Every encounter with a medical professional over the past two years has mostly been met with a simple yet puzzling request: “Please rate your pain on a scale of 0 to 10.”
As a physician by training, and someone who has asked patients this question thousands of times, I think hard about how to quantify the pain that combines the pain in my lower back, the tingling in my thighs, and the numbness and itching near my left shoulder blade. I pause, then choose a number, almost arbitrarily. “Three or four?” I venture, knowing that the real answer is long and complicated and cannot be measured in this one-dimensional way.
Pain is fickle. Sometimes it’s burning, sometimes it’s drilling, sometimes it’s clenching deep in my muscles. My pain varies depending on my mood and how much attention I’m paying, but if I’m engrossed in a movie or work, it subsides almost completely. Sometimes the pain is so disruptive that I have to cancel a vacation, and other times it’s so severe that I become addicted to opioids. Even pain above a 10 can be tolerated for a good reason, like childbirth. But what is the pain I’m in now, the aftereffects of a head injury, for?
The concept of reducing pain to a single number dates back to the 1970s. But the 0 to 10 scale is now ubiquitous, thanks to what was called the “pain revolution” in the ’90s, where new attention was paid to managing pain (mainly with opioids) and it was seen as progress. Doctors today have a deeper understanding of what can (and should) be thoughtful about treating pain, and the dire consequences of prescribing opioids too easily. What doctors are only now learning is how to better measure pain and treat different types of pain.
Nearly 30 years ago, opioid advocates reinvigorated the previously niche specialty of pain management. They began to promote the idea that pain should be measured at every doctor’s visit as the “fifth vital sign.” The American Pain Society Copyright The phrase “pain is the most important thing in the body.” But unlike other vital signs like blood pressure, temperature, heart rate, and respiratory rate, there was no objective measure for pain. How can you measure what you can’t measure? The association encouraged doctors and nurses to use a 0 to 10 rating system. Around that time, the FDA approved OxyContin, a sustained-release opioid painkiller made by Purdue Pharma. Encouraged by the pharmaceutical companies themselves To the doctor Record and treat pain regularlyAnd they aggressively promoted opioids as the obvious solution.
In fairness, the 0-10 rating system can be considered progress in an era when pain was often ignored or undertreated. Cancer patients I saw in the ’80s, even those suffering from severe pain from bone cancer, did not have access to morphine pumps; doctors viewed pain as an inevitable part of the illness. In the emergency room where I worked in the early ’90s, prescribing even a few opioid pills was a hassle. I had to ask the charge nurse to unlock a special prescription form and make a copy to the state agency that tracks prescribing patterns. Regulators (rightly) worried that distribution of narcotics would lead to addiction. As a result, some patients who needed pain relief likely did not receive treatment.
After pain specialists and opioid manufacturers campaigned for more widespread use of opioids, arguing that the new forms were not addictive or much less so than previous forms, the drugs became much easier to prescribe and were recommended for all kinds of pain, from knee arthritis to back problems. As a young physician who joined the “pain revolution,” I probably asked patients thousands of times to rate their pain on a scale of 0 to 10 and wrote many prescriptions for painkillers every week, because monitoring the “fifth vital sign” quickly became routine in the health care system. Before long, the 0 to 10 pain measure became a required box to fill in the electronic health record. The Joint Commission on Accreditation of Healthcare Organizations states, Regularly assess pain Prerequisites for admission to the medical center Federal Health Care CostsMedical group added Treating pain Added to the list of patient rights, satisfaction with pain treatment is now a factor in post-consultation patient surveys. (Poor results can mean lower reimbursements from some insurance companies.)
However, this approach to pain management had obvious drawbacks. Measuring patients’ pain was unreliable improved pain control; physicians showed little interest in or did not know how to respond to the recorded responses; and patients’ satisfaction with physician discussions about pain Does not necessarily mean They were receiving proper treatment. At the same time, the drugs were fueling the opioid epidemic. Estimated 3 to 19 percent The percentage of people who receive a prescription for painkillers from a doctor who develop an addiction.
But doctors wanting to treat pain had few other options: “We were well aware that these drugs were not the only way to manage pain.” Linda Porter“But there was a lack of understanding of its complexities and alternatives,” John F. Kennedy, director of the Office of Pain Policy and Programs at the National Institutes of Health, told me. The craze for opioids left many types of pain understudied and undertreated for years. It wasn’t until 2018, when nearly 50,000 Americans died from overdoses, that Congress began funding a program aimed at studying different types of pain and finding better solutions: the Early Phase Pain Research and Clinical Network (EPPIC-Net). The network brings together experts from 12 specialized clinical centers, aiming to stimulate new research in the field and find tailored solutions for different types of pain.
A scale from 0 to 10 may make sense in certain situations, such as when a nurse adjusts medication for a patient hospitalized for surgery or an accident. Researchers and pain experts have tried to create better assessment tools, and while there are dozens of them, none of them are good enough to capture the complexity of pain. The European Panel of Experts concludedFor example, the Veterans Health Administration created a survey with supplemental questions and visual prompts; a rating of 5 correlated with grimacing and a level of pain that “interrupted some activities.” It took much longer to conduct the survey and publish the results. It wasn’t better than the zero to ten system.By the 2010s, many medical organizations, American Medical Association And the American Academy of Family Physicians Reject Not just a scale from 0 to 10 concept Pain can be self-reported by patients in a meaningful, numerical way.
When opioids were the mainstream painkillers, gabapentin and pregabalin for neuropathy, lidocaine patches, cream Medications that work for musculoskeletal pain are now available. “There was a growing awareness of the incredible complexity of pain, and therefore the need to find the right medication for the right patient,” Rebecca Homer, interim director of EPICC-Net, told me. Researchers are now looking for biomarkers associated with different types of pain so that drug studies can assess the effectiveness of drugs on a more objective scale. A better understanding of the neural pathways and neurotransmitters that produce different types of pain could also help researchers design drugs that interrupt and suppress pain.
Any treatments that come out of this research won’t be blockbuster hits like opioids because, by design, they will only benefit a small number of people, making them an unattractive prospect for pharmaceutical companies. So EPICC-Net helps small pharmaceutical companies, researchers, and even individual physicians design and conduct early-stage trials to test the safety and efficacy of promising pain-relieving molecules. That information is then handed over to pharmaceutical companies for later-stage trials, with the goal of getting new drugs approved by the FDA more quickly.
The first trials of EPICC-Net have just begun. Finding better treatments is no easy task, as the nervous system is a largely unexplored universe where molecules, cells and electronic connections interact in countless ways. The 2021 Nobel Prize in Physiology or Medicine The mechanism was discovered Our senses allow us to feel the most basic sensations, like cold and heat. Pain is like a hydra in comparison. A simple number may seem definitive, but it doesn’t help ease the pain.
