Measuring pain and relief
Sharon Conley, M.D.
Medicine has categorized, labeled and measured the pathways and physiology of pain including the molecular receptors for pain relieving drugs. We can perform sophisticated surgeries to address sources of pain with the hope that recovery has removed or diminished the source of the pain.
With all this science, we still are not able to find a way to objectively measure pain from person-to-person. This is the unknown primitive black box in medicine. In acute and post-acute care, the numeric pain scale is frequently used to measure pain from zero to 10, with zero conveying no pain and 10 being excruciating pain. This seems so easy and straightforward, until you start using it with patients.
What you discover is Charlie's pain score at five might be Sandra's equivalent of an eight pain score. At least, that is what seems to be the case from trying to compare individual reactions to painful scenarios. Then there are those myriad other contributors in the mix – like anxiety, stress, depression, and cultural backgrounds - which can contribute to the patient's final interpretation of how they feel about their pain at that point in time. Even having to wait on a medication to be delivered can exacerbate pain since the longer the wait the higher the number climbs further escalated by the stress of the wait.
If that is not hard enough – then how can we measure relief of pain or what the patient says is acceptable for them to tolerate and call it adequate relief? In this case, maybe this is really easier. In a recent post-operative orthopedic clinical trial using an oral patient controlled analgesia device for the delivery of pain tablets, compared to the manual delivery of pain medication by nursing, all patients were asked what pain score if achieved would likely be tolerable for them for adequate relief.
Both groups reported three with no significant difference between the two groups. This was easy – just titrate down to three. The information was there but very few patients ever got down to a score of three. Why was that? Part of the problem was a hidden number in a mishmash of other data neatly stored away in electronic medical records not to be seen again. The likely perils of too much documentation. Sometimes it's hard to see the obvious from all the data.
This reminds of my days as a medical student on the general surgery service at Mizzou. We were to round on our patients before regular rounds with the real doctors. As an overwhelmed student I entered the surgical critical care unit one morning and found the huge chart of my patient from the day before on a ventilator with what seemed like a thousand numbers of ventilator settings, vital signs, cardiac parameter measurements etc. Having spent too much time trying to decipher the still “Greek to me” data I finally found the patient's nurse and said, “What are the ventilator settings this morning?” Shaking her head and tolerating my obvious ignorance of the situation, she said “Why don't you just break down and go over and look at the patient. He was taken off the ventilator yesterday afternoon.” Need I say more?! I was so overwhelmed by the data and numbers, I ignored the obvious. That, I think is part of the problem with pain management. We just have to break down and spend some time with the patients.
Sharon Conley, M.D., Ph.D., is a certified pain educator – CPE and chief medical officer at Avancen MOD Corporation.