Pain became the 5th vital sign and doctors were initially told to take tabs on severity through scales out of 10 testing. Now, out of fear severity analysis will over-treat pain with opioids, doctors in USA are being encouraged not to question pains severity and stick to level of function. There is evidence that, removed from placebo effect, opioids only reduce pain by 1/10 on average. For clinicians that are not trained in orthopedic medicine, opioids, and now marijuana, are the main tools to control pain. This is what fuels the opioid epidemic. I did an analysis of my practice and find other measures I do drops pain by 2/10 bringing pain to more acceptable levels. Those with 7/10 of more can be often dropped in pain by 3/10 for 3 days at a time by ketamine shots done 1-2 times a week and control depression. Regular treatments using alternatives written in this blog, can do more.
“Pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the US:
Why?
N. Levy, J. Sturgess, P. Mills
British Journal of Anaesthesia 120 (3): 435e438 (2018)
doi: 10.1016/j.bja.2017.11.098
https://www.ncbi.nlm.nih.gov/pubmed/29452798
no abstractVAS_Nomore
- they quote one study stating: “One US hospital reported that following introduction of treating pain according to a numerical pain treatment algorithm the incidence of opioid over-sedation adverse drug reactions per 100,000 inpatient hospital days increased from 11.0 to 24.5.”
Vila Jr H, Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesth Analg 2005;101:474e80.No wonder, when you can only get 1/10 plus placebo effect out of opioids on average. - Blaming the pain scale:
“The Joint Commission, which acts as the regulatory body for many US healthcare institutions, now recognises there is a direct link between healthcare policies, the numerical pain scale, pain expectations and opioid addiction.”If opioids is the only nail you have, then it’s going to be hammered. – the answer is to diversify treatment, not nail opioids. Using gabapanetinoids? – ineffective in back pain and sciatica which accounts for 1/2 of pain issues. Amitriptyline and cymbalta? – maybe 1/10 drop eventually -2/10 if lucky- need to look elsewhere . - Alternatives include functioning – after abdominal surgery would be ability to sit up and ability to get up to washroom.
a simple 5 point scale I came across:
1/5- pain can be forgotten
2/5 – does not interfere with activities but cannot be forgotten
3/5 – able to work but puts off luxuries
4/5 – able to do simple tasks but puts off necessities
5/5 – forced to bed
To get a clearer picture of pain, more questions are suggested (verbatim) -though admit might be too unwieldy)
1. Onset and pattern (When did the pain start? How often does it occur?
Has its intensity changed?)
2. Location (Where is the pain? Is it local to the incisional site, referred, or elsewhere?)
3. Quality of pain (What does the pain feel like?)
4. Aggravating and relieving factors; What makes the pain better or worse?
5. Previous treatment (What types of treatment have been effective or ineffective in the past to relieve the pain?)
6. Effect (How does the pain affect physical function, emotional distress, and sleep?)
7. Whether there are barriers to pain assessment (eg cultural or language barriers, cognitive barriers, misconceptions about interventions).7
(from 7 Roger CD, Gordon D, Oscar A, et al. Guidelines on the Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on regional Anesthesia, Executive Committee, and Administrative)
- to support use of less opioids they contend there would be less opioid induced side effect like drowsiness and constipation.
- US figures suggest 1/16 opioid naïve surgical patients become dependent so post op use is an issue.
- I find the opposite here – where post hip/knee patients can be sent home on an NSAID without much regard for their pain
Comment – somewhere there has to be a happy medium. Drugs like tramadol, butrans patch, and nucynta have low addiction potential but our government has chose not to cover cost for any of them suggesting to me that they aren’t serious about the opioid problem.