When the standard of care is bad medicine

By | July 26, 2019

For the last three decades, the numeric pain score has been the go-to assessment for acute pain in the hospital setting. Since this methodology was developed for research purposes to see if drug “A” had an effect on patient “A,” its clinical utility is not just worthless but dangerous.

Let’s look at a simple example of a pain order set that is commonly used across the country. If a patient says their pain is between 0 to 3 give X. If a patient says their pain is between 4 to 7 give 2x and If a patient says their pain is between 8 to 10 give 3x. Wow, 3x can be a whopping dose of an opioid. You won’t believe this, but there are even order sets giving instructions to increase the dose to 4x for a score of 9 and 5x for a score of 10.

Can someone tell me how these type of pain orders are patient-specific? Can someone tell me why a 75 year old who says their pain is a 9 gets the same dose as a 27-year-old Navy Seal who says their pain is a 9 as well? The answer is you can’t tell me since the numeric pain score should not, cannot, and must not be used as a guide for the assessment and treatment of acute pain.

When you say “everyone” who says their pain is a 10 out of 10 gets 25 mg of Oxycodone IR every 6 hours PRN, you end up with many respiratory “events.” Unfortunately, this is the standard of care in our nation’s hospitals: Bad medicine! I really dislike bad medicine, especially when it ends up harming thousands every year.

Should I complicate the issue even more? How do you treat the patient who says their pain is a 9 and has COPD, obstructive sleep apnea, a BMI of 45, and who is opioid naïve or opioid-tolerant? That is a conundrum. Isn’t the nurse just supposed to take the word of the patient and treat according to the number? According to the World Health Organization, untreated pain can be considered torture! We certainly can’t “torture” people, so we might as well take them at their word and give them the opioid dose that goes with the number 9. By the way, the CDC says go low and slow when treating pain unless of course your 95-year-old grandmother who weighs all of 102 pounds soaking wet says her hip fracture pain is a 10 out of 10, then give the maximum opioid dose on the order set – who cares about starting low and going slow and following a logical opioid progression, right?

If any of you are wondering how should I treat pain in light of my new-found knowledge regarding the useless numeric pain score, then you are most likely less than 50 years old. For us dinosaurs who were around before the ubiquitous use of the numeric pain score in the hospital setting, there is something called objective signs of pain. I know it’s hard to believe, but when your body is in severe pain, it tells us with such crazy things as heart rate, respiratory rate, blood pressure, and pupil size. It’s amazing how you can observe an individual in pain and use these objective signs to guide your analgesic therapy and even incorporate them into your pain order sets. Is anyone currently practicing this method? Yes, every day with patients in the ICU on ventilators as well as hundreds of thousands of individuals having surgery under general anesthesia every year.

So please tear up your numeric scoring method for analgesic treatment and help join the movement to start a new standard of care that is safe and based on objective measures.

Myles Gart is an anesthesiologist.

Image credit: Shutterstock.com

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