The pain scale: Why it matters to your doctor, and why it doesn’t

I was recently taking care of a young patient with a bad toothache in the emergency department. As part of my routine questioning, I asked her to rank her pain on a scale of one to 10, clarifying, “Ten is the worst pain you’ve ever felt.” She immediately replied, “It’s a 10.”

Soon afterward, I met an elderly gentleman who was also presented in significant pain. He had slipped a disc in his lower spine, a notoriously excruciating condition. I asked him to rate his pain, and he quickly said, “10.”

Both patients were sitting quietly in their beds during our conversation. It was hard to imagine that they were experiencing the worst agony of their lives. And yet, I knew their pain was all-consuming; that they couldn’t sleep, couldn’t eat, and couldn’t escape it. This could truly be the “worst pain” they had ever felt, even if I’d seen worse conditions as an emergency physician.

Ultimately, though, their number meant very little to me. In neither case did I go sprinting for the morphine, and in neither case did I prescribe narcotics for them to take home. I had my own system for treating these conditions, including dental nerve blocks, muscle relaxers, and high-dose ibuprofen.

So why had I bothered asking the question?

In large part, it was from force of habit. As a medical student, I had been taught to assess pain “severity” as a part of my history-taking. I knew that the timeline of a patient’s symptoms can serve as an important diagnostic tool. For example, a sudden-onset headache of maximal intensity could be concerning for a subarachnoid brain hemorrhage, whereas a gradually worsening headache was more likely a benign, tension-type headache. In these cases, though, specific numbers for pain were used to make the diagnosis, not to guide my treatment plan.

Now in residency, I can’t escape the pain scale. Nurses routinely stop by my desk to update me on my patients’ pain (“Mr. Smith is still 9 out of 10.”) Most triage notes and medical charts reference patient pain levels. The pain “score” has become such a pervasive part of medical culture that my patients often volunteer a number to me without my asking. There is the unspoken expectation that a high score should prompt immediate treatment. After all, why else are we asking patients to quantify their pain, if not to address it?

The answer involves understanding the complex history of pain management in medicine. For many centuries, physicians largely viewed pain as a natural part of healing, championing a spartan approach toward suffering. However, in the latter half of the 20th century, there was a movement toward more empathetic medicine, supported by new “wonder drug” narcotics and the burgeoning field of pain medicine.

In 1996, the American Pain Society introduced the concept of “pain as the fifth vital sign,” and in 2000, the Joint Commission on Accreditation of Healthcare Organizations set the national standard that pain should be “assessed” in all patients. Thereafter, a variety of pain scales were adopted by different hospitals, with the most popular being the numerical scale. Many doctors and hospitals began to treat pain as they would any abnormal vital sign, such as high blood pressure or fast heart rates.

Consequently, the next decade saw a sharp rise in opioid prescriptions. According to the National Institutes of Health, the number of annual prescriptions for opioids (such drugs as Vicodin and Percocet) skyrocketed from about 76 million in 1991 to nearly 207 million in 2013. Narcotic overdoses rapidly followed suit, laying the groundwork for the modern “opioid epidemic” facing this country.

In the last decade, amid a growing body of addiction research and federal investigations, the “pain pendulum” has swung the other way. Hospitals and physicians are now making a concerted effort to curb opioid prescriptions. Unfortunately, this cultural shift has been abrupt, leaving many older patients with the understandable expectation for powerful painkillers when they visit the hospital.

As an emergency physician, I often find it challenging to convince my patients that their medical condition will be more effectively treated with seven days of anti-inflammatory medications, such as ibuprofen, rather than a fast-acting narcotic such as oxycodone.

I believe that because the medical community helped create a culture of opioid dependence many years ago, it is now on our shoulders to address the epidemic in a manner that embraces an empathetic approach toward suffering.

Therein lies the problem of the pain scale. We physicians continue to ask our patients to rank their pain again and again, and then we routinely disregard scores that we feel are exaggerated or unrealistic. This has created an erosion of trust between patients, who feel their pain is not being taken seriously, and physicians, who want to safeguard their patients against opioid dependency.

But there is a middle ground here and it involves candid conversations between doctors and their patients. I have found that most patients are quite understanding of the dangers of opioid addiction when the time is taken to explain the data (citing, for example, the large studies that have shown that the risk of lifelong opioid dependency increases dramatically after only three to five days of taking pills). Likewise, physicians might be more willing to prescribe short courses of opioids if they knew that their patients understood the risks involved.

So the next time your doctor or nurse asks you to rate your pain, ask why that question is being asked. You can better understand how your doctor is using this number, and in turn, you can start a conversation that addresses, and does not avoid, everyone’s true concerns.

Matthew Trifan is a resident physician in emergency medicine at Jefferson University Hospital.