How should medical providers measure pain?

The concept of reducing these shades of pain to a single number dates back to the 1970s. But the zero-to-10 scale is ubiquitous today because of what was called a “pain revolution” in the ’90s, when intense new attention to addressing pain—primarily with opioids—was framed as progress. Doctors today have a fuller understanding that they can (and should) think about treating pain, as well as the terrible consequences of prescribing opioids so readily. What they are learning only now is how to better measure pain and treat its many forms.

About 30 years ago, physicians who championed the use of opioids gave robust new life to what had been a niche speciality: pain management. They started pushing the idea that pain should be measured at every appointment as a “fifth vital sign.” The American Pain Society went as far as copyrighting the phrase. But unlike the other vital signs—blood pressure, temperature, heart rate, and breathing rate—pain had no objective scale. How to measure the unmeasurable? The society encouraged doctors and nurses to use the zero-to-10 rating system. Around that time, the FDA approved OxyContin, a slow-release opioid painkiller made by Purdue Pharma. The drugmaker itself encouraged doctors to routinely record and treat pain, and aggressively marketed opioids as an obvious solution…

But this approach to pain management had clear drawbacks. Studies accumulated showing that measuring patients’ pain didn’t result in better pain control. Doctors showed little interest in or didn’t know how to respond to the recorded answer. And patients’ satisfaction with their doctor’s discussion of pain didn’t necessarily mean they got adequate treatment. At the same time, the drugs were fueling the growing opioid epidemic. Research showed that an estimated 3 to 19 percent of people who get a prescription for pain medication from a doctor developed an addiction…

A zero-to-10 scale may make sense in certain situations, such as when a nurse uses it to adjust a medication dose for a patient hospitalized after surgery or an accident. And researchers and pain specialists have tried to create better rating tools—dozens, in fact, none of which was adequate to capture pain’s complexity, a European panel of experts concluded. The Veterans Health Administration, for instance, created one that had supplemental questions and visual prompts: A rating of 5 correlated with a frown and a pain level that “interrupts some activities.” The survey took much longer to administer and produced results that were no better than the zero-to-10 system. By the 2010s, many medical organizations, including the American Medical Association and the American Academy of Family Physicians, were rejecting not just the zero-to-10 scale but the entire notion that pain could be meaningfully self-reported numerically by a patient.

Measurement in many areas is not an easy process. There appear to be multiple complicating factors in this situation: pain perception can differ across patients; people are self-reporting pain; reports of pain are tied to particular medical options; doctors, nurses, and others are interpreting reports of pain; and there are numerous ways this could be measured.

If measurement is so difficult, what else could be done? I would guess people will continue to look for accurate measurement tools. Having such tools could prove very beneficial (and perhaps profitable?). It could also hint at the need for relational holistic care where a point-in-time report of pain is understood within a longer-term understanding between patient and provider. And greater scientific understanding of pain – and managing it – could help.

In the meantime, imprecise measurement of pain will continue. Should this affect how we answer the 0-10 question when asked?