FAILURE of clinicians to ask patients about their pain and to accept and act on patients’ reports of pain are probably the most common causes of unrelieved pain and unnecessary suffering. Basic pain assessment is a simple but, unfortunately, infrequently performed task. Even when appropriate assessments are made, clinicians do not necessarily accept the findings and might not take appropriate action. Some of the misconceptions that cause this are listed in Table 1-1, and these and others are discussed later in this chapter and in other chapters in Section II.
Table 1-1
Misconceptions: Barriers to the Assessment and Treatment of Pain
Misconception* | Correction |
The best judges of the existence and severity of patients’ pain are the physicians and nurses caring for the patients. | Patients are the authorities on their pain. Patients’ self-reports are the most reliable indicators of the existence and intensity of pain. |
Clinicians should use their personal opinions and beliefs about the truthfulness of patients to determine patients’ true pain status. | Allowing each clinician to act on personal beliefs presents the potential for different pain assessments by different clinicians, leading to different interventions by each clinician. This results in inconsistent and often inadequate pain management. It is essential to establish the patients’ self-reports of pain as the standard for pain assessment. |
Clinicians must believe what patients say about pain. | Clinicians need not believe the patients’ reports of pain, but clinicians must accept and respect patients’ reports of pain and proceed with appropriate assessment and treatment. Clinicians are always entitled to their personal opinions, but those opinions cannot be allowed to guide professional practice. |
Comparable noxious stimuli produce comparable pain in different people. The pain threshold is uniform. | Findings from numerous studies have failed to support the notion of a uniform pain threshold. Comparable stimuli do not result in the same pain in different people. After similar injuries, one person may suffer moderate pain and the other severe pain. |
There is no reason for patients to hurt when no physical cause for pain can be found. | Pain is a new and inexact science, and it would be foolish of us to think that we will be able to determine the cause of all the pains that patients report. |
Patients should not receive analgesics until the cause of pain is diagnosed. | Pain is no longer clinicians’ primary diagnostic tool. Symptomatic relief of pain should be provided while the investigation of cause proceeds. Early use of analgesics is now advocated for patients with acute abdominal pain. |
Visible signs, either physiologic or behavioral, accompany pain and can be used to verify its existence and severity. | Even with severe pain, periods of physiologic and behavioral adaptation occur, leading to periods of minimal or no signs of pain. Lack of pain expression does not necessarily mean lack of pain. |
When it is time to reassess patients’ pain following an analgesic and the patients are sleeping, it is not necessary to awaken them. | Sleep does not mean the absence of pain, and not all patients who appear to be sleeping are actually sleeping. Until patients’ responses to analgesics are established as being effective and safe, patients should be awakened to obtain a pain rating. This should be explained to patients. However, if the same analgesic dose has been administered before and has produced effective pain relief, and patients are not aroused by simple stimuli such as calling their names in a normal tone of voice, patients with acceptable respiratory status may be allowed to sleep. If patients’ pain is relatively constant and the analgesic effect is known to wear off after a certain time, e.g., 4 hours, consider awakening patients for the next dose before pain awakens the patients. Discuss this option with the patients. |
Anxiety makes pain worse. | Anxiety is often associated with pain, but the cause-and-effect relationship has not been established. Pain often causes anxiety, but it is not clear that anxiety necessarily makes pain more intense. |
Patients who are knowledgeable about opioid analgesics and who make regular efforts to obtain them are drug seeking (addicted). | Patients with pain should be knowledgeable about their medications; use of opioids for pain relief is not addiction. When patients are accused of drug seeking, it may be helpful to ask, “What else could this behavior mean? Might these patients be in pain?” |
When patients report pain relief after a placebo, it means that the patients are malingerers or that the pain is psychogenic. | About one third of patients who have obvious physical stimuli for pain (e.g., surgery) report pain relief after a placebo injection. Therefore, placebos cannot be used to diagnose malingering, psychogenic pain, or any psychologic problem. Sometimes placebos relieve pain, but why this happens remains unclear. |
The pain rating scale preferred for use in daily clinical practice is the Visual Analog Scale (VAS). | For patients who are verbal and can count from 0 to 10, the Numeric Rating Scale (NRS) is preferred for adult patients. It is easy to explain, measure, and record, and it provides numbers for setting pain-management goals. The VAS is a straight line with anchors at each end and no numbers or adjectives in between. |
Cognitively impaired older patients are unable to use pain rating scales. | When an appropriate pain rating scale (e.g., 0 to 5) is used and patients are given sufficient time to process information and respond, many cognitively impaired elderly people can use a pain rating scale. |
Cognitively impaired patients, especially those who are unable to self-report, do not experience as much pain as those who are cognitively intact. | Recent studies examining mechanisms and differences in pain transmission and perception in older adults with dementia document that the pain transmission process is unaltered, but these adults may respond with behaviors that are different from those of cognitively intact adults. In other words, cognitive impairment may result in less pain being reported, but there is no evidence that cognitive impairment reduces the ability to feel painful stimuli. |
Critically ill patients, especially those who appear to be unconscious or have received a neuromuscular blocking agent, do not feel pain and do not recall painful episodes in intensive care units (ICUs). | Levels of consciousness are difficult to determine, and patients who are thought to be unconsciousness in the ICU often recall moderate to severe pain. Patients under the influence of neuromuscular blocking agents may still be fairly alert and able to feel pain. Patients with endotracheal tubes are unable to self-report verbally but may be able to provide self-reports if attempts are made, such as establishing head nod, pointing, or eye blink in response to questions about a pain. |
Persons with intellectual disabilities (IDs) or mental retardation are either insensitive to pain or have greater tolerance for it. | This perception appears to be based on observations that behavior following a potentially painful event is delayed or unconventional. These observations are often valid but do not necessarily indicate insensitivity to pain or indifference to it. Measurements of sensitivity to pain using heat-pain thresholds indicated greater sensitivity to pain than is experienced by normal controls. Behavioral responses to pain may not occur in some individuals with IDs because of physical disabilities such as cerebral palsy. |
Schizophrenic patients’ reports of pain are commonly expressions of the mental illness. | For some time, decreased reactivity to pain in some patients with schizophrenia has caused clinicians to believe they were experiencing insensitivity to pain. Some patients with schizophrenia fail to report pain until it becomes severe. As a result, these patients seek medical care at a later stage of the physical disease and may suffer complications as a consequence. Postoperative pain is a risk factor for postoperative confusion and should be treated with analgesics. The appearance of insensitivity to pain by schizophrenic patients is poorly understood but may be the result of abnormal processing of sensory input. In one study of experimental pain, it was noted that individuals with schizophrenia had difficulty focusing on their pain. Furthermore, pain is rarely a hallucination. Recently, studies have suggested that absence of pain reactivity does not mean absence of pain sensitivity. |
Patients with posttraumatic stress disorder (PTSD) show low sensitivity to acute pain and rarely have chronic pain. | Although a few studies have shown that patients with PTSD are less sensitive to very brief painful stimuli, chronic pain is commonly present in patients with PTSD and, conversely, patients with chronic pain often have PTSD, although both of these co-occurences are underdiagnosed. |
*These misconceptions are discussed in this section, along with appropriate references.
From Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management, p. 17, St. Louis, Mosby. Pasero C, McCaffery M. May be duplicated for use in clinical practice.
Some of the problems related to the assessment of pain and decisions about treatment have been studied using vignettes such as the ones in Box 1-1 (p. 18). These vignettes are used to illustrate several problems revealed by research and encountered in clinical practice. Take time now to review Box 1-1 and answer the questions (without previewing the answers presented in the tabulated surveys in Table 2-1, p. 21).
For years, many studies have shown that either the lack of pain assessment or the existence of differences between clinicians’ pain ratings and those of patients has been a major cause of inadequate pain management (Grossman, Sheidler, Swedeen, et al., 1991; Von Roenn, Cleeland, Gonin, et al., 1993). In one study of the skills of resident physicians in assessing chronic cancer pain, only 58% were deemed competent (Sloan, Donelly, Schwartz, et al., 1996). Assessment of simple characteristics of the pain was often omitted. For example, more than half the physicians failed to assess pain intensity.
Approximately 7 years later, research shows that such problems still exist in some cancer centers. In a review in five hospitals of 117 charts of 80 inpatients and 37 outpatients with cancer who had pain documented in their medical records, pain intensity was noted for only 57% of outpatients and 55% of inpatients (Cohen, Easley, Ellis, et al., 2003). In a study of medical patients, 11% who reported unbearable pain had never been assessed, and 14% were never offered analgesics. The authors concluded that one reason for poor analgesia was inadequate pain assessment (Dix, Sandhar, Murdoch, et al., 2004).
Initial efforts to improve pain assessment are not always successful. The Veterans Health Administration launched a study of the impact of a pain initiative requiring that a pain rating be recorded at all clinical encounters (Mularski, White-Chu, Overbay, et al., 2006). The initiative was adopted in 1999 and fully implemented in 2001. In a general medicine outpatient clinic, a retrospective review of 300 charts before 1999 and 300 after 2001 was conducted. The quality of care was unchanged before and after the pain initiative. For example, pain ratings were documented 49.5% of the time prior to the initiative and 48.7% afterwards.
Overall, research shows that when clinicians do not obtain pain ratings from patients, they are likely to underestimate pain, especially moderate to severe pain (Graffam, 1981; Larue, Fontaine, Colleau, 1997; Zalon, 1993). In a study of 103 patients with cancer pain, the pain ratings of the patients were compared with those of nurses, house officers, and oncology fellows. All groups underestimated the patients’ pain (Grossman, Sheidler, Swedeen, et al., 1991). When pain was severe, only 7% of nurses, 20% of oncology fellows, and 27% of house officers correctly assessed the pain levels. These caregivers were more accurate in rating moderate pain and even better when identifying mild pain. It is interesting to note that in another study, nurses tended to overestimate mild pain (Zalon, 1993).
Underestimation of pain by caregivers understandably contributes to undertreatment of pain. In a study of more than 1000 outpatients with metastatic cancer, the most powerful predictor of inadequate analgesia was the discrepancy between the physicians’ and the patients’ estimates of pain severity (Cleeland, Gonin, Hatfield, et al., 1994). For almost half the patients, physicians underestimated the extent to which pain interfered with the patients’ activities.
When clinicians do obtain pain ratings from patients, they do not necessarily accept what the patients say. In a study of 24 surgical patients, the pain ratings by patients were compared with those documented on the patient-controlled analgesia record by the nurses (Carey, Turpin, Smith, et al., 1997). The nurses consistently documented lower pain ratings than those reported by patients. Once again, the greatest discrepancies occurred at the highest pain levels. Findings from other research using patient vignettes also reveal that even when patients report pain intensity as a specific number on a pain rating scale, some nurses record a different number in patients’ records (McCaffery, Ferrell, 1991a, 1991b, 1992a, 1992b, 1992c, 1997a; McCaffery, Pasero, Ferrell, 2007).
The findings of several studies suggest that clinicians believe that patients exaggerate their pain. In one study, when medical and nursing staff were asked to rate what they believed were patients’ pain intensities, they rated the pain levels lower than the patients did (Krivo, Reidenberg, 1995). However, when they were asked what pain rating they thought the patients would report, more than two thirds of the staff stated higher pain ratings that were much closer to those the patients gave, revealing that they thought the pain was really less intense than the patients said it was.
In a comparison of oncology nurses and long-term care facility nurses, the latter were more likely to believe that patients with cancer pain overreport their pain (Ryan, Vortherms, Ward, 1994). Nurses in long-term care facilities believed that about 25% of these patients were exaggerating the severity of their cancer pain. In another study of nurses across the United States, more than one third of them believed that 20% or more of patients with cancer overreport their pain (McCaffery Ferrell, 1995b).
In a study of hospitalized oncology patients, physicians and nurses were asked to have patients rate their pain daily (Au, Loprinzi, Chodapkar, et al., 1994). Compliance with this request was poor, but when they did ask their patients for pain ratings, they tended to downgrade patient pain scores when they reported them verbally to the investigators.
If clinicians believe that patients overstate their pain, this would help explain why assessment of pain using patients’ self-reports does not necessarily result in improved pain management. The clinicians may assess pain accurately but may be planning pain management on the basis of their own beliefs rather than on what the patients say.
This possibility was illustrated in a study of pain ratings by nurses and surgical patients in the critical care setting (Puntillo, Miaskowski, Kehrie, et al., 1997). These nurses consistently, although not significantly, underestimated mild to moderate pain. Most important, the amount of opioid administered was better correlated with the nurses’ own pain ratings than those they obtained from the patients.
In a prospective study of patients admitted to the emergency department with long-bone fractures versus those without fracture, clinicians’ decisions about pain management were not based primarily on patients’ reports of pain intensity (Bijur, Berard, Esses, et al., 2006). Statistical analysis showed that at every level of pain intensity, a consistently higher proportion of patients with fractures received opioid analgesics than did those without fractures. Apparently, clinicians gave more credence to pain ratings when a physical cause such as fracture was documented.
Some improvement has been shown in pain assessment. From 1992 to 2001 data from 20 studies at eight hospitals analyzed pain intensity and pain documentation. There was increased frequency of pain assessment but no significant decrease in pain intensity or in pain’s interference with activities (Gordon, Pellino, Miaskowski, et al., 2002). Clearly, pain assessment is not enough. It is essential to tie pain assessment to pain treatment.
A study by the Veterans Health Administration, mentioned earlier, described the results of pain management before and after the implementation of a pain initiative (Mularski, White-Chu, Overbay, et al., 2006). Not only did pain assessment not improve, but also the quality of pain treatment showed no signs of improvement. After the initiative was implemented, 39% of patients reported substantial pain (a rating of 4 or more on a 0-to-10 scale) but often did not receive recommended care; 59% received no new therapy for pain.
Failure to act on patients’ reports of pain also is influenced by many other factors, in particular, institutional barriers. For example, many hospitals do not have policies that allow nurses to titrate analgesic doses or to implement analgesics as needed around the clock when pain is present most of the day. And, as mentioned throughout this book, many clinicians lack knowledge about appropriate pain management.
Clearly, many clinicians need instruction about how to conduct even the most basic pain assessments such as pain intensity. Clinicians also need education about the importance of regularly scheduled assessments, the responsibility to accept what the patient says rather than downgrading reports of pain, and the necessity of planning action on the basis of a patient’s report of pain, not their own personal judgments. It is essential that clinicians understand their own attitudes and misconceptions about pain so they can assess and treat pain effectively.
Although the subject is not covered in this book, clinicians are reminded that comprehensive initial and ongoing assessments of patients with pain also should include appropriate physical and neurologic examinations as well as inquiries about psychosocial factors related to the pain, such as the patients’ and their families’ concerns about pain and the financial impact of pain. Every effort should be made to diagnosis the underlying mechanism or cause of pain, not only initially but also at regular intervals when the pain does not subside. Any significant increase in pain or change in the characteristics of pain should signal the need for another comprehensive physical assessment and possibly neurologic, psychosocial, and other examinations. Increases in pain should never be explained solely as drug-seeking behavior or as simply the result of tolerance to opioid analgesia or psychosocial problems.