Thursday 12 May 2016

Getting back to common sense with an acute pain titration protocol: “Do you want more pain medication?”

The Joint Commission (TJC) is the peak hospital accreditation body in the USA. In the year 2000, they mandated screening pain assessments.  Since then, pain has been considered the “fifth vital sign” and the numerical rating scale (NRS) has taken over ED’s around the world. “Rate your pain 0 to 10?” often bellows through the corridors of the ED. But is this practice asking the wrong question?

Out of the ashes of all this mess comes an interesting study from the Bronx, New York. Hey... fagitaboutit. As can be imagined, this is a very busy and underserved emergency department. So perhaps a pain protocol might be more effective in this setting.

They devised a prospective cohort study of adults with acute severe pain defined as requiring IV opiods. The protocol called for an initial 1mg of hydromorphone (equivalent to 7mg of morphine). About 30 minutes later they asked, “Do you want more pain medication?” This was repeated until they reached a maximum of 4mg of the drug.

They considered the protocol a success if at any time they declined the offer of more pain medication. If they got all 4mg and still wanted more, they failed.

As would be predicted, the success rate was very high. 205 of 207 (99%; 95%CI 97% to 100%) subjects achieved satisfactory analgesia. There were only very few adverse events.   

But this is not why I liked this paper...

They also explored the relationship to a request for more pain mediation with their reported pain score on the NRS.

Perhaps the most interesting part of this study was the results of this comparison. They plotted the relationship graphically. This showed large variability in pain scores when patients requested and declined additional pain medication.

So what are we to take home from all of this?

I think Dr Steve Green sums it up best in the accompanying editorial entitled, “The Numerical Scoring of Pain: This Practice Rates a Zero out of Ten.”

Dr Green’s conclusion is so good that I dare not paraphrase:

The numeric rating scale is helpful for pain research but is inaccurate and counterproductive for standard patient care. TJC mandates that pain be identified and addressed but does not specifically require pain scoring. What happened to the old-fashioned question such as “Are you in pain?” and “Do you want pain medication?” Pain scoring in electronic medical records could be more appropriately replaced with a single yes/no checkbox per encounter: “Was pain evaluated and addressed?” As noted by Walid et al, “The use of the 0-to-10 pain scale... as a sole measure of pain assessment undercuts compassionate communication.” Let’s evaluate pain as the complex, nuanced symptom that it is, rather than oversimplifying it as a single integer of dubious merit. Routine pain scoring is a proven failure and should be abandoned.

Wow... perhaps he should tell us what he really thinks.


Chang, AK, Bijur PE, Holden L, et al. Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query: Do You Want More Pain Medication? Ann Emerg Med. 2016;67:565-72.

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