medicine is in large part based on objective evidence. If you can’t see, touch,
taste or weigh it, it simply does not exist. Unfortunately, pain is
subjective, with no “litmus test.” Each individual’s pain experience may vary
depending on one’s genes, culture and/or world view, including religious
scales were an attempt by well-meaning people to address this problem. The idea
was that if a mechanism were devised to make pain more comprehensible, less
subjective, not quite so “slippery,” people with pain would get better care.
And, at the same time, those who care for them could be more confident that
they were doing the right thing when prescribing medications that have serious
side effects, including addiction and unintended death. Pain scales also helped
assure providers that they were treating people fairly — without
regard to age, race, ethnicity, etc. - so that a person with a pain score of
seven would be treated like any other person with a pain score of a seven.
this grand experiment has not worked.
today pain is assessed far more often than it was before pain was labeled the 5th Vital
Sign and pain scales were devised, there is significant evidence that pain care
is no better than before.
March 30, an article by Amy Dockser Marcus appeared in the Wall Street Journal
titled, “In search of a better definition of pain.” In it, Tamara
Michael, a 45-year old women who lives with chronic pain due to Multiple
Sclerosis, describes work she has done with a group of researchers to come up
with a better way to assess patients’ needs for pain control. They have come up
with a narrative assessment based on functionality, i.e., a person’s ability to
do activities of daily living (ADLS) – things most of us take for granted like
the ability to dress ourselves, prepare a meal, or drive a car.
applaud Ms. Michael and the researchers working with her and others in the
article who commented on the need for a better mechanism to accomplish the
goals that motivated those who developed the Pain Scale. However, I think there
is a bigger issue here than what assessment tool we use and that is the
stigmatization of those who live with chronic pain, which has led to the
erosion of trust between healthcare providers and those who live with chronic
patients are often characterized as “drug seekers,” malingerers, lazy and told
that their real problem is “all in their head.” They are also seen as putting
those who care for them and prescribe pain medications at risk of scrutiny by state
medical boards, as well as local, state and federal law enforcement agencies.
Although pain is the number one reason people seek medical care and the desire
to address pain and suffering is what “calls” most people to the healthcare
professions, we are at a “medical impasse.” Doctors feel threatened by their
patients, and those living with pain feel abandoned by their physicians.
how do we find our way out of this quagmire? The Institute of Medicine
report, Relieving Pain in America, published in 2011, called for a
“cultural transformation in the way pain is perceived, judged and treated.” It
also called for a shift from a biomedical to a bio-psychosocial pain management
models, i.e., an approach that provides access to multi-modal treatment that
could include medications and interventional procedures, but also access to
counseling and behavioral health, physical therapy and exercise, diet and
nutrition counseling, chiropractic care, acupuncture, massage and other
complementary and alternative treatments. Bio-psychosocial approaches are both
comprehensive and individualized.
2015, a National Pain Strategy Report, which is an effort to operationalize
recommendations made in the IOM report, will be published. I am hopeful that it
will serve as the springboard for the “cultural transformation” called for in
the IOM report. However, I believe that, until the loss of trust between pain
patients and healthcare professionals is restored, it will have little impact,
and from my point of view, the only thing that will restore that is
communication – respectful communication.
was in the hospital recently and noticed that at the foot of my bed was a
whiteboard that told me the name of the hospitalist, the nurse and the nurse
aide on duty. It also included a 1-10 pain scale printed right on the board,
including little happy-to-sad faces for patients who do not read. When one of
my daughters saw it, she said, “Wow! Mom, the pain scale is printed right on
the board. That ought to make you feel great.” Unfortunately, it did not. It
made me think about how difficult it will be to undo the 1-10 Numeric Pain
Scale and to put in its place a more patient-centered approach, like the one
reported in the Wall Street Journal, or an even simpler, more humanistic
approach such as physicians asking, “How are you today?” Then listening to and
respecting the patient’s response.
Written by Myra Christopher
Kathleen M. Foley Chair in Pain and Palliative Care
Learn more at http://www.practicalbioethics.org