Steven Littlehale

“Pain is whatever the experiencing person says it is.”

“We just hope that you don’t say it. Oh, and we’ll likely not hear you anyway.”

We credit Mary Margo McCaffery, MS, RN-BC, FAAN, a pioneer in the field of pain management, for the first phrase; I credit our healthcare system and the prevailing opioid crisis for the second. 

Two recent experiences reminded me how far back we’ve stepped in our healthcare system’s pain management dance. In both scenarios, the aged patients had catastrophic events that resulted in invasive surgery and subsequent hospitalization (and for one patient, a post-acute stay in skilled nursing). In both instances, their acute pain management consisted of acetaminophen (Tylenol) as needed for pain (PRN).

There is a time and place for acetaminophen, but I am hard pressed to consider it an acceptable “go to” for day-one, postoperative care. Would the argument be more compelling if I shared that one of the patients had her chronic pain management regimen of PRN hydrocodone abruptly stopped upon acute hospitalization?

As a young clinician in the late 1990s, I was well schooled in the American Pain Society’s groundbreaking work and the Joint Commission pain management standards. Pain emerged as a “fifth vital sign” (P5VS) to increase the visibility of its management and treatment. In my practice, it was also common to talk about methods for non-pharmacological treatment of pain.

However, these initiatives were short-lived, and subsequent published data indicated that implementation of the P5VS did not meaningfully alter pain outcomes for patients in acute, ambulatory, and long-term care settings; nor was the linear numeric rating scale for pain particularly meaningful.

There are those who believe, with some support from published studies, that asking patients about their pain contributed to the emergence of the opioid crisis. Others hold that adding questions about pain management to mandated patient satisfaction surveys — and then linking these responses to hospital reimbursement — was another factor that precipitated our crisis. Inarguably, the for-profit pharmaceutical companies that took advantage of the situation and wrongly reassured prescribers as to the safety of opioids were foremost in bringing us to this moment.

Have we lost sight of our patients in the process? In the scenarios described above, we found both patients not sleeping and challenged to eat due to pain. When asked about their pain management, the patients said, “The nurses are busy,” or “Of course I have pain; I have cancer.” Sadly, neither patient had their pain properly assessed or consciously managed in anything vaguely resembling patient-centered care. Family members needed to constantly intervene and advocate for better pain assessment and management. 

The nursing and medical staff did not resist the family’s advocacy, and in fact, the nurses expressed frustration about how facility policy prevented them from doing a better job. We heard a lot about “floor policy” on administering analgesic medications. In the end, we achieved better pain management, but we had to fight every step of the way.

How are nursing homes doing with the assessment and management of pain?

In October 2019, CMS removed the two quality measures that reported on residents with moderate and severe pain, believing that the measure, and its inclusion in Five-Star, might contribute to the overuse of opioids. Also in 2019, less than 5% of nursing homes received F697, the deficiency cited for failing to provide pain management to residents consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. The absence of the QM and the low rate of F697 make it appear that we’re doing just fine. 

Are we really?

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.