We need to talk about the 1-10 pain scale.
(Thread.)
(1/ )

Everyone mocks it. And rightly so; how could a single number hope to encapsulate such a complex human experience as pain? But here’s the thing: the problem isn’t the scale, it’s that no one knows how to use it correctly. (2/ )

This thread is primarily geared toward doctors and nurses, who are, more often than not, never taught the correct way to use the pain scale. (Spoiler: it’s treated like a measurement tool, but it’s not actually a measurement tool! For further details, read on….) (3/ )

Before I get to the part where I tell you how it’s actually supposed to be used, we need to talk about basic pain management theory. Pain is by nature a subjective experience, and the only person who has a right to comment on the severity of pain is THE PATIENT. (4/ )

You can’t diagnose pain or absence of pain with vital signs. You can’t diagnose it by observation of a person’s behavior. The only way to know how much pain a person is in is by the person’s self-report. And you have to believe them when they tell you. (5/ )

(This is especially important because, for example, black people are at extremely high risk for pain under-treatment, especially when treated by white doctors. There are studies.) (6/ )

The most successful pain management results from a collaborative partnership between a patient and their practitioner. (7/ )

The patient is the expert on their body, how things make them feel, how things affect their life, and how things are working or not working. (8/ )

The practitioner is ideally the expert on anatomy/physiology, other contributing factors to the experience of pain, what managements are available, what has been shown to be most likely to help in certain circumstances, and what should be avoided for likelihood of harm. (9/ )

Pain management is an ONGOING CONVERSATION between these two bases of expertise. Without that conversation, any success is accidental if it even happens at all. (10/ )

Where does the 1-10 pain scale factor in here? After all, pain is a subjective experience with multifactorial inputs, many/most of which are not objectively measurable. Why bring numbers into it at all? (11/ )

But the pain scale NOT a measurement tool! It’s a communication tool! When it’s used right, the numbers FACILITATE THE CONVERSATION about pain management in certain ways. They can be a common language that helps the meeting of minds. But only if they’re used correctly. (12/ )

What does 9/10 pain mean? What does 3/10 pain mean? Individually? NOTHING AT ALL. Single measures are meaningless when it comes to the pain scale. I can’t stress this enough. SINGLE NUMBERS ON THE PAIN SCALE MEAN NOTHING. (13/ )

The only way to make the pain scale numbers meaningful is BY COMPARISON. How a person’s pain MOVES AROUND on the pain scale is the only relevant information the 1-10 numbers can give. How do you create the comparison? Conversation with the patient! (Getting a theme here?) (14/ )

What do the numbers mean to the patient? It is different for every person, so every person must be given the opportunity to establish their own parameters. Here are some helpful questions that can establish the parameters that can make the pain scale actually useful: (15/ )

What number corresponds to severe pain for you?
What number represents a tolerable level?
What is your baseline everyday pain level?
When you take X medication, what # does it bring your pain to?
What number should we shoot for as your goal for well-controlled pain?
Etc.
(16/ )

These questions, and others, are NECESSARY to create meaning for the 1-10 numbers. And, I cannot stress this enough, the questions have to be asked to EACH PERSON INDIVIDUALLY. Without these questions, the 1-10 scale is MEANINGLESS and USELESS. (17/ )

Example: I had a patient with breast cancer, whose most-severe pain was 5/10. When her pain was uncontrolled, she described it as 6/10. Anything below a 3/10 was tolerable for her. Her goal was to keep her pain at a level of 3/10 or below. (18/ )

If we used the pain scale the way everyone uses the pain scale, we would conclude that she was never in “severe pain”, because she wouldn’t use the higher numbers. But she still experienced severe pain that interfered with her ability to live her life! (19/ )

Example: I had another patient with breast cancer, who unfortunately died recently. Her most-severe pain was 10/10. When her pain was uncontrolled, it was 9/10. Anything below an 8/10 was tolerable for her. Her goal was to keep her pain at a level of 7/10 or below. (20/ )

At that level, she could live her daily life with only minimal amounts of interference from her pain. But if we used the pain scale the way everyone does, we would assume that her pain was still uncontrolled at 7/10, and we would be at risk for overdosing her. (21/ )

Do you see from only two examples how it can’t be used as an objective measuring tool? (22/ )

Speaking of the concept that the important part of the pain scale is the MOVEMENT on the pain scale: an extremely helpful use of the 1-10 scale is to help someone articulate whether an intervention is working for them, and how well. (23/ )

If someone is at a level of 7/10 pain and their goal is 4/10, and you give them a dose of medication which lowers their pain to 6/10…you know the medication has worked slightly, but not enough. You can make dose adjustments accordingly. (24/ )

Anyway. That’s the basics on the pain scale. The fact that it is never used this way is the reason no one has any respect for it. (25/ )

It’s not the tool that’s the problem; it’s the fact that we’re holding it upside down and backwards, and trying to use the blunt handle as the business end. Of course it doesn’t work. (26/26)

Obligate Soundcloud section (1/3):
Black people are at high risk for pain undermanagement, especially from white doctors
Believe patients’ pain self-reports

Agitation nearly always has a primary cause (pain, infection, constipation, urinary retention, dyspnea, etc) Identify and address before sedating medications are used. (2/3)

When used properly, morphine does not hasten death.
“Drug-seeking” behavior should immediately trigger an evaluation for pain undermanagement
(3/3)