Researchers: How 'pain scores' cause more suffering

Pain intensity may be the wrong goal for treating chronic pain, authors argue

The way clinicians typically measure chronic pain is contributing to the opioid addiction epidemic—but there is a better way, two researchers write in a New England Journal of Medicine perspective.

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For several decades, note Jane Ballantyne and Mark Sullivan of the University of Washington School of Medicine, "there has been hope that more liberal use of opioids would help reduce the number of Americans with unrelieved chronic pain."

Yet that hasn't happened, they argue, and has instead led to "an epidemic of prescription-opioid abuse, overdoses, and deaths—and no demonstrable reduction in the burden of chronic pain."

The authors attribute this epidemic in part to clinicians frequently employing the pain intensity scale, asking patients to rate their pain from a low of zero (no pain) to a high of 10 (worst possible pain). That has incentivized clinicians to focus on reducing pain intensity, often by continuing or escalating opioid doses.

But while pain intensity scores may have more efficacy for treating end-of-life or acute pain, Ballantyne and Sullivan argue that it may be the wrong goal for treating chronic pain—prioritizing the use of painkillers "at the expense of worsening function and quality of life."

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Another reason to deprioritize pain intensity, they argue, is that those who often report the greatest amount of pain—individuals with mental health or substance misuse issues—"are least likely to benefit from opioid treatment and most likely to be harmed by it."

An alternative solution

Instead, Ballantyne and Sullivan say, clinicians should treat chronic pain using a multimodal approach, involving "behavioral, physical, and integrated medical approaches," with the "primary goal of reducing pain-related distress, disability, and suffering."

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"When it does that successfully," they add, "a reduction in pain intensity might follow—or acceptance might make the intensity of pain less important to a person's functioning and quality of life."

It's the norm of people in other countries to self-manage pain, Ballantyne tells STAT News, adding, "We need to make it the standard of care in the United States" (Ballantyne/Sullivan, NEJM, 12/2; Skerrett, STAT News, 11/30).

Cost and quality effects of multimodal pain regimens

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