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. ...

[meanmaryjean, DNP, RN]

"a bad system in which we set unreasonable expectations"

hherrn hit the nail directly on the head!

When the expectation is "no pain ever/ pain is always bad and should always be avoided at all costs" - then you CREATE this massive problem.

[Guest219794]

I think this is an interesting thread, and just wondering when somebody becomes offended and indignant.

Plenty of room for debate amongst experienced professionals.

I predict it will be somebody with limited experience providing care with PTs experiencing pain.

[JKL33]

"a bad system in which we set unreasonable expectations"

hherrn hit the nail directly on the head!

When the expectation is "no pain ever/ pain is always bad and should always be avoided at all costs" - then you CREATE this massive problem.

Yes.

And CMS' involvement and culpability in the situation is more than the sum of the facts they presented about their involvement.

For example:

During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

1 Never

2 Sometimes

3 Usually

4 Always

Sure, it sounds pretty bad to think that a hospital (or nurse, physician) didn't "do everything they could to help you with your pain."

But when there is a preconceived idea (or a knowingly dishonest understanding) by patients of what "everything" should or does involve, combined with the undeniable fact that patients' ideas of "everything" may very well involve non-therapeutic, medically-incorrect, unethical interventions, well then now you have a problem.

Add in the idea that the only acceptable answer we seek to receive on these questionnaires (as we have all heard a million times) is "always."

So the question is one that puts healthcare providers between a rock and a hard place. CMS knows this. Well, their utilitarian "ends-justify-the-means" approach to saving a few dollars on care that has already been provided in good faith was never a secret, and has now officially backfired spectacularly.

[Kitiger, RN]

I think a big part of the problem is the way nurses have been required to keep asking about pain. If you ask often enough, the client/patient will start to focus on pain. After surgery, or when pain is expected, then, yes, be sure to talk to them about pain, ask them how they're doing, etc..

But it can be taken too far.

I work private duty home care, with patients who are not expected to be in pain, yet the agencies want me to ask them every 2 hours whether they have pain. (One agency wants us to chart in the client's own words; I can't just chart that they appear comfortable.) If the client is sleeping, I am allowed to chart "no signs of pain".

Every 2 hours, I have to use the word "pain" in my charting.

[Here.I.Stand, BSN, RN]

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.

Some things to consider...

1) pts have the right to know their plan of care -- we shouldn't conceal the prn order based on our own *subjective* observation. I say "subjective" because there is no quantifiable data to confirm our observation -- any more than we can quantify the pt's report.

2) I hope that you are taking the specific situation into account. For example, if someone just had foot surgery and c/o a headache, offering the Tylenol is very reasonable. If they are having post surgical pain however, there is a real possibility that Tylenol alone will have no effect... and by the time you determine it was ineffective, the pain has become even harder to relieve.

3) Will every pt be willing to ask for more pain meds if their nurse has just offered plain Tylenol? There are folks who are will request narcotics at least in part for their side effects, and have no qualms exaggerating their pain. However, there are those who are well aware of the "drug seeking" perception... such as those in healthcare. If that person is not assertive, they may be hesitant to say "I need something stronger than an OTC." Then throw in a nurse who in a trusted professional opinion says by her actions that plain Tylenol is an appropriate treatment, this type of pt will feel even less comfortable advocating for himself.

And if pt has a hx of opioid abuse?? Those pts simultaneously carry the stigma AND legitimately requiring higher doses to achieve appropriate pain control.

Heck I am assertive, and that thought has crossed my mind when I have required short-term prn opioids -- "does anyone think I'm drug-seeking?"

To be clear, I do consider some practices to be harmful. Pain is not a vital sign, and post surgical pain typically can't be completely eliminated -- at least not safely. However, we shouldn't be *needlessly* making pts suffer based on fear of getting them addicted.

[Persephone Paige, ADN]

I am a nurse and a part of the Opioid epidemic. I have been clean now for 4 1/2 years. I have been very fortunate not to have had pain severe enough to need narcotics since getting clean and I live in fear of the day I might. I recently went through shingles, which was pretty painful. All my providers are aware of my history and we worked together. I took Gabapentin and it was bearable.

I have a plan that if I ever need narcotics that it will only be in an acute care setting, where someone else controls the dosage and administration. There have been times during my active addiction that I've had horrible pain ( kidney stone ), a foot broken straight across all metatarsals, where I was denied pain meds. I was honest about my history then, and I was honest about the struggle. I was denied pain relief. And I get it...

After reading some of the posts, I really hope there is someone in place, some middle ground. A history of addiction is nothing to mess around with and the amount of pills hitting the streets has to stop. I want help and I take precautions everyday to see to it that I do not return to my old ways. But, I am petrified of what will happen if I am honest ( which I always will be ) and I am truly in need of pain relief. I don't want to be discharged with a prescription, but if I am in the hospital I hope someone will have compassion and not say, "NO! You were an addict, no pain relief for you!" Because that HAS happened...

[heron, ASN, RN]

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...

IOW suck it up, buttercup?

Sorry, but there's nothing heroic about suffering in silence ... that demand has more to do with making us comfortable instead of our patients. Swinging the pendulum back to the previous extreme of total failure to address the problem won't solve it, it merely drives it deeper underground.

Pain and addiction are different problems. It's possible to address the first without potentiating the other.

[Penelope_Pitstop, BSN, RN]

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)

I have never heard of this scale until now and I think I'm in love! This needs to be implemented globally.

[dudette10, MSN, RN]

verene,

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.

Agreed!

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.

I didn't really think positively or negatively about your objection to verene's statement (although I think calling it "offensive" is a bit strong)...until I looked at the DVPRS link and the way it's supposed to be used.

Verene has a point with "given without any reference points," "active listening," and "patient education." Active listening is far more than acting like you care, which you imply sarcastically that that is all it is.

The DVPRS now gives a reference point of function and mood rather than just pain intensity. At the end of the short video on the website, the narrator states that over time, the answers to supplemental questions move, even if the intensity rating stays the same.

The scale is definitely something I'm planning to read the research on.

[dudette10, MSN, RN]

Some things to consider...

1) pts have the right to know their plan of care -- we shouldn't conceal the prn order based on our own *subjective* observation. I say "subjective" because there is no quantifiable data to confirm our observation -- any more than we can quantify the pt's report.

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?

[cardiacfreak, ADN]

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

[JKL33]

Agreed!

I didn't really think positively or negatively about your objection to verene's statement (although I think calling it "offensive" is a bit strong)...until I looked at the DVPRS link and the way it's supposed to be used.

Verene has a point with "given without any reference points," "active listening," and "patient education." Active listening is far more than acting like you care, which you imply sarcastically that that is all it is.

The DVPRS now gives a reference point of function and mood rather than just pain intensity. At the end of the short video on the website, the narrator states that over time, the answers to supplemental questions move, even if the intensity rating stays the same.

The scale is definitely something I'm planning to read the research on.

You have entirely missed my point.

I have never used the pain scale without the elements verene originally mentioned (which was perhaps why I felt the statement was a little insulting, unintentional as that probably was).

Most nurses I work with don't use it without those elements either. As for me, being ready to listen to what patients say about their pain, conveying (through body language, etc.) that you have time for them, and using an appropriately caring tone is not an act. For goodness' sake, studies are all over the place about nurses' "caring behaviors" - if you believe I meant all of that sarcastically, you have misunderstood. My point was that despite genuinely trying to include elements of care and concern when discussing pain with patients, the traditional pain scale doesn't seem to serve a therapeutic purpose, and many times (historically) it has simply been a tool that facilitates poor care despite its proper use by nurses. Which....is part of what this thread is about.

Reference points are always given - they always have been; they were included in the way we were originally taught to administer the pain scale. Education about pain, the pain scale, pain medication, etc., has also always been the nurse's role, and good nurses have been doing those things all along.

However, are definitions and thoughts about what is meant by "reference points" and "education" changing? You bet! In fact, they are changing to encompass more of what RNs have been saying for a very long time were legitimate elements of assessing pain! Hallelujah. Those of us who believe that the pain scale has played a role in the opioid crisis are not talking about the DVPRS. We are talking about they way we have been hobbled in using the pain scale by being told that elements (like those addressed in the DVPRS) amount to us "judging" patients.

I too, am very interested in using a tool that is more broadly based and holistic. I am not sure how additional 0-10 ratings about other areas of being (such as mood) will play out in a place like the ED, but that's a discussion for another day. For now it is good to see movement in a better direction.