“How many of you still use the comparative pain scale (0–10)?” asked John Bowman, CEO of Sure Med Compliance, during his talk at the annual meeting of the Medical Group Management Association (MGMA) this fall. Half the audience raised their hands. He then asked, “If a [chronic pain] patient walks into your practice, and you ask them what their pain level is, what do they say?” Multiple voices called out, Ten. “I’ve done this talk 50 times in the last two years and every single time I’ve asked that question [the answer is] ‘patient reports a ten.’”
It wasn’t always like this. Two decades ago and before the opioid epidemic, pain wasn’t such a numbers game. “In 2000, Congress, in fact, declared the next decade… the decade for improving pain,” said Myra Christopher, a bioethicist and activist, in this NPR interview. At the time there was growing concern that physicians were too callous about patients’ pain.
In response to all of this, The Joint Commission decided that they should include the assessment of pain as one of their quality measures. “The notion was—if pain was assessed more often, then it would be treated better,” said Christopher.
The 0–10 pain scale likely became as popular as it is today because of its combined qualities: objectivity and ease of use. It’s easy to remember, quick to administer, and simple to document. Quality control groups like it, and in many cases insurance companies require it to dole out reimbursement. The problem is that pain usually isn’t quite that simple.
“We understand better now that pain is what we call a bio-psychosocial experience, meaning it’s got physical, emotional, and psychological components beyond just that intensity measure,” Dr. Chester Buckenmaier, director of the Defense and Veterans Center for Integrative Pain Management, also told NPR.
There is another problem, according to our MGMA speaker John Bowman. The simple measure of pain offered by the comparative pain scale can get physicians into trouble now that we are facing the opioid epidemic.
More than 630,000 people died from a drug overdose in the United States between 1999 and 2016, according to the CDC. Despite the fact that the rate of opioid prescribing has decreased steadily since 2010, drug companies and healthcare providers continue to be held accountable.
In the meantime, chronic pain patients have learned that a high pain rating is one way to get their caregivers to take their suffering more seriously. “It becomes really important in your practices that when you’re assessing [chronic] pain, you know you’re probably going to get a 10. What happens then when the patient comes back 30 days, 60 days, or 90 days later and still reports a 10? What happens to the prescriber’s liability when they reissue that prescription?” Simple: It will go up because they’ve not proven effectiveness of the medication.
Bowman says this is the number one discrepancy in most state board inquiries across this country: “The provider is not showing benefit of the opioid.” Your prescribing decisions should not, therefore, rely on this simple numerical pain scale. “They should be tied to specific treatment goals that are activity-of-daily-living and functional-impairment specific.”
Bowman recommends The Brief Pain Inventory (BPI). This multidimensional pain questionnaire addresses issues like sleep, enjoyment of life and work impairment. A briefer and sometimes easier-to-implement adaptation of the BPI is the PEG Scale. The three-question PEG pairs functional activity with a 0–10 pain scale, and it is recommended by the Centers for Disease Control in their Checklist for Prescribing Opioids for Chronic Pain.
While some physicians are to blame for bad opioid-prescribing practices, most genuinely want to help their patients overcome suffering and sometimes opioids are the right choice. “Pain catastrophizing is not something that is always people misusing medications,” said Bowman. “It’s people that sometimes just really want relief because they have legitimate pain.” These are the patients that make diligence during pain assessment a necessity. Pain affects so many aspects of a patient’s life, it really deserves more than just a number.