pain can't be solely objectively measured and so we must listen carefully to what patients say their pain is to them. There's nothing wrong with remembering that pain is important and we shouldn't forget to assess it, just as we wouldn't forget to assess vital signs.

Perhaps you didn't ride along on the original swing of the pendulum - but at some point a lot of individuals and entities signed on to the idea that "0-10 pain scale" plus "the pain is what the patient says it is" plus "pain is the 5th vital sign" should be understood to mean that making any observations whatsoever, amounted to judging patients and not believing them.

I will spare you the details of how this played out in a large urban teaching hospital and how it absolutely did contribute to the situation in which we now find ourselves.

My opinion and experience has been that

0-10 + the pain is what the patient says it is + it is also a "vital sign" = nothing short of a disasterous way of thinking and has brought harm to our patients over time. Moreover, although I can grant that the original intentions were good and ethical, in reality, effectively banning the reasonable use of objective data about a patient's pain was never an honest or ethical way to interact with patients about their pain or their reason for seeking care.

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.

This statement is....well, it's offensive because it assumes that the only problem there ever was with pain scales was the person administering them. It implies that if they are reviewed in a calm and pleasant manner (as opposed to "rattled off") while making good eye contact +/- an appropriate "look of concern" and a sympathetic tone of voice and then being ready to carefully listen to what the patient says about their pain, then everyone will use the pain scale to give a reasonable rating of their physical pain and there will be no problems! And, that is simply not how all of this has played out over time.

OldDude · Apr 7, 2018

Well it looks like CMS is trying to cover their tracks in role that HCAHPS plays....
https://www.qualityreportingcenter.com/wp-content/uploads/2016/01/IQR-VBP_HCAHPS-and-Pain-Management_20160128_vFINAL508.pdf

Pretty colors.

KatieMI, BSN, MSN, RN · Apr 7, 2018

Welcome to reality, everyone.

The problem is, lay people got in around 2000 what they now for second generation think to be "theirs". They know they have right to demand treatment, they know how to get that treatment and how to cheat the system. No one "new" and "newest" assessment tool directed on subjective feelings of patient which cannot be objectively measured can be normally used under these conditions. Patients will just feel "unable to do anything/unable to function normally/quality of life zero/etc" mark boxes instead of stating that their "level" is 10/10. And, as long as HCAPS are here, they will get what they want, in one place or another.

This is not only about pain management but about the general perception of lack of personal responsibilities toward one's health. It is about "can you do something to help me" to be read as "I want you to do it for me so I can sit back and continue my old ways 'cause that's what I like". It is about octagenarians wanting to live like they were in their early 50th. It is about children pressured to sacrifice everything, including their health, to senseless "sports". It is about going vegan, organic and vaccination-free, relying on others' herd immunity.

It all is not something that cannot be changed. But it will be WAY more difficult feat to do, and I am afraid that under the best circumstances we all here will expire due to very advanced age before the public opinion could be changed toward more realistic goals in pain control and life in general.

Emergent, RN · Apr 7, 2018

I agree Katie MI. As long as people crave the drugs, they'll say whatever it takes to get them. A new assessment tool won't replace good old fashioned tough love.

America, in general, could use a kick in the pants. We've gone soft...

Guest219794 · Apr 7, 2018

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.

KatieMI, BSN, MSN, RN · Apr 7, 2018

I agree Katie MI. As long as people crave the drugs, they'll say whatever it takes to get them. A new assessment tool won't replace good old fashioned tough love.
America, in general, could use a kick in the pants. We've gone soft...

Craving is not a problem by itself. It was here, and will be here doesn't matter what - that's why there were not a single civilization on the Earth do far which wouldn't use drugs of some type. The problem is that people refuse to apply minimal efforts toward management of their healtn problems because they got easily available and highly addictive things which treat SYMPTOMS of these problems really well. The drugs did not do anything with problems themselves and actually cause harm on the long way, but try to explain that to someone 100%assured that there is a pill for everything.