Thursday, September 10, 2009

'Pain Scale' Kills Patients

All of us who practice in the hospital setting and probably those of you who practice in clinics are familiar with the 'visual analog pain scale'. I wrote a bit about it on 3/17/07 (can't get a link to work... you can search the blog under 'arithmetic' and get right to it).

I got to thinking the other day, as I wrote out another prescription for Lortab for someone with "ten out of ten" pain, that one of the unintended consequences of the 'visual analog pain scale' has been a huge overprescription of narcotics and the skyrocketing of drug abuse by people who would not otherwise do it. After all, it's from a doctor, no?

I can't pull a .jpg image off the web for you but someone got a few million dollars from the NIH to come up with this 'scale' which is a series of human face caricatures progressing from smile to frown. You then ask THE PATIENT which one represents their pain at that moment. That's it. Science?

At the same time that one of my former employers was taping the pain scale to the back of every chart (at the behest of the 'Joint Commision' or JCHAO, or whatever they call themselves these days), and dinging us for not using it on every patient, the admin-weenies who are, almost to a man, not physicians, started dinging us for 'customer service complaints'. Usually these complaints were about the treating physician's refusal to prescribe narcotic pain medicine. Getting it from both ends, most of us just shrugged and came to some reasonable middle ground. My middle ground is that I will prescribe ten Lortab, no refills, to just about anyone. Sorry... that's just the way it is.

So this little theory of mine was quickly (partially) verified by a google search. Interesting, no? Oh those unintended consequences!

There are those who will still fight this battle... but with every patient that we fight we spend more and more time and field more and more complaints, and it's a wonder some of my colleagues still have the energy.

Medicine is an art and a science, and the assessment of pain can not be reduced to a silly-ass, third-grade, completely subjective cartoon. Docs, why did we surrender to these buffoons? We surely did (in almost all areas of the practice of medicine) ... but why?


  1. Good question! Pain is pretty subjective. I have had the opposite problem with our oldest son ... he gets undertreated because he has a high threshold for discomfort. I am aware of this, so when he complains I listen. But I have a heck of a time imparting that concern to health care providers!

    Four years ago, he complained that one of his front teeth hurt. It turned out he had an abscessed tooth and ended up getting a root canal. They did not crown the tooth or give him antibiotics for the abscess. This surprised me, as those things were part of my previous experience with root canals.

    Following the root canal procedure, the boy continued to say that there was pain when he bit down on the tooth. Since the nerve had been killed, this struck me as odd. But ... back to the endodontist, who ended up draining a large amount of junk out of an infected tooth and prescribing amoxicillin. After two days on the amoxicillin, my son mentioned that it was still hurting. Additionally his face had swelled up - from the area of the invoved tooth up to his eye on that side of his face. By the next morning he had developed a high fever and chills and nausea. One MORE call to the endodontist, who seemed peeved that I was not comfortable giving the amoxicillin more of a chance. In the end, he prescribed another antibiotic and hydrocodone (sp?) for the pain.

    The pain pills were never used.

  2. But don't you know JCAHO knows best. Even though most of them have never actually seen a patient. They are all knowing. Patients will die if we don't do everything that they and CMS says. (OK now I have to go wash my mouth out after saying all of that BS)

  3. 911, I hate it when you shove barbed wire up my shaft! Would U stop it!!!
    OMG, the phucking "payne skale" Y'all know I've been at this party for a while. I will here, at this time, state that the mandated use of this thing is the single worst plague on practioners ever! If I was presented with the choice of forever doing away with the "obama care" or this "pain scale" I would have to have 24 hours to decide which..
    PeggyU, some advice, NEVER tell any doctor that your son has a "high pain threshold" Most of us, at least ED doc's, will politely leave the room to VOMIT!!! And then ignore your son for the rest of his visit and probably prescribe him acetominophen when he leaves. It would be much better for him if you just tell your dumbass son to just say that it hurts, sorry.
    My patients know they don't even have to pretend they are hurting. They will get their Vicodin because I don't want to cause a hassle for our administrative nurses. It's just not worth my time..
    I gotta stop,
    If I think about it to much my blood pressure will hit "volcanic"..

  4. I think you know how I feel about the pain scale. Seriously? A smiley face?

    I tend to underestimate my pain. Finally last time my nurse told me that they don't usually give pain medicine until you name a certain number or higher. They were giving it to me even when I was saying 2 for my pain after my surgery because I looked horrible I guess, but she wanted me to understand that my pain after major abdominal surgery was not a 2 on their pain scale. Especially when in answer to their question of what is my pain scale number I answered "it fucking hurts" and whimpered then gave a 2 or 3 as my answer. After that, I used a number lower than their arbitrary threshold if I wanted them to not give me anything (or my precious toradol that I am in love with and would marry and have babies with if I could) and higher if my pain was so bad that it made me feel like I was going to puke or pass out and I actually wanted the stupid stuff that made the room spin. It would be great if people could be trusted to be honest about their pain, although that won't ever happen. Either way, I don't see how the pain scale helps anyone. My son did get a kick out of it when he was in for his messed up thumb but he's 5 and maybe that is/should be the target audience for it?

  5. Per the article googled: "Dr. B.P. House has some concerns..." ? Dr. HOUSE?? Do I sense a pwned journalist??

    And I love the thought that 95% of patients are responsible about narcotic use...the posseurs and dealers in this country are a mere five percent.....not buyin it.

    Pattie, RN

  6. My pain scale reads, mild, moderate, severe. JACHO can take it dry for all I care. It is my judgment not theirs in how to treat the patient, end of story.

    I have seen colleagues write for hydrocodone for finger lacerations. I hate the cliche, but if you are not part of the solution, you are just contributing to the problem.

  7. As RadGirl noted, somewhere around 6 or 7, a person looks *sick*. If experienced ED nurses/ docs have to ask, then it is probably "moderate" pain at most.

  8. what about ignoring patient satisfaction when it comes to inappropriate requests for pain medicine? I know your scores would suffer, but so be it. If your admin types start barking up your ass, just ask them to go over some of the unsatified patient surveys and then politely explain to their clipboard carrying selves that you practiced good medicine and sometimes the patients don't want that. Which, of course, is not your problem

  9. dear anon.,
    oh were it that simple. complaints are noticed and it's not just a matter of losing YOUR job. entire ER groups are hired and fired based on these scores so take into account that your 'doing the right thing' may lose your colleagues THEIR jobs too.

  10. OldFart: Most of us, at least ED doc's, will politely leave the room to VOMIT!!!

    Some of us would appreciate an honest VOMIT in lieu of pseudo "politeness".

    I would have thought a fever, chills, and swollen face would have been sufficient to indicate some discomfort. Go figure.

  11. Ugh.
    This is another of those conversations where you have to live it to "get it". Sounds stupid but 911 tells it just like it is. Most of you guys (non-medical), have much more autonomy in daily decision-making. I know this to be true as I used to be you guys.


  12. I can't imagine being a doctor these days. I had no idea of the length and breadth of the interference inflicted on doctors and other hospital personnel by the "clipboards."

    I work in a small clinic, and some bean-counters tried to muscle us. Luckily we were able to leagally beat them out of there with a stick, so-to-speak. Might have felt a tad better if it had been a real stick.

    At least those with the poles up their a$$es are gone....for now.

  13. Huh. Never saw the faces, but have seen the numbers. (Maybe I didn't notice the faces...and instead the numbers with corresponding descriptions as those are also familiar.) I won't take pain meds unless I absolutely cannot function. I think they're dangerous in too many ways.

    The scale I've seen (minus the faces) is here: by the way.

    I can't imagine the need for the faces. I can't say from looking at the 3rd face that that caricature is in moderate pain. Do those faces help illiterates or children define their pain? I can't imagine they do.

    According to the chart, why can pain that's worse than #2 not be ignored (implied by the descriptors)?

    Ha! Just noticed. The caricatures are called the Wong-Baker facial grimace scale. Are the caricatures then supposed to help the docs assess the level of pain based on facial expressions? Now that is funny as I've never seen a person look like any of those caricatures. And if you docs have...lay off the free samples.

  14. It really was developed for children, and for adults who are non-verbal for whatever reason, or non-english speaking or of language other than staff (depending where you are in the world).

    The idea was that, a patient must never fear that they are being forced to deal with pain without supportive therapy - one of the horrors of illness/injury we all fear. People demonstrate pain and tolerance for it differently. If serious and painful illness/injury is involved, being stoic and trying to "man-up" by refusing pain meds will likely only delay your healing (physiological fact). On the other side of the coin those skilled with years of assessment experience can usually "call it" when there is malingering going on, but still... there are exceptions. Know that we see a lot of drug seekers!!! The best policy is to just be honest no big "king or queen of pain tolerance" stories to make us think you might be up to something. Keep it simple, just the facts.

    And all this doesn't even matter when you are not allowed to act based on your assessment skill due to corporate override.

    So can you see that I am avoiding all this crap research I should be doing... blah blah blah...


  15. I find the pain scale laughable. I have little trouble determining whether my non-verbal patients are in pain... I'm a veterinarian.

    Old Fart: I'm stoic, and it has nothing to do with either pretending to be "tough" or drug-seeking behavior (remember, I have my very own DEA license and narcotics on the shelf). It's just the way I'm wired; pain doesn't register as it does for other people. I've seen this with certain of my patients, too, who I KNOW have no ulterior motives. But I can utilize the stupid pain scale in terms medical personnel can understand, because I realize that pain meds are essential for healing in some instances. Never had the need for narcotics, though, even after abdominal surgery (did just fine with NSAIDs and avoided confusion and GI side effects).

  16. OK, 15 Comments and I've heard better material from old 3 Stooges episodes.. I treat the "Pain Scale" like I"ve done with all medical paperwork for the last 25 years...and WTF does "SOAP" stand for anyway???
    Reminds me of 5th grade when we'd debate what would hurt more...
    1: Sliding naked down a rusty razorblade tipped bannister, ending in a vat of 200 Proof Rubbing Alcohol??? or

    2: Foghorn Leghorn grabbing you by the tail, and beating you mercilessly with a 2x4 thats been soaking in a can of 50wt Motor Oil for the last 3 months, so that the straightchain petroleum hydrocarbons can intercalate inbetween the Cellulose of the wood, making for a bludgeon that won't splinter when it hits bone...
    3: umm you get the idea..


  17. I just love when as Glen said "experienced ED nurses/ docs have to ask" it is moderate....but those people say "oh, it is 15/10" while they calmly flick through a tabloid magazine.

  18. Speaking of pain meds, what should a person do with them when they are done but have leftovers? I have a drawer full of vicodin and other things that I have no idea what to do with. Throw them away? Flush them? Sell them and make a lot of money (totally kidding)? What???

  19. Radgirl, the general recommendation for disposal of drugs is to crush your pills and mix it with something like kittylitter. Toss the mix into the garbage! :)

  20. Hey PharmD: you're right about the kitty litter, but add 1/2 cup of water so that the medication will dissolve and then be sopped up by the litter...

    I always say that next folks will be rolling up the kitty litter and smoking it!

    If you don't have a cat you can just dissolve the meds in water and pour out into the ground (it's all going to end up back in the water table eventually)....Pour where pets are not likely to get into it. Septic tanks are ideal, as the meds will just leach out over time back into the earth.

  21. I haven't heard as much collective Idiocy since the President's last Cabinet Meeting...
    I've never had a problem with leftover Narcotics, but you can have a GREAT time with the leftover bottles...
    My fave is the old "Thorazine/in the Oxycontin Bottle" trick, best results when you leave it next to where they fill out the Lotto playslips, Where do I get the Thorazine??? Umm
    The whole Kitty Litter thing is so much Kat-poo, its just a variation of flushing it down the toilet. Even Einstein said that matter cannot be created or destroyed, only converted into energy, and he was a lifelong Cocaine addict so he should know. Or was that Freud??


  22. JCAHO- The opiate providers to the masses. "On a scale of 1 to 10, with 10 being the worst pain you've ever had, WHERE WOULD YOU PUT YOUR PAIN RIGHT NOW?" It's a script I use 50 times a day.
    And the next semi toothless meth head tells me 15, or uses fractions or decimal points, I'm gonna scream!

  23. i think a pain scale for doctors and nurses would be good. my pain level in dealing with most 'pain' patients is exactly 7.432.

  24. radioactive: we always take leftover meds to a pharmacy for proper disposal.

  25. My God left over pain medicine. Well I've never been asked that question before and I suspect it'll be a cold day in hell(or Obamacare) before someone aks to have their precious hydrocodone dstroyed.(only the 10's for me please those 5's are like Pez)

    Where did people get this idea that they could live their entire lives pain free? I mean seriously some shit just hurts and people need to man up and deal with it.

    For comparison I worked in New Zealand for a bit. Some tough SOB's over there. Walk in with a broken wrist, get some dilaudid, reduce, splint, go home with tylenol and motrin. That's right - no narcotics. I started giving out codeine scripts for shit that hurts (i.e. bone going wrong direction) and they looked at me like I was nuts.

  26. The truly ironic thing about the pain scale is how obnoxious and condescending it is to those who know....actually in real pain.

    Let me tell you...when I dislocated my shoulder skiing...if ANYONE would have DARED to ask me to rate my pain as I was diaphoretic, rocking back and forth, and dry heaving....I would have punched the shit out of them with my good arm:-O

    My pain scale is this...... do you hurt " a lot...or a fucking lot"....don't need anything else than that:-)

  27. This is just too funny! I just got back from the hospital, having spent the weekend there getting my gallbladder removed. Shoud have done it before it caused the pancreatitis, but I didn't, and I ended up in the ER on Saturday. Waited about 4 hours to be seen, though I was in a fair bit of pain and had puked my way to the dry heaves. It sucked, but I know they have to triage according to seriousness of the disease/injury, not pain. However, when my husband went up to the counter and asked if he could get an aspirin or something to take the edge off, she asked about what number it would be on the "pain scale". When he said about a 8 or 9, she said she had an emergency room full of 10's and, no, I couldn't take anything. Shoulda had him look in my purse for some tylenol, but prolly would have barfed it back up anyway.

    Interestingly, after the surgery I think they gave me some pain medication, but I haven't had any since and I feel great! In retrospect, I wish I'd have had that sucker yanked out a long time ago. But an OR nurse gave me her two cents. She said if you want pain meds tell them something over a 5 and that'll work. Oh, and OldFart, btw, I heard a person in the area adjacent to me in the pre-op area tell the nurse that her mother under reported her pain and had a high tolerance. Unfortunately, I couldn't see if the nurse rolled her eyes! ;)

  28. That pain scale is pure crap. This hooker that I beat half to death one time was asked what her pain rating was, and passed out before I guess her answer was 0.