Wednesday, April 1, 2015

It is Time to Ditch Pain Scales

Western 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 beliefs.
Pain 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.
Unfortunately, this grand experiment has not worked.

Although 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.
On 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.
I 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 pain.
Pain 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.  
So, 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. 
In 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.
I 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

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